Predictive factors for prolonged hospital stay after retropubic radical prostatectomy in a high-volume teaching center

ABSTRACT Objective: To evaluate the length hospital stay and predictors of prolonged hospitalization after RRP performed in a high-surgical volume teaching institution, and analyze the rate of unplanned visits to the office, emergency care, hospital readmissions and perioperative complications rates. Materials and Methods: Retrospective analysis of prospectively collected data in a standardized database for patients with localized prostate cancer undergoing RRP in our institution between January/2010 - January/2012. A logistic regression model including preoperative variables was initially built in order to determine the factors that predict prolonged hospital stay before the surgical procedure; subsequently, a second model including both pre and intraoperative variables was analyzed. Results: 1011 patients underwent RRP at our institution were evaluated. The median hospital stay was 2 days, and 217 (21.5%) patients had prolonged hospitalization. Predictors of prolonged hospital stay among the preoperative variables were ICC (OR. 1.40 p=0.003), age (OR 1.050 p<0.001), ASA score of 3 (OR. 3.260 p<0.001), prostate volume on USG-TR (OR, 1.005 p=0.038) and African-American race (OR 2.235 p=0.004); among intra and postoperative factors, operative time (OR 1.007 p=0.022) and the presence of any complications (OR 2.013 p=0.009) or major complications (OR 2.357 p=0.01) were also correlated independently with prolonged hospital stay. The complication rate was 14.5%. Conclusions: The independent predictors of prolonged hospitalization among preoperative variables were CCI, age, ASA score of 3, prostate volume on USG-TR and African-American race; amongst intra and postoperative factors, operative time, presence of any complications and major complications were correlated independently with prolonged hospital stay.

Predictive factors for prolonged hospital stay after retropubic radical prostatectomy in a high-volume teaching center.

OBJECTIVE: To evaluate the length hospital stay and predictors of prolonged hospitalization after RRP performed in a high-surgical volume teaching institution, and analyze the rate of unplanned visits to the office, emergency care, hospital readmissions and perioperative complications rates. MATERIALS AND METHODS: Retrospective analysis of prospectively collected data in a standardized database for patients with localized prostate cancer undergoing RRP in our institution between January/2010 - January/2012. A logistic regression model including preoperative variables was initially built in order to determine the factors that predict prolonged hospital stay before the surgical procedure; subsequently, a second model including both pre and intraoperative variables was analyzed. RESULTS: 1011 patients underwent RRP at our institution were evaluated. The median hospital stay was 2 days, and 217 (21.5%) patients had prolonged hospitalization. Predictors of prolonged hospital stay among the preoperative variables were ICC (OR. 1.40 p=0.003), age (OR 1.050 p<0.001), ASA score of 3 (OR. 3.260 p<0.001), prostate volume on USG-TR (OR, 1.005 p=0.038) and African-American race (OR 2.235 p=0.004); among intra and postoperative factors, operative time (OR 1.007 p=0.022) and the presence of any complications (OR 2.013 p=0.009) or major complications (OR 2.357 p=0.01) were also correlated independently with prolonged hospital stay. The complication rate was 14.5%. CONCLUSIONS: The independent predictors of prolonged hospitalization among preoperative variables were CCI, age, ASA score of 3, prostate volume on USG-TR and African-American race; amongst intra and postoperative factors, operative time, presence of any complications and major complications were correlated independently with prolonged hospital stay.

Ureteroileal bypass: a new technic to treat ureteroenteric strictures in urinary diversion

ABSTRACT Objective: To present our technique of ureteroileal bypass to treat uretero-enteric stric- tures in urinary diversion. Materials and Methods: One hundred and forty-one medical records were reviewed from patients submitted to radical cystectomy to treat muscle-invasive bladder cancer between 2013 and 2015. Twelve (8.5%) patients developed uretero-enteric anastomotic stricture during follow-up. Five patients were treated with endoscopic dilatation and double J placement. Four were treated surgically with standard terminal-lateral im- plantation. Three patients with uretero-enteric anastomotic stricture were treated at our institution by "ureteroileal bypass", one of them was treated with robotic surgery. Results: All patients had the diagnosis of uretero-enteric anastomotic stricture via computerized tomography and DTPA renal scan. Time between cystectomy and diag- nosis of uretero-enteric anastomotic stricture varied from five months to three years. Mean operative time was 120±17.9 minutes (98 to 142 min) and hospital stay was 3.3±0.62 days (3 to 4 days). Mean follow-up was 24±39.5 months (6 to 72 months). During follow-up, all patients were asymptomatic and presented improvement in ure-terohydronephrosis. Serum creatinine of all patients had been stable. Conclusions: Latero-lateral ureter re-implantation is feasible by open or even robotic surgery with positive results, reasonable operation time, and without complications.

Ureteroileal bypass: a new technic to treat ureteroenteric strictures in urinary diversion.

OBJECTIVE: To present our technique of ureteroileal bypass to treat uretero-enteric strictures in urinary diversion. MATERIALS AND METHODS: One hundred and forty-one medical records were reviewed from patients submitted to radical cystectomy to treat muscle-invasive bladder cancer between 2013 and 2015. Twelve (8.5%) patients developed uretero-enteric anastomotic stricture during follow-up. Five patients were treated with endoscopic dilatation and double J placement. Four were treated surgically with standard terminal-lateral implantation. Three patients with uretero-enteric anastomotic stricture were treated at our institution by "ureteroileal bypass", one of them was treated with robotic surgery. RESULTS: All patients had the diagnosis of uretero-enteric anastomotic stricture via computerized tomography and DTPA renal scan. Time between cystectomy and diagnosis of uretero-enteric anastomotic stricture varied from five months to three years. Mean operative time was 120±17.9 minutes (98 to 142 min) and hospital stay was 3.3±0.62 days (3 to 4 days). Mean follow-up was 24±39.5 months (6 to 72 months). During follow-up, all patients were asymptomatic and presented improvement in ureterohydronephrosis. Serum creatinine of all patients had been stable. CONCLUSIONS: Latero-lateral ureter re-implantation is feasible by open or even robotic surgery with positive results, reasonable operation time, and without complications.

Low serum testosterone is a predictor of high-grade disease in patients with prostate cancer.

OBJECTIVE: To evaluate the relation between serum total testosterone (TT) and prostate cancer (PCa) grade and the effect of race and demographic characteristics on such association. METHOD: We analyzed 695 patients undergoing radical prostatectomy (RP), of whom 423 had serum TT collected. Patients were classified as having hypogonadism or eugonadism based on two thresholds of testosterone: threshold 1 (300 ng/dL) and threshold 2 (250 ng/dL). We evaluated the relation between TT levels and a Gleason score (GS) ≥ 7 in RP specimens. Outcomes were evaluated using univariate and multivariate analyses, accounting for race and other demographic predictors. RESULTS: Out of 423 patients, 37.8% had hypogonadism based on the threshold 1 and 23.9% based on the threshold 2. Patients with hypogonadism, in both thresholds, had a higher chance of GS ≥ 7 (OR 1.79, p=0.02 and OR 2.08, p=0.012, respectively). In the multivariate analysis, adjusted for age, TT, body mass index (BMI) and race, low TT (p=0.023) and age (p=0.002) were found to be independent risk factors for GS ≥ 7. Among Black individuals, low serum TT was a stronger predictor of high-grade disease compared to White men (p=0.02). CONCLUSION: Hypogonadism is independently associated to higher GS in localized PCa. The effect of this association is significantly more pronounced among Black men and could partly explain aggressive characteristics of PCa found in this race.

Low serum testosterone is a predictor of high-grade disease in patients with prostate cancer / Baixa testosterona sérica é prognóstica de doença de alto grau em pacientes com câncer de próstata

Summary Objective: To evaluate the relation between serum total testosterone (TT) and prostate cancer (PCa) grade and the effect of race and demographic characteristics on such association. Method: We analyzed 695 patients undergoing radical prostatectomy (RP), of whom 423 had serum TT collected. Patients were classified as having hypogonadism or eugonadism based on two thresholds of testosterone: threshold 1 (300 ng/dL) and threshold 2 (250 ng/dL). We evaluated the relation between TT levels and a Gleason score (GS) ≥ 7 in RP specimens. Outcomes were evaluated using univariate and multivariate analyses, accounting for race and other demographic predictors. Results: Out of 423 patients, 37.8% had hypogonadism based on the threshold 1 and 23.9% based on the threshold 2. Patients with hypogonadism, in both thresholds, had a higher chance of GS ≥ 7 (OR 1.79, p=0.02 and OR 2.08, p=0.012, respectively). In the multivariate analysis, adjusted for age, TT, body mass index (BMI) and race, low TT (p=0.023) and age (p=0.002) were found to be independent risk factors for GS ≥ 7. Among Black individuals, low serum TT was a stronger predictor of high-grade disease compared to White men (p=0.02). Conclusion: Hypogonadism is independently associated to higher GS in localized PCa. The effect of this association is significantly more pronounced among Black men and could partly explain aggressive characteristics of PCa found in this race.

Resumo Objetivo: Avaliar a relação entre testosterona sérica total (TT) e grau do câncer de próstata (CP) e o efeito da raça e de características demográficas sobre essa associação. Método: Foram analisados 695 pacientes submetidos a prostatectomia radical (PR), dos quais 423 tinham medidas dos níveis séricos de TT. Os pacientes foram classificados como portadores de hipogonadismo ou eugonadismo com base em dois limites de testosterona: limite 1 (300 ng/dL) e limite 2 (250 ng/dL). Avaliou-se a relação entre nível de TT e escore Gleason (GS) ≥ 7 em amostras de PR. Os resultados foram avaliados por análises univariada e multivariada, com ajuste para raça e outros fatores prognósticos demográficos. Resultados: Do total de 423 pacientes, 37,8% apresentavam hipogonadismo com base no limite 1, e 23,9% com base no limite 2. Os pacientes com hipogonadismo, independentemente do limite de referência, tiveram uma chance maior de GS ≥ 7 (OR 1,79, p=0,02 e OR 2,08, p=0,012, respectivamente). Na análise multivariada, após ajuste para idade, TT, índice de massa corporal (IMC) e raça, baixo TT (p=0,023) e idade (p=0,002) foram considerados fatores de risco independentes para GS ≥ 7. Entre os indivíduos negros, baixo TT sérico foi mais preditivo de doença de alto grau em comparação com os brancos (p=0,02). Conclusão: O hipogonadismo é independentemente associado a escores mais altos de GS no CP localizado. O efeito dessa associação é significativamente mais pronunciado entre homens negros, o que poderia explicar, em parte, as características agressivas do CP observadas nessa população.

Malignant paraganglioma in children treated with embolization prior to surgical excision.

BACKGROUND: Paragangliomas (PGL) are rare tumors derived from neural crest cells, whose origins may vary along the chain of the sympathetic nervous system. Such tumors are often characterized by secretion of catecholamines, but sometimes they are biochemically inactive, which makes diagnosis often challenging. Malignant paraganglioma is defined by the presence of this tumor at sites where chromaffin cells are usually not found or by local invasion of the primary tumor. Recurrence, either regional or metastatic, usually occurs within 5 years of the initial complete resection but long-term recurrence is also described. Malignancy is often linked to a SDHB mutation. Preoperative embolization has been applied in the surgical management of PGLs with the objective to decrease intra-operative blood loss and surgery length without complications. CASE PRESENTATION: We report two cases of patients with abdominal or pelvic malignant PGLs who have been treated surgically at our center after preoperative embolization. Surgery was a very challenging procedure with multiple surgical teams involved and embolization did not prevent major blood loss and intraoperative complications. Patients required adjuvant treatment with either chemotherapy or radiotherapy. CONCLUSIONS: Many studies in the adult population have established recommendations for the diagnosis and therapeutic management of PGL, but few studies concern the pediatric population. Because malignant PGL is more important in the pediatric population, screening and early diagnosis of PGL is advisable in children with genetic predisposing. Surgical resection is the mainstay of treatment, but a multimodal approach is often required due to the complexity of cases.  The role of preoperative embolization is not established and in our experience it has provided little benefit and major complications.

Outcomes of surgical treatment of ureteral strictures after laser ureterolithotripsy for impacted stones.

INTRODUCTION: To evaluate the outcomes of ureteral strictures treatment after endoureterotomy using the holmium laser or open/laparoscopic surgery. MATERIAL AND METHODS: From a database of 1101 patients that underwent semi-rigid holmium laser ureterolithotripsy from 2003 to 2013, we performed a search for patients treated for ureteral stricture. Parameters analyzed included patient demographic, stone burden, and ureteral stricture characteristics. Treatment included holmium laser endoureterotomy for stenosis ≤ 1 cm and open/laparoscopic repair for stenosis > 1 cm or for failed endoscopic treatment. Outcomes and complications were assessed. Success was defined as symptom improvement and radiographic obstruction resolution. RESULTS: Of all the patients, 32 (2.8%) evolved with ureteral stenosis and all had impacted calculi at the time of surgery. Twenty-two patients with complete follow up were studied. After a mean follow up of 18.5 months (range 3-70), the success rates for endoureterotomy and open/laparoscopic stricture repair group were 50% and 82%, respectively. The hospitalization period was significantly shorter for patients who had undergone endoureterotomy (2.7 +/- 1.4 days versus 4.8 +/- 1.4 days; p = 0.003). Only minor complications occurred in both groups. CONCLUSION: The rate of ureteral stricture after holmium laser ureterolithotripsy for impacted calculi is higher than reported for non-impacted stones. Holmium laser endoureterotomy for stenosis shorter than 1 cm treated half of the cases. Open/laparoscopic repair had good outcomes in cases of longer stenosis.

Percutaneous nephrolithotomy in patients with solitary kidney: a critical outcome analysis.

PURPOSE: To describe our experience with percutaneous nephrolithotomy (PCNL) in patients with solitary kidneys and analyze factors that can impact on intra-operative bleeding and postoperative complications. MATERIALS AND METHODS: We reviewed our stone database searching for patients with solitary kidney who underwent PCNL from Jan-05 through Oct-13. Demographic data, stone characteristics, and intra- and postoperative outcomes were recorded. Spearman correlation was performed to assess which variables could impact on bleeding and surgical complications. Linear and logistic regressions were also performed. RESULTS: Twenty-seven patients were enrolled in this study. The mean age and BMI were 45.6 years and 28.8Kg/m(2), respectively; 45% of cases were classified as Guys 3 (partial staghorn or multiple stones) or 4 (complete staghorn) - complex cases. Stone-free rate was 67%. Eight (29.6%) patients had postoperative complications (five of them were Clavien 2 and three were Clavien 3). On univariate analysis only number of tracts was associated with increased bleeding (p=0.033) and only operative time was associated with a higher complication rate (p=0.044). Linear regression confirmed number of access tracts as significantly related to bleeding (6.3, 95%CI 2.2-10.4; p=0.005), whereas logistic regression showed no correlation between variables in study and complications. CONCLUSIONS: PCNL in solitary kidneys provides a good stone-free rate with a low rate of significant complications. Multiple access tracts are associated with increased bleeding.

Percutaneous nephrolithotomy in patients with solitary kidney: a critical outcome analysis

To describe our experience with percutaneous nephrolithotomy (PCNL) in patients with solitary kidneys and analyze factors that can impact on intra-operative bleeding and postoperative complications.

Peripyelitis: A risk factor for urinary fistula after tubeless PCNL.

A 43 years-old man presented to our stone clinic complaining of back pain for the last 3 months. He had significant past medical history for nephrolithiasis: he had undergone unsuccessful SWL for left renal calculi five years ago and also presented with several episodes of pyelonephritis in the last months, requiring hospitalization for intravenous antibiotics. Initial laboratory work-up revealed normal serum creatinine (0.92 mg/dL) and hemoglobin levels (15.3 g/dL); urine culture was negative. Abdominal computed tomography (CT) revealed a 140 mm2 stone in the left renal pelvis with 1500 Hounsfield Units (Figure-1a); thickening of the urothelium surrounding the stone was suspected after contrast infusion (Figure-1b) and confirmed in the excretory phase (Figure-1c).

Monti's principle in the treatment of congenital uterovesical fistula.

Congenital uterovesical fistula is rare and generally associated with genital tract abnormalities derived from mullerian ducts or urogenital sinus. Management is usually challenging, and it involves vaginal reconstruction. A 15-year-old female patient presented with a 2-year history of cyclical hematuria. Investigation revealed a bicornuate uterus and complete vaginal agenesis associated with congenital uterovesical fistula. The fistula was repaired, and a neovagina was created using Monti's technique. Postoperative recovery was uneventful with normal voiding and initiation of regular menstruation through the neovagina. We discuss the options of vaginal reconstruction and stress the advantages of the technique used in this case.

Long-term Treatment Outcomes Between Surgical Correction and Conservative Management for Penile Fracture: Retrospective Analysis.

PURPOSE: Early surgical management is the standard of care for penile fracture. Conservative treatment is an option with recent reports revealing lower success rates. We reviewed the data and long-term outcomes of patients with penile injury submitted to surgical or conservative treatment. MATERIALS AND METHODS: Between January 2004 and February 2012, 42 patients with penile blunt trauma on an erect penis were admitted to our center. We analyzed the following variables: age, etiology, symptoms and signs, diagnostic tests, treatment used, complications and erectile function during the follow-up. One patient was excluded due to missing information. Thirty-five patients underwent surgical repair and 6 patients were submitted to conservative management. RESULTS: Mean follow-up was 19.2 months (range, 7 days to 72 months). The mean elapsed time from trauma to surgery was 21.3±12.5 hours. Trauma during sexual relationship was the main cause (80.9%) of penile fracture. Urethral injury was present in five patients submitted to surgery. Dorsal vein injury occurred in three patients with false penile fracture and concomitant spongious corpus lesion was present in three patients. During follow-up, 31 cases (88.6%) of the surgical group and four cases (66.7%) of the conservative group reported sufficient erections for intercourse, with no voiding dysfunction and no penile curvature. However, the remaining two patients (33.3%) from the conservative group developed erectile dysfunction and three patients (50%) developed penile deviation. CONCLUSIONS: Surgical approach provides excellent functional outcomes and lower complications. Early surgical management of penile fracture provides superior results and conservative approach should be avoided.

Bladder autoaugmentation in dogs: assessment of different laparoscopic methods.

PURPOSE: Bladder autoaugmentation was described in 1989, and the effectiveness of this surgical technique in the management of neurogenic bladder dysfunctions is still debated. Few experimental studies with different animals and diverse changes in technique have been described, making comparison of studies difficult. The aim of this study was to assess laparoscopic bladder autoaugmentation in dogs, allowing future studies to be developed using a uniform surgical technique and the results to be compared. MATERIALS AND METHODS: Seven male mongrel dogs weighing from 15 to 20 kg under general anesthesia underwent urodynamic evaluation. Laparoscopic bladder autoaugmentation was then attempted either with or without the use of the intravesical silicone balloon. RESULTS: The reproduction of the open technique caused complications. Changing the method of dissection was essential for completing the surgery. As different limitations appeared solutions were found as well. The use of the intravesical balloon requires the surgery to be different, although quite similar. CONCLUSIONS: Laparoscopic bladder autoaugmentation is feasible in the canine model with and without the intravesical silicone balloon. The best way to perform the surgery was identified for both methods. Future studies can be developed using a uniform surgical technique, and the functional results will be comparable.