Penile and Urethral Reconstructive Surgery.

Penile and urethral reconstructive surgical procedures are used to treat a variety of urologic diagnoses. Urethral stricture disease can lead to progressive lower urinary tract symptoms and may require multiple surgical procedures to improve patient's symptoms. Male stress urinary incontinence is associated with intrinsic sphincter deficiency oftentimes associated with radical prostatectomy. Men suffering from urethral stricture disease and stress urinary incontinence should be referred to a urologist because multiple treatment options exist to improve their quality of life.

Racial Disparities Differ for African Americans and Hispanics in the Diagnosis and Treatment of Penile Cancer.

OBJECTIVE: To evaluate racial disparities in the diagnosis and treatment of penile cancer among a contemporary series of men from a large diverse national data base. MATERIALS AND METHODS: Using the 1998-2012 National Cancer Data Base, all men with squamous cell carcinoma (SCC) were stratified by race and ethnicity. Demographic and disease characteristics were compared between groups. Likelihood of undergoing surgery and type of surgery were compared among patients with nonmetastatic disease. Factors influencing disease stage and treatment type were analyzed with univariate and multivariable logistic regressions. Overall survival was examined with Kaplan-Meier and adjusted Cox proportional hazard models. RESULTS: We identified 12,090 men with penile SCC with median age 66 years (range 18-90). Distribution of patients is as follows: 76.8% Caucasian, 10.2% African American (AA), 8.7% Hispanic. On multivariable analysis, Hispanic men are more likely to present with high-risk (≥T1G3) penile SCC (odds ratio [OR] 1.6; confidence interval [CI] 1.20-2.00; P = .001) and tend to undergo penectomy rather than penile-sparing surgery (OR 1.46; CI 1.15-1.85; P = .002) for equal stage SCC compared to Caucasian patients. Whereas AA men are less likely to undergo surgery of any type (OR 0.67; CI 0.51-0.87; P = .003) and have higher mortality rates than Caucasian patients (hazard ratio 1.25; CI 1.10-1.42; P < .001). CONCLUSION: Hispanic men with penile SCC are more likely to present with high-risk disease and undergo more aggressive treatment than Caucasian patients but have comparable survival. AA men are less likely to undergo surgical management of their disease and have higher mortality rates.

Racial Disparities in Partial Nephrectomy Persist Across Hospital Types: Results From a Population-based Cohort.

OBJECTIVE: To assess the national utilization of partial nephrectomy (PN) for T1a renal masses across different racial groups by hospital type. Although clinical guidelines recommend PN for small renal masses (SRMs), racial disparities persist in the use of PN. High-volume and academic hospitals have been associated with greater use of PN for SRMs. However, it is unknown whether racial disparities persist in the use of PN across different types of hospitals. METHODS: Using the National Cancer Database, we identified patients with localized T1a renal cancer (≤4 cm) from 1998 to 2011. The primary outcome was receipt of PN among patients surgically treated for SRMs. Multivariable logistic regression analyses were used to assess for racial differences in treatment with PN stratified by hospital characteristics. RESULTS: Among 118,207 patients diagnosed with clinical T1a renal masses, 36.5% underwent PN (n = 43,134). Overall, a greater proportion of white patients underwent PN (37.3%) compared with African-American (32.4%) and Hispanic (33.7%) patients with SRMs (P <.001). When stratified by hospital type, disparities persisted in the use of PN; African-American patients had lower adjusted odds ratios for being treated with PN when treated at comprehensive community cancer (odds ratio: 0.90; P = .003) and academic (odds ratio: 0.65; P <.001) hospitals compared with white patients. CONCLUSIONS: In this population-based cohort, we found that racial disparities persist across all types of hospitals in the use of PN for SRMs. Further research is needed to identify, and target for intervention, the factors contributing to racial disparities in the surgical management of SRMs.

Comorbid Disease Burden is Independently Associated with Higher Risk Disease at Prostatectomy in Patients Eligible for Active Surveillance.

PURPOSE: Comorbid medical conditions are highly prevalent among patients with prostate cancer and may be associated with more aggressive disease. We investigated the association between comorbidity burden and higher risk disease among men eligible for active surveillance. MATERIALS AND METHODS: Using the National Cancer Data Base we identified 29,447 cases of low risk (Gleason score 6 or less, cT1/T2a, prostate specific antigen less than 10 ng/ml) prostate cancer managed with prostatectomy from 2010 to 2011. The primary outcome was pathological upgrading (Gleason score greater than 6) or up staging (T3-T4/N1). The association between Charlson score and upgrading/up staging was analyzed using multivariate logistic regression. RESULTS: The study sample comprised 29,447 men, of which 449 (1.5%) had Charlson scores greater than 1. At prostatectomy 44% of cases were upgraded/up staged. On multivariate analysis Charlson score greater than 1, age 70 years or greater, nonwhite race, higher prostate specific antigen and higher percentage of cores involved with disease were significantly associated with upgrading/up staging. After further adjusting for age, race, prostate specific antigen and core involvement, Charlson score remained a significant predictor of upgrading/up staging for younger white men. Specifically, white men less than 70 years old with Charlson comorbidity index greater than 1 had 1.3-fold higher odds of upgrading/up staging than men with Charlson comorbidity index 1 or less (OR 1.31, 95% CI 1.03-1.67, p=0.029). CONCLUSIONS: Comorbidity burden is strongly and independently associated with pathological upgrading/up staging in men with clinically low risk prostate cancer. This finding may help improve disease risk assessment and clinical decision making in men with comorbidities considering active surveillance.

Economic Burden Associated with Hospitalization for Radiation Cystitis: Results from a Statewide Inpatient Database.

INTRODUCTION: Radiation cystitis is associated with a significant burden to patients and the health care system. However, the regional burden of treatment and its associated costs remains poorly described. We assessed the health care costs and need for intervention among patients admitted to the hospital with radiation cystitis. METHODS: Using data from the Ohio Hospital Association we identified patients admitted with a diagnosis of radiation cystitis from 2009 to 2013. The primary outcome was the adjusted inpatient cost (adjusted to 2013 U.S. dollars) associated with in-hospital treatment of radiation cystitis. Secondary outcomes included percentage of patients requiring endoscopic urological procedures, blood transfusions and nephrostomy tubes. We used a generalized estimating equation model to determine in-hospital costs. Multivariate logistic regression analyses were used to determine factors associated with requiring an invasive procedure. RESULTS: We identified 1,111 patients admitted to Ohio hospitals between 2009 and 2013 with a diagnosis of radiation cystitis. Mean patient age (±SD) was 73.9 (±12.5) years. Median length of stay was 4 days (IQR 3-8). The adjusted median cost of hospitalization per admission in 2013 for these patients was $7,151 (IQR $4,251-$16,569). Overall 28.9% of patients required blood transfusions, 34.4% required endourological procedures and 3.4% required nephrostomy tubes. The odds of undergoing an invasive procedure were associated with increasing length of stay, need for blood transfusion and male gender. CONCLUSIONS: This study is the first population based study to our knowledge to assess the treatment burden and health care costs from radiation cystitis. A diagnosis of radiation cystitis carries with it a significant economic and treatment associated burden.

National Trends of Local Ablative Therapy Among Young Patients With Small Renal Masses in the United States.

OBJECTIVE: To assess national trends in the usage of local ablative therapy for small renal masses (SRMs) in a cohort of young patients. Ablation of SRMs has been shown to offer cancer control with limited follow-up. Although ablation is considered effective for patients with limited life expectancy, its use among younger patients may be considered controversial. METHODS: We used the National Cancer Data Base to identify patients between the ages of 40 and 65 years who were diagnosed with SRMs from 2004 to 2011. The primary outcome was the use of local ablative therapy. Multivariable logistic regression analysis was used to identify patient and hospital factors associated with ablation therapies in this cohort. RESULTS: During the study period, we identified 49,441 patients with SRMs, of which 2789 (5.6%) were treated with ablative therapies. The proportion of patients undergoing ablation gradually rose from 2.2% in 2004 to 6.2% in 2011 (P < .001). On multivariable analysis, patients were more likely to receive local ablation at academic hospitals (odds ratio [OR]: 1.5; P < .001) compared with community hospitals, or primarily insured by Medicaid (OR: 1.4; P < .001) or Medicare (OR: 1.3; P < .001) compared with private insurance. CONCLUSION: The use of local ablative therapies is gradually rising but has so far been limited to a small fraction of young patients with SRMs. Patients treated at high-volume, academic hospitals or insured with Medicaid or Medicare were treated to a greater degree with ablation. These results have important implications for the adoption of ablation and the need for long-term surveillance.

Increasing Biopsy Utilization for Renal Cell Carcinoma Is Closely Associated With Treatment.

OBJECTIVE: To describe recent temporal trends in biopsy use for renal cell carcinoma and to identify factors associated with biopsy. MATERIALS AND METHODS: Renal cell carcinoma diagnoses from 2003 to 2011 were identified using the National Cancer Data Base. Cases were classified by traditional (clinical stage T4, N1, or M1, or history of other malignancies) or expanded biopsy indications. Time trends were plotted, and multivariate analysis was performed to identify factors associated with biopsy. RESULTS: Of 171,406 eligible patients, we identified 21,019 patients (12.3%) who were biopsied. We observed a significant increase in biopsy usage with time for both the traditional (range, 16.7%-20.6%) and expanded (range, 6.9%-10.9%) subgroups (P < .01 for the trends). By the end of the study period, expanded indications accounted for most biopsies. By far, eventual treatment was the strongest factor associated with biopsy utilization for either subgroup. Compared with patients treated with partial nephrectomy, the odds of being biopsied were 2.7-4.3, 6.0-9.8, 14.6-23.0, and 3.0-4.4 times higher for patients managed with observation, cryoablation, radiofrequency ablation, or chemotherapy (including targeted therapy), respectively (P < .01). In the expanded-indications subgroup, other factors significantly associated with biopsy included sex, race, income, insurance, travel distance, case volume, region, and tumor size (P < .01 for all). Other significant factors in the traditional-indications subgroup were income, region, and Charlson score (P < .01 for all). CONCLUSION: In recent years, renal cell carcinoma biopsy has been increasingly used in patients with traditional and expanded indications. Its use is strongly associated with treatment and treatment-related factors.

Nonclinical Factors Predict Selection of Initial Observation for Renal Cell Carcinoma.

OBJECTIVE: To determine the rate of observation utilization over time and to identify factors influencing its use. MATERIALS AND METHODS: Using the National Cancer Data Base, we studied observation utilization in patients diagnosed with localized renal cell carcinoma from 2003 to 2010. Relationships between temporal, demographic, provider, and clinical factors and the likelihood of observation were evaluated using multivariate logistic regression. RESULTS: Of 109,410 analyzed patients, 7047 (6.4%) underwent observation with stable use over time (range, 6.1% to 6.8%). Patient and disease factors were the strongest predictors of observation. Specifically, the odds of biopsy were 1.8-11 times higher for elderly or comorbid patients and 1.6-8.4 times higher for small (clinical T1a), biopsied, or bilateral tumors (P <.01 for all). Racial and socioeconomic factors also significantly predicted observation usage. In particular, observation rates were higher among poor, African American, and uninsured or socially insured patients, with these groups having 1.2-3.5 times higher odds of observation (P <.01). Patients receiving care at community, low-volume, or nearby hospitals were also significantly more likely to undergo observation (P <.01). CONCLUSION: Despite the continued rise in the incidence of incidental renal masses, initial observation use has remained stable. In accordance with treatment guidelines, observation is preferentially utilized in elderly and comorbid patients. However, nonclinical factors also predict observation use, suggesting that utilization may be influenced by racial and socioeconomic disparities in health care quality.

Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal Masses.

PURPOSE: We assessed the relationship of surgical margins across different surgical approaches to partial nephrectomy in patients with clinical T1a renal cell carcinoma in a population based cohort. MATERIALS AND METHODS: We used NCDB (National Cancer Database) to identify all patients who underwent partial nephrectomy for clinical T1a renal cell carcinoma (tumor size less than 4 cm) from 2010 to 2011. The primary outcome was surgical margin status in patients treated with partial nephrectomy by the open, laparoscopic or robotic approach. Multivariable logistic regression analysis was done to identify patient, hospital and surgical factors associated with positive surgical margins. RESULTS: Partial nephrectomy was done in 11,587 patients, including open, laparoscopic and robotic nephrectomy in 5,094 (44%), 1,681 (14%) and 4,812 (42%), respectively. Mean±SD age was 56±12 years. Overall 806 patients (7%) had positive surgical margins. The positive surgical margin prevalence was 4.9%, 8.1% and 8.7% for the open, laparoscopic and robotic approaches, respectively (p<0.001). Laparoscopic and robotic partial nephrectomy had a higher adjusted OR for positive surgical margins (OR 1.81 and 1.79, respectively, each p<0.001) than open nephrectomy. When stratified by hospital type, differences in positive surgical margin rates remained, such that patients treated at academic medical centers who underwent laparoscopic and robotic partial nephrectomy had a higher adjusted OR (1.38, p=0.074 and 1.73, p<0.001, respectively) than patients treated with open partial nephrectomy. CONCLUSIONS: Laparoscopic and robotic partial nephrectomy is associated with higher positive surgical margin rates compared to open partial nephrectomy for clinical T1a renal cell carcinoma. The effect of margin status on long-term oncologic outcomes in this context remains to be determined.