Reducing Postoperative Opioids for Outpatient Endoscopic Urological Surgery: A Resident Driven Quality Improvement Initiative.

INTRODUCTION: Opioid dependency has become a public health crisis in the United States and surplus prescriptions of opioids after surgery may be contributing to this problem. This resident driven quality improvement initiative sought to study the prescribing patterns of opioids for patients undergoing outpatient urological surgery at our institution, reduce prescriptions where possible and monitor patient outcomes. METHODS: A chart review and telephone survey were conducted of patients undergoing outpatient endourological surgery. Type and quantity of narcotics prescribed were identified, and patients were surveyed on quantity of medication consumed. Physicians were then counseled on prescribing quantities closer to the average amounts reportedly used by patients. After 30 days we assessed emergency room visits, readmissions and telephone calls related to pain. RESULTS: Before our initiative patients were prescribed an average of 156.6 morphine milligram equivalents (median 150) after endourological surgery. Patients reported using between 0-37.5 morphine milligram equivalents, with 71% reporting using no narcotics. Following 30 days of surgeon advisement, the average prescription decreased to 38.6 morphine milligram equivalents (median 0), representing a 75.3% reduction. Following reductions there were no significant differences in emergency room visits, telephone calls, readmissions or rate of drug refills. CONCLUSIONS: Resident driven quality improvement initiatives can lead to reductions in the prescription of surplus opioids after certain types of urological surgery. These efforts can play an important role in reducing the supply of available narcotics at the local level.

A clinical prediction tool to determine the need for concurrent systematic sampling at the time of magnetic resonance imaging-guided biopsy.

OBJECTIVE: To develop a clinical prediction tool that characterises the risk of missing significant prostate cancer by omitting systematic biopsy in men undergoing transrectal ultrasonography/magnetic resonance imaging (TRUS/MRI)-fusion-guided biopsy. PATIENTS AND METHODS: A consecutive sample of men undergoing TRUS/MRI-fusion-guided biopsy with the UroNav® system (Invivo International, Best, The Netherlands) who also underwent concurrent systematic biopsy was included. By comparing the grade of cancer diagnosed on targeted and systematic biopsy cores, we identified cases where clinically significant disease (Gleason score ≥3+4) was only found on systematic and not targeted cores. Multivariable logistic regression analyses were used to identify predictive factors for finding significant cancer on systematic cores only. We then used these data to develop a nomogram and evaluated its utility using decision curve analysis. RESULTS: Of the 398 men undergoing TRUS/MRI-fusion-guided biopsy in our study, there were 46 (11.6%) cases in which clinically significant cancer was missed on targeted biopsy and detected on systematic biopsy. The clinical setting, number of MRI lesions identified, and the highest Prostate Imaging-Reporting and Data System (PI-RADS) score of the lesions, were all found to be predictors of this. Our model had a good discriminative ability (concordance index = 0.70). The results from our decision curve analysis show that this model provides a higher net clinical benefit than either biopsying all men or omitting biopsy in all patients when the threshold probability is <30%. CONCLUSION: We found that omitting concurrent systematic biopsy in men undergoing TRUS/MRI-fusion-guided biopsy would miss significant disease in more than one in 10 patients. We propose a prediction model with good discriminative ability that can be used to improve patient selection for performing concurrent systematic biopsy in order to minimise the number of missed significant cancers. It is important that our model is validated in external cohorts before being employed in routine clinical practice.

Which scores need a core? An evaluation of MR-targeted biopsy yield by PIRADS score across different biopsy indications.

INTRODUCTION: Magnetic resonance imaging is being widely adopted in the clinical management of prostate cancer. The correlation of the Prostate Imaging Reporting and Data System (PIRADS) to the presence of cancer has been established but studies have primarily evaluated this in a single clinical setting. This study aims to characterize the correlation of PIRADS score to the diagnosis of cancer on fusion biopsy among men who are undergoing primary biopsy, those who have had a previous negative biopsy or men on active surveillance. MATERIALS & METHODS: A consecutive sample of men undergoing US-MR biopsy at a single academic institution from 2014 to 2017 were included in this retrospective study. Men were stratified into groups according to their clinical history: biopsy-naïve, previous negative transrectal ultrasound (TRUS) biopsy or on active surveillance. The correlation of PIRADS score to the diagnosis of any and clinically significant cancer (Gleason score ≥ 3 + 4) was determined. RESULTS: A total of 255 patients with 365 discrete lesions were analyzed. PIRADS score 1-2, 3, 4 and 5 yielded any prostate cancer in 7.7, 29.7, 42.3 and 82.4% of the cases, respectively, across all indications while clinically significant cancer was found in 0, 8.9, 21.4 and 62.7%, respectively. The area under the receiver operative curves for the diagnosis of any and significant cancer was 0.69 (95%CI: 0.64-0.74) and 0.74 (95%CI: 0.69-0.79) respectively. Men who have had a previous negative biopsy had lower detection rates for any prostate cancer for PIRADS 3 and 4 lesions compared to those that were biopsy-naïve or on active surveillance. CONCLUSION: Cancer detection rates are significantly associated with PIRADS score. Biopsy yields differ across biopsy indications which should be considered when selecting a PIRADS score threshold for biopsy. Biopsy of PIRADS 3 lesions could potentially be avoided in men who have previously undergone a negative TRUS biopsy.

Contemporary Management of Prostate Cancer.

Prostate cancer represents a spectrum ranging from low-grade, localized tumors to devastating metastatic disease. We discuss the general options for treatment and recent developments in the field.

Urologic considerations of placenta accreta: a contemporary tertiary care institutional experience.

BACKGROUND: As the incidence of cesarean delivery has increased, we are experiencing a higher incidence of subsequent placenta accreta and the associated complications, including urologic complications. METHODS: This is a retrospective review of all patients delivered from 2000 to 2011 with a histologically proven diagnosis of placenta accreta. Data were analyzed for baseline maternal characteristics, intraoperative and postoperative outcomes and complications. RESULTS: 83 patients were included in the analysis. The depth of placenta accreta invasion varied in the cohort, with 48, 25 and 27% being classified as placenta accreta, placenta increta and placenta percreta, respectively. 88% of patients had had a previous cesarean delivery, and 58% had more than one prior operative delivery. Cystotomy was encountered in 27% of patients and ureteral injury occurred in 4%. Degree of placenta accreta invasion, number of prior cesarean deliveries and intraoperative blood loss were associated with a higher likelihood of urologic injury. CONCLUSIONS: Urologic injuries are among the most frequently encountered intraoperative complications of placenta accreta. Surgeons involved in these cases need to be aware of this risk and maintain a high level of surveillance intraoperatively.

Impact of ischemia on renal function after laparoscopic partial nephrectomy: a multicenter study.

PURPOSE: We assessed the influence of renal ischemia on long-term global renal function after laparoscopic partial nephrectomy in patients with 2 functioning kidneys in a large, multicenter cohort. MATERIALS AND METHODS: Collected data included demographic, clinical and surgical characteristics, tumor parameters and renal function outcomes at 4 institutions in a total of 401 patients with 2 functioning kidneys who underwent laparoscopic partial nephrectomy. Renal function was assessed in the immediate postoperative period (days 1 to 3) and at last followup (greater than 1 month) using the estimated glomerular filtration rate calculated by the 4-variable Modification of Diet in Renal Disease equation. Ischemia time and covariates were modeled on the percent change in the estimated glomerular filtration rate using linear regression. RESULTS: Median ischemia time was 29 minutes (IQR 22, 34). The postoperative change and the last (long-term) change in the estimated glomerular filtration rate were -16% and -11%, respectively. Median time to the last estimated glomerular filtration rate measurement was 13 months (IQR 6, 24). On multivariate analysis shorter ischemia and operative times, external or ureteral irrigation with cold saline and female gender were associated with less postoperative percent change in the estimated glomerular filtration rate. Smaller tumor size and absent diabetes were associated with less of a final percent change in the estimated glomerular filtration rate. Ischemia time was not associated with a percent change in the estimated glomerular filtration rate at last followup. CONCLUSIONS: Within the range of times in these series renal ischemia did not have a clinically significant impact on global renal function in patients with 2 functioning kidneys who underwent laparoscopic partial nephrectomy, as measured by the estimated glomerular filtration rate.

Pilot study of Alteplase (tissue plasminogen activator) for treatment of urinary clot retention in an in vitro model.

INTRODUCTION: The management of urinary clot retention and hematuria involves manual irrigation with sterile water or normal saline via a Foley catheter followed by continuous bladder irrigation. Irrigation may become difficult because of the formation of dense blood clots. Tissue plasminogen activator (t-PA/Alteplase) may be a useful pharmacological agent to improve the efficacy of manual irrigation of large, dense clots. The goal of the current study was to compare t-PA to sterile water for clot irrigation in an in vitro model. MATERIALS AND METHODS: In vitro models of clot retention were created using 500-cc urinary leg bags each filled with 80 cc of unpreserved whole blood from a healthy volunteer. Each model was incubated at 25 degrees C for 24 hours to allow clot formation. Four models each with 25 mL solution of t-PA at concentrations of 2, 1, 0.5, and 0.25 mg/mL were evaluated and compared to a control (25 mL sterile water). Models were instilled with solution (t-PA or control) and incubated for 30 minutes at 37 degrees C, and then irrigated with sterile water via 18F Foley by a blinded investigator. Three separate experiments were conducted, and statistical analysis was performed comparing various irrigation parameters. RESULTS: Clot evacuation with 25 mL of t-PA at a concentration of 2 mg/mL (50 mg) was significantly easier (p = 0.05) and faster (p < 0.05) than the sterile water control. The mean time for clot evacuation in this model was 2.7 minutes for t-PA solution 2 mg/mL versus 7.3 minutes for the control (p < 0.05). Compared to the control, irrigation with t-PA solution 2 mg/mL also required less irrigant (180 mL vs. 500 mL) (p < 0.05) for complete evacuation. There was a similar trend in efficacy for the lower doses of t-PA, but this was not statistically significant. CONCLUSION: In this in vitro study, a single 25 mL instillation of t-PA solution 2 mg/mL is significantly better than sterile water alone for clot evacuation. In vivo animal studies are pending.

Renal cell carcinoma in young and old patients--is there a difference?

PURPOSE: Renal cell carcinoma is rare in patients younger than 40 years and conflicting data regarding presentation and outcome are present in the literature. We reviewed our experience with young patients with renal cell carcinoma and compared them to their older counterparts. MATERIALS AND METHODS: We identified 1,720 patients 18 to 79 years old who were treated with partial or radical nephrectomy for renal cell carcinoma between 1989 and 2005. Patients were grouped according to age and outcome analysis was performed. RESULTS: Of the 1,720 patients with renal cell carcinoma 89 (5%), 672 (39%) and 959 (56%) were younger than 40, 40 to 59 and 60 to 79 years old, respectively. There were no significant differences in sex, tumor size, TNM stage or multifocality by age group. However, patients younger than 40 years were significantly more likely to present with symptomatic tumors (p = 0.028). Additionally, there were significant differences in histology by age (p <0.001), that is chromophobe histology decreased while papillary histology increased with age. Despite similar tumor sizes in each age group the percent of patients treated with partial nephrectomy decreased with age. Of patients younger than 40 years 49% were treated with partial nephrectomy compared with 35% and 30% of those 40 to 59 and 60 to 79 years old, respectively (p <0.001). At a median followup of 2.6 years (range 0 to 14.5) we did not observe a significant difference in cancer specific survival according to age (p = 0.17). CONCLUSIONS: Younger patients with renal cell carcinoma are more likely to have symptomatic tumors with chromophobe histology, although the prognosis appears similar across age groups. Older patients are more likely to be treated with radical nephrectomy, which requires careful scrutiny for current clinical practice.