Cost-Effectiveness of Extended Duration Venous Thromboembolism Prophylaxis in High Risk Urological Oncology Surgical Patients.

INTRODUCTION: Major urological oncology surgery carries a significant risk of postoperative venous thromboembolism events, resulting in major morbidity, possible mortality and substantial costs. We determined the incremental cost-effectiveness for in-hospital and low molecular weight heparin extended duration prophylaxis for venous thromboembolism prevention in patients at high risk following major urological oncology surgery. METHODS: A decision analytical model was developed to compare inpatient hospital costs, venous thromboembolism incidence within 365 days and outcomes associated with extended duration prophylaxis for 4 prophylaxis strategies. The 4 strategies grouped by protocol adherence were 1) per protocol in-hospital prophylaxis with extended duration prophylaxis in 88 cases, 2) per protocol in-hospital prophylaxis without extended duration prophylaxis in 42, 3) not per protocol in-hospital prophylaxis with extended duration prophylaxis in 80 and 4) not per protocol in-hospital prophylaxis without extended duration prophylaxis in 99. Between June 2011 and March 2014, 707 patients underwent major urological oncology surgery. Using the Caprini risk score 309 patients were at high risk. RESULTS: The group 1 strategy was the dominant (most effective) strategy when the probability of preventing venous thromboembolism with extended duration prophylaxis was greater than 80%. Effectiveness for preventing venous thromboembolism was most influenced by the group 2 venous thromboembolism incidence rate. Costs in group 1 vs group 2 were calculated at $1,531 vs $1,563. Using the incremental cost-effectiveness ratio to compare groups 1 and 2, which were the 2 groups with the closest costs and effectiveness, an overall cost savings of $1,390 per patient was seen. CONCLUSIONS: Compared with competing strategies in-hospital and extended duration prophylaxis for venous thromboembolism prevention in patients at high risk undergoing major urological oncology surgery is effective to prevent venous thromboembolism and it is cost saving.

Effectiveness and safety of extended-duration prophylaxis for venous thromboembolism in major urologic oncology surgery.

PURPOSE: To examine the association between extended-duration prophylaxis (EDP), low-molecular-weight heparin prophylaxis for 28 days after surgery for urologic cancer in patients at high risk of developing a venous thromboembolism (VTE), the risk of VTE, and the complications resulting from VTE prophylaxis. MATERIALS AND METHODS: The cohort included 332 patients at high risk for VTE who were surgically treated for urologic cancer from June 2011 to June 2014. Adherence to VTE prophylaxis protocol, VTEs, and complications within 365 days from surgery were tracked. Patients were grouped as follows: (1) per protocol in-hospital prophylaxis with EDP (n = 107), (2) per protocol in-hospital prophylaxis without EDP (n = 42), (3) not per protocol in-hospital prophylaxis with EDP (n = 83), and (4) not per protocol in-hospital prophylaxis without EDP (n = 100). The risk of VTE was compared between the 4 groups using the Cox model, with adjustment for baseline risk factors. RESULTS: The rates of VTEs and median times to VTE were 7% and 58 days in group 1, 17% and 44 days in group 2, 17% and 46 days in group 3, and 21% and 15 days in group 4, respectively. Adjusted hazard ratios (HR) for VTE were HR = 0.27 (95% CI: 0.11-0.70) for groups 1 vs. 4; HR = 0.66 (95% CI: 0.25-1.60) for groups 2 vs. 4; and HR = 0.66 (95% CI: 0.29-1.26) for groups 3 vs. 4 with a trend of P = 0.002. The incidence of complications from VTE prophylaxis was not significantly different between the groups, with a rate of 8% in group 1, 17% in group 2, 6% in group 3, and 12% in group 4 (P = 0.33). CONCLUSIONS: In high-risk urologic cancer surgery patients, a clinical protocol, with perioperative and EDP, is safe and effective in reducing VTE events.

Management of priapism: an update for clinicians.

Priapism is a prolonged erection that persists beyond or is unrelated to sexual stimulation. It is associated with significant morbidity: psychological, socioeconomic, and physical, including pain and potentially irreversible compromise of erectile function. There are three major types of priapism: ischemic, nonischemic, and stuttering. Establishing the type of priapism is paramount to safely and effectively treating these episodes. Ischemic priapism represents a urological emergency. Its treatment may involve aspiration/irrigation with sympathomimetic injections, surgical shunts, and as a last resort, penile prosthesis implantation. Nonischemic priapism results from continuous flow of arterial blood into the penis, most commonly related to penile trauma. This is not an emergency and may be managed conservatively initially, as most of these episodes are self-limiting. Stuttering priapism involves recurrent self-limiting episodes of ischemic priapism. The primary goal of therapy is prevention, but acute episodes should be managed in accordance with guidelines for ischemic priapism. In this paper we review the diagnosis and treatment of the three priapism variants, as well as discuss future targets of therapy and novel targets on the horizon.

Overall Survival after Partial Versus Radical Nephrectomy for a Small Renal Mass: Systematic Review of Observational Studies.

INTRODUCTION: In EORTC trial 30904 of partial versus radical nephrectomy overall survival was significantly better in the radical nephrectomy arm. However, many observational studies reported better survival after partial than radical nephrectomy. We present an updated systematic review of observational studies of overall survival after partial versus radical nephrectomy with assessment of quality of evidence. METHODS: The literature search was performed until December 31, 2013, and all studies reporting overall survival after partial vs radical nephrectomy were included in the initial review. Further inclusion criteria for complete review were malignant tumors 7 cm or smaller, or benign tumors of any size, and survival analysis performed with adjustment for confounding variables. Studies not meeting these criteria were excluded from full review because of selection bias in favor of patients treated with partial nephrectomy who were younger and with less advanced tumors. RESULTS: A total of 34 studies were included in the initial review and 13 were included in the full review. The 13 studies were based on the SEER database (6) or on institutional cohorts (7). In 8 of the 13 studies the estimated hazard ratios were significantly below 1, indicating better overall survival after partial nephrectomy, while in the remaining 5 studies estimated HR was not significantly different from 1. Median HR was 0.80 (interquartile range 0.57 to 0.96, absolute range 0.40 to 1.10). CONCLUSIONS: In most observational studies overall survival was better after partial than after radical nephrectomy. However, because residual confounding could be present despite adjustment for measured covariates, another randomized trial of partial vs radical nephrectomy may be needed to confirm or refute the findings of EORTC 30904.

Single cell network profiling assay in bladder cancer.

The aim of this study was to assess the feasibility of applying the single cell network profiling (SCNP) assay to the examination of signaling networks in epithelial cancer cells, using bladder washings from 29 bladder cancer (BC) and 15 nonbladder cancer (NC) subjects. This report describes the methods we developed to detect rare epithelial cells (within the cells we collected from bladder washings), distinguish cancer cells from normal epithelial cells, and reproducibly quantify signaling within these low frequency cancer cells. Specifically, antibodies against CD45, cytokeratin, EpCAM, and cleaved-PARP (cPARP) were used to differentiate nonapoptotic epithelial cells from leukocytes, while measurements of DNA content to determine aneuploidy (DAPI stain) allowed for distinction between tumor and normal epithelial cells. Signaling activity in the PI3K and MAPK pathways was assessed by measuring intracellular levels of p-AKT and p-ERK at baseline and in response to pathway modulation; 66% (N = 19) of BC samples and 27% (N = 4) of NC samples met the "evaluable" criteria, i.e., at least 400,000 total cells available upon sample receipt with >2% of cells showing an epithelial phenotype. The majority of epithelial cells detected in BC samples were nonapoptotic and all signaling data were generated from identified cPARP negative cells. In four of 19 BC samples but in none of the NC specimens, SCNP assay identified epithelial cancer cells with a quantifiable increase in epidermal growth factor-induced p-AKT and p-ERK levels. Furthermore, preincubation with the PI3K inhibitor GDC-0941 reduced or completely inhibited basal and epidermal growth factor-induced p-AKT but, as expected, had no effect on p-ERK levels. This study demonstrates the feasibility of applying SCNP assay using multiparametric flow cytometry to the functional characterization of rare, bladder cancer cells collected from bladder washing. Following assay standardization, this method could potentially serve as a tool for disease characterization and drug development in bladder cancer and other solid tumors.

Medical management of ischemic stuttering priapism: a contemporary review of the literature.

Priapism is defined as a prolonged and persistent erection of the penis without sexual stimulation. This is a poorly understood disease process with little information on the pathophysiology of this erectile disorder. Complications from this disorder are devastating due to the irreversible erectile damage and resultant erectile dysfunction (ED). Stuttering priapism, though relatively rare, affects a high prevalence of men with sickle-cell disease (SCD) and presents a challenging problem with guidelines for treatment lacking or resulting in permanent ED. The mechanisms involved in the development of priapism in this cohort are poorly characterized; therefore, medical management of priapism represents a therapeutic challenge to urologists. Additional research is warranted, so we can effectively target treatments for these patients with prevention as the goal. This review gives an introduction to stuttering priapism and its clinical significance, specifically with regards to the patient with SCD. Additionally, the proposed mechanisms behind its pathophysiology and a summary of the current and future targets for medical management are discussed.

Laparoscopic live donor nephrectomy: a technical road map.

Laparoscopic live donor nephrectomy is a safe, minimally invasive alternative to the customary open approach. During the past two decades, laparoscopic renal surgery has increased the availability of renal allograft specimens for transplantation. Specifically, the laparoscopic approach has minimized postoperative pain and duration of recovery, making it a more attractive option for potential altruistic organ donors. Here we detail the techniques, challenges, and troubleshooting approaches necessary for this technically challenging, yet valuable operation.

Pain assessments and the provision of analgesia: the effects of a templated chart.

OBJECTIVES: Many emergency departments (EDs) have incorporated pain assessment scales in the medical record to improve compliance with the requirements of the Joint Commission on Accreditation of Healthcare Organizations. The authors conducted a pre-post trial investigating the effects of introducing a templated chart on the documentation of pain assessments and the provision of analgesia to ED patients. METHODS: A total of 2,379 charts were reviewed for inclusion based on the presence of a chief complaint related to trauma or nontraumatic pain, with 1,242 charts included in the analysis. RESULTS: Baseline demographic characteristics, mechanism of injury, location of injury, and initial pain severity were similar in the two groups. The proportion of patients with documentation of pain assessment increased from 41% to 57% (p < 0.001). In particular, traumatic mechanisms and chest, abdominal, and extremity pain yielded the largest improvements in documentation after introduction of the templated charts. Documentation of pain descriptors also improved for time of onset, duration, timing, and context (p < 0.01). Pain control in the templated chart group, however, remained unchanged and the provision of analgesia in the ED was not altered, with the exception of nonsteroidal medications, which decreased from 46% to 36% (p < 0.01). CONCLUSIONS: Although documentation is improved with a templated chart, this improvement did not translate into improved patient care.