Practice patterns and outcomes of urgent versus elective ureteroscopy in a statewide surgical collaborative.

PURPOSE: Urgent indications for nephrolithiasis treatment include obstruction with intractable pain or renal impairment without untreated infection. Patients and hospitals may benefit from urgent primary ureteroscopy. We aimed to examine variation in urgent ureteroscopy utilization and associated outcomes. METHODS: Using Reducing Operative Complications from Kidney Stones (ROCKS), we identified all ureteroscopy's between 2016 and 2019. Cases were classified by acuity (elective versus urgent). We assessed practice/urologist variation in urgent ureteroscopy performance. We characterized patients demographic, operative and outcomes data, making bivariate comparisons with elective ureteroscopy to understand implications of urgent surgery. We performed multilevel modeling to understand factors associated with unplanned healthcare encounters after urgent ureteroscopy. RESULTS: 12,859 cases were identified from 33 practices and 204 urologists, 10,854 (84.4%) elective and 2005 (15.6%) urgent. Urgent ureteroscopy was performed on younger patients (53 vs 57, p < 0.001), with higher rates of ureteral stones (72.8% vs 56.8%, p < 0.001). Urgent ureteroscopy rates varied widely by practice (2-70%) and urologist (0-98%). Urgent ureteroscopy had higher stenting rates (77.4% vs 72.5%, p < 0.001), stone free rates (66% vs 58.4%, p < 0.001), and postoperative ED visits (11% vs 7.2%, p < 0.001). There were no differences in intraoperative complications or unplanned hospitalizations. Factors predictive of ED visits in urgent ureteroscopy included concomitant ureteral/renal stone location (OR = 1.53, CI = 1.05-2.23, p = 0.035). CONCLUSIONS: In Michigan elective ureteroscopy is performed 5 times more frequently than urgent ureteroscopy with wide variation. Urgent ureteroscopy demonstrated low morbidity. Urgent ureteroscopy produced modestly higher stone free rates with a slightly increased frequency of unscheduled ED visits particularly for ureteral stones.

Ureteral Stent Placement following Ureteroscopy Increases Emergency Department Visits in a Statewide Surgical Collaborative.

PURPOSE: Ureteral stents are commonly placed after ureteroscopy. Although studies indicate that stents are associated with patient discomfort, their impact on downstream health services use is unclear. We examined patterns of stent utilization in Michigan and their association with unplanned health care encounters. MATERIALS AND METHODS: We used the Michigan Urological Surgery Improvement Collaborative's Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) clinical registry to identify ureteroscopy cases between 2016 and 2019. Factors associated with stent placement were examined using bivariate and multivariable statistics. Using multivariable logistic regression, we evaluated whether stent placement was associated with emergency department visits and hospitalizations within 30 days. RESULTS: We identified 9,662 ureteroscopies and a stent was placed in 7,025 (73%) of these. Frequency of stent use across the 137 urologists varied (11%-100%, p <0.001) and was not associated with total case volume. Factors associated with stent use included age and stone size. Pre-stented cases and renal stones had a decreased odds of stent placement. On multivariable analysis after adjusting for risk factors, stent placement was associated with a 1.25 higher odds of emergency department visit (OR 1.25, 95% CI 1.01-1.54, p=0.043) but not hospitalization (OR 1.28, 95% CI 0.94-1.76, p=0.12). In a single high volume practice, 0.5% of cases that omitted a stent required urgent stenting postoperatively. CONCLUSIONS: There is substantial variation in the use of stents in Michigan, irrespective of case volume. Stent placement significantly increased the odds of an emergency department visit after surgery. Importantly, stent omission rarely required subsequent urgent stent placement.

Use of medications or devices for erectile dysfunction among long-term prostate cancer treatment survivors: potential influence of sexual motivation and/or indifference.

OBJECTIVES: To evaluate the potential association between sexual motivation and patterns of erectile dysfunction (ED) therapy among a large cohort of localized prostate cancer treatment survivors. METHODS: The use of medications and devices to improve erections and sexual health-related quality of life (HRQOL) were evaluated using a mailed Expanded Prostate Cancer Index Composite survey administered to 896 men 4 to 8 years after brachytherapy, three-dimensional conformal external beam radiotherapy (3D-CRT), or radical prostatectomy and 112 control men. The responding participants (73% of those surveyed) were classified by prostate cancer treatment, sexual motivation, and ED therapy use. Bivariate and multivariate analyses were used to identify the factors associated with ED therapy use and sexual HRQOL outcome. RESULTS: The quality of erections unassisted by medications or devices was not different among the treatment groups. Prostate cancer survivors used medications or devices for ED more commonly than did the control men (30% versus 13%; P <0.01). One half of the prostate cancer survivors with ED reported indifference regarding their ED (small to no sexual bother despite absent or poor unassisted erections). Conversely, among men who were bothered by poor erections, 48% of the brachytherapy, 61% of the 3D-CRT, and 23% of radical prostatectomy subjects had never tried commonly available medications or devices to improve their erections (P <0.01). The current use of at least one erection aid was an independent determinant of more favorable sexual HRQOL (P <0.01). CONCLUSIONS: Many men who are bothered by posttreatment ED reported never having tried medications or devices to improve their erections. The lack of ED therapy was more prevalent among patients with erectile concerns after brachytherapy or 3D-CRT than after radical prostatectomy, suggesting possible opportunities for improving sexual HRQOL among long-term survivors.

Long-term outcomes among localized prostate cancer survivors: health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy.

PURPOSE: We sought to elucidate long-term changes in health-related quality-of-life (HRQOL) outcomes by prospectively re-evaluating a well-characterized cohort of prostate cancer (PC) survivors 4 to 8 years after primary treatment. PATIENTS AND METHODS: Patients who had been evaluated previously at a median of 2.6 years after radical prostatectomy (RP), external radiation (three-dimensional conformal radiation therapy [3-D CRT]), or brachytherapy (BT) were recontacted at a median of 6.2 years after treatment. The clinical relevance of long-term HRQOL impairment among survivors was established by comparison with controls of similar age. Factors associated with HRQOL changes during this interval were evaluated. RESULTS: Of the 964 eligible men, 709 (73.5%) completed measurable questionnaires. In four domains (urinary irritative-obstructive, urinary incontinence, bowel, and sexual), significant HRQOL differences were detected for at least one of the therapy groups, compared with controls (all P < .05). During the 4-year interval, significant improvement was observed for the urinary irritative-obstructive (P < .0001) and bowel (P < .0001) domains among BT patients, whereas urinary incontinence HRQOL worsened for both the BT (P = .0017) and 3-D CRT (P = .0008) treatment groups. Overall sexual HRQOL deteriorated for the 3-D CRT cohort (P = .0017), as well as for controls (P = .0136). Among RP patients, significant HRQOL changes were not observed. CONCLUSION: During a 4-year interval from earlier to longer-term phases of PC treatment survivorship, sexual, urinary, and bowel dysfunction remain significant concerns among early-stage PC treatment survivors, compared with control men. Although postprostatectomy HRQOL remains relatively stable during this interval, disease-specific HRQOL continues to evolve among men treated with BT and 3-D CRT.