A Contemporary Analysis of the 30-day Morbidity and Mortality Associated With Cytoreductive Nephrectomy.

OBJECTIVE: To examine the rates of adverse surgical outcomes in patients undergoing cytoreductive nephrectomy (CN) compared to patients undergoing radical nephrectomy in the nonmetastatic setting using a large administrative database. METHODS: Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) who underwent a radical nephrectomy between 2011 and 2016 were included. Patients were stratified by the preoperative variable of presence or absence of metastatic cancer. Perioperative outcomes were compared. A multivariable logistic regression analysis was performed to test the association between patients with metastatic cancer and perioperative morbidity and 30-day mortality. RESULTS: There were 15,869 total patients included in this analysis of whom 1322 (8%) patients had metastatic cancer. Of the entire cohort, the majority of patients were over 60 years old (58%) and 9621 (61%) were male. Seventy-three of the patients were Caucasian. Patients with metastatic cancer had more minor (P< .01) and major (P< .01) complications, a higher rate of reoperation (P< .01), and a higher rate of unplanned readmissions (P< .01). Finally, the cohort with metastatic cancer had a higher rate of postoperative 30-day mortality (P< .01) than patients without metastatic cancer. CONCLUSION: Patients undergoing a CN have significantly worse perioperative outcomes than patients undergoing a radical nephrectomy without evidence of metastases. Careful surgical risk stratification and appropriate patient counseling should be undertaken when selecting candidates for CN.

Isolated adrenal metastectomy has a low morbidity rate irrespective of performing surgical sub-specialty.

INTRODUCTION: There has been growing use of adrenalectomy as a potentially curative treatment option for patients with oligometastatic disease to the adrenal gland. We sought to compare the perioperative outcomes of patients undergoing isolated adrenalectomy in the setting of disseminated cancer using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Furthermore, we examined the impact of performing surgical sub-specialty on outcomes. MATERIALS AND METHODS: Data from the ACS-NSQIP database was obtained for patients between 2011 and 2016 who underwent adrenalectomy. Patients were stratified by the presence or absence of disseminated cancer. Univariate and multivariate regression analyses were performed to test for an association between the presence or absence of disseminated cancer and perioperative outcomes. The relationship between performing specialist and outcomes was also compared. RESULTS: A total of 4,207 patients were identified, with 270 (6.4%) in the disseminated cancer group. There was no significant difference in perioperative outcomes between patients with disseminated cancer and without disseminated cancer. On multivariate analysis, neither the presence of disseminated cancer (p = 0.47) nor the surgical sub-specialty performing adrenalectomy (p = 0.52) were associated with an increased risk postoperative morbidity or mortality. Of note, there was a statistically significant increase in the number of adrenalectomies performed by urologists in the setting of disseminated cancer (19.3% versus 10.4%, p < 0.01). CONCLUSIONS: Patients undergoing adrenalectomy in the setting of disseminated cancer did not have significantly worse perioperative outcomes compared to patients undergoing adrenalectomy for other indications. The adverse perioperative event rate was similar whether the operation was performed by a urologist or a general surgeon.

Effect of the Need for Preoperative Dialysis on Perioperative Outcomes on Patients Undergoing Laparoscopic Nephrectomy: An Analysis of the National Surgical Quality Improvement Program Database.

OBJECTIVE: To investigate whether patients requiring dialysis are a higher risk surgical population and would experience more perioperative adverse events even when undergoing a perceived less invasive operation as a laparoscopic radical nephrectomy (LRN). LRN is generally a well-tolerated surgical procedure with minimal morbidity and mortality. Prior to transplantation, dialysis patients will often have to undergo a LRN to remove a native kidney with a suspicious mass. MATERIALS AND METHODS: Patients in the American College of Surgeons National Surgical Quality Improvement Program who underwent a LRN between 2011 and 2016 were included. Patients were stratified by the need for preoperative dialysis 2 weeks prior to surgery, and perioperative outcomes were compared. A multivariable logistic regression analysis was performed to test the association between the need for preoperative dialysis and perioperative risk. RESULTS: There were 8315 patients included in this analysis of which 445 (5.4%) patients required preoperative dialysis. Patients who required preoperative dialysis had more minor (P <.0001) and major (P = .0025) complications, a higher rate of return to the operating room (P = .002), and a longer length of stay (P <.0001) than those patients not requiring preoperative dialysis. In a multivariate analysis, the need for preoperative dialysis was independently associated with adverse perioperative outcomes (OR= 1.45, CI = 1.08-1.95, P = .015). CONCLUSION: Patients requiring preoperative dialysis were more likely to experience a perioperative complication and have a longer length of stay. For LRNs performed prior to transplantation, further risk stratification is needed, and treatment sequencing may need to be reconsidered.

An Evaluation of Reported Follicle-stimulating Hormone, Luteinizing Hormone, Estradiol, and Prolactin Reference Ranges in the United States.

OBJECTIVE: To characterize US clinical laboratory reference range reporting and testing methods of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and prolactin. METHODS: One hundred and seventeen US laboratories were surveyed. Outcomes measured were variation in lower and upper limits of normal male reference ranges for serum FSH, LH, estradiol, and prolactin, method of analysis and source of reference range RESULTS: The upper limit of normal reference ranges for FSH, LH, estradiol, and prolactin varied substantially across laboratories compared to the lower limits. The range of upper limits of FSH, LH, estradiol, and prolactin respectively are 7.9-20.0, 4.9-86.5, 37.7-77.0, and 7.4-25.0. Ninety-four percent of laboratories performed measurements on in-house high throughput analyzer utilizing immunoassays. Seventy percent of reported reference ranges for each hormone were based on validation studies of the analyzer's package insert values. Ten percent of laboratories derived their own reference ranges. Both the validation studies and derivations were based on a limited number of patient samples, ranging from 20 to 200. CONCLUSION: Current reference ranges are based on small population studies of men with unknown medical histories, sexual or reproductive function. Influence of race and age has not been evaluated and could potentially be important in normal variation. The absence of standard information has yielded a spectrum of upper and lower normal values, which could delay an appropriate male infertility evaluation. Our findings highlight the need for a large population study of males with known normal sexual and reproductive function to formulate more accurate clinical reference ranges.

Robotic Cystectomy.

Retrospective observational studies support the utility of robotic-assisted radical cystectomy (RARC). Randomized controlled trials (RCTs) have shown that RARC with extracorporeal urinary diversion may lead to decreased estimated blood loss, decreased rate of transfusion, similar oncologic outcomes, cost-effectiveness, and variable increased operative times. Although RCTs comparing RARC with open radical cystectomy are currently ongoing, it may be several years before the utility of RARC is known. The discussion on the role of cystectomy, indications, outcomes, care pathways, access to high-volume care centers, and efforts to decrease complications may prove as important as the technique itself.

Factors Affecting the Completion of Genitourinary Physical Examinations Prior to Urologic Consultation.

BACKGROUND: Proper instruction during medical training regarding performing adequate physical examinations prior to urologic consultations greatly improves patient care. We evaluated the frequency of genitourinary (GU) physical examinations performed prior to urologic consultation to determine the influence of factors affecting the completion of these examinations. METHODS: Between January 2013 and December 2014, 1,596 consultations were requested by primary providers and completed by the urology department at a major tertiary care teaching institution. We reviewed patient medical records retrospectively and recorded the number of GU examinations performed prior to consultation. Patient demographics were evaluated for trends in the rates of examination. A total of 9 available urology residents saw at least one consult each. RESULTS: We identified a total of 1,596 urologic consultations during the study period, of which 233 of 407 (57.2%) (51 female and 182 male patients) received GU examinations prior to the urologic consult in the emergency department (ED) and 394 of 1,189 (33.1%) (118 female and 276 male patients) received GU examinations by the inpatient care team. Staff in the ED were 3.11 times more likely to perform a GU examination on a male patient than a female patient, and the inpatient teams were 1.48 times more likely to perform a GU examination on a male patient than a female patient. The likelihood of examination by either team was low in patients aged ≥65 years. CONCLUSION: Prior to urologic consultation, GU examinations are inconsistently performed. This variability may affect patient care and could be the subject of a future study.

Current Practices of Measuring and Reference Range Reporting of Free and Total Testosterone in the United States.

PURPOSE: The evaluation and management of male hypogonadism should be based on symptoms and on serum testosterone levels. Diagnostically this relies on accurate testing and reference values. Our objective was to define the distribution of reference values and assays for free and total testosterone by clinical laboratories in the United States. MATERIALS AND METHODS: Upper and lower reference values, assay methodology and source of published reference ranges were obtained from laboratories across the country. A standardized survey was reviewed with laboratory staff via telephone. Descriptive statistics were used to tabulate results. RESULTS: We surveyed a total of 120 laboratories in 47 states. Total testosterone was measured in house at 73% of laboratories. At the remaining laboratories studies were sent to larger centralized reference facilities. The mean ± SD lower reference value of total testosterone was 231 ± 46 ng/dl (range 160 to 300) and the mean upper limit was 850 ± 141 ng/dl (range 726 to 1,130). Only 9% of laboratories where in-house total testosterone testing was performed created a reference range unique to their region. Others validated the instrument recommended reference values in a small number of internal test samples. For free testosterone 82% of laboratories sent testing to larger centralized reference laboratories where equilibrium dialysis and/or liquid chromatography with mass spectrometry was done. The remaining laboratories used published algorithms to calculate serum free testosterone. CONCLUSIONS: Reference ranges for testosterone assays vary significantly among laboratories. The ranges are predominantly defined by limited population studies of men with unknown medical and reproductive histories. These poorly defined and variable reference values, especially the lower limit, affect how clinicians determine treatment.