Outcomes and peri-operative complications of robotic pyelolithotomy.

Standard of care for large or complex renal stones is percutaneous nephrolithotomy. Robotic pyelolithotomy, however, may be a feasible alternative, but limited data exist on its outcomes and complications. Our study objective was to describe the outcomes and peri-operative complications of robotic pyelolithotomy for complex renal calculi. We performed a retrospective analysis of robotic pyelolithotomy at our tertiary academic institution from 2015 to 2018. Demographics, stone clearance rates, complications, estimated blood loss, operative time, and length of stay were reported. 15 patients were included with a median age of 59 years (SD 15.3, 27-80) and BMI 25 kg/m2 (SD 4.6, 20.9-35.7). Median follow-up was 4 months. Median stone size was 3 cm (SD 1.2 cm, 2-5 cm). Concomitant pyeloplasty was performed in 2 patients, complete stone clearance in 11 (73%) cases and 4 out of 5 (80%) with a solitary stone. Median operative time was 191.5 min (SD 64.8 min, 110-303 min), with no open conversion. Median EBL was 70 ml (SD 65 ml, 20-250 ml) and median length of stay was 1 day (SD 1 day, 1-5 days). Median change in creatinine and eGFR were - 0.02 mg/dl and + 3 ml/min/1.73 m2. There were no cases of sepsis or post-operative fever and only one case of transfusion. Robotic pyelolithotomy appears safe and effective. Ultimately, less bleeding, lower septicemia, renal parenchymal preservation, and favorable stone-free rates in a single procedure make this as an attractive option in the management of select patients with large renal stone disease.

Racial and Socioeconomic Disparities in Bladder Cancer Survival: Analysis of the California Cancer Registry.

PURPOSE: To examine the California Cancer Registry (CCR) for bladder cancer survival disparities based on race, socioeconomic status (SES), and insurance in California patients. PATIENTS AND METHODS: The CCR was queried for bladder cancer cases in California from 1988 to 2012. The primary outcome was disease-specific survival (DSS), defined as the time interval from date of diagnosis to date of death from bladder cancer. Survival analyses were performed to determine the prognostic significance of racial and socioeconomic factors. RESULTS: A total of 72,452 cases were included (74.5% men, 25.5% women). The median age was 72 years (range, 18-109 years). The racial distribution among the patients was 81% white, 3.8% black, 8.8% Hispanic, 5.2% Asian, and 1.2% from other races. In black patients, tumors presented more frequently with advanced stage and high grade. Medicaid patients tended to be younger and had more advanced-stage, higher-grade tumors compared to patients with Medicare or managed care (P < .0001). Kaplan-Meier analysis demonstrated significantly poorer 5-year DSS in black, low SES, and Medicaid patients (P < .0001). When controlling for stage, grade, age, and gender, multivariate analysis revealed that black race (DSS hazard ratio = 1.295; 95% confidence interval, 1.212-1.384), low SES (DSS hazard ratio = 1.325; 95% confidence interval, 1.259-1.395), and Medicaid insurance (DSS hazard ratio = 1.349; 95% confidence interval, 1.246-1.460) were independent prognostic factors (P < .0001). CONCLUSION: An analysis of the CCR demonstrated that black race, low SES, and Medicaid insurance portend poorer DSS. These findings reflect a multifaceted socioeconomic and public health conundrum, and efforts to reduce inequalities should be pursued.

Tracking and assessment of technical skills acquisition among urology residents for open, laparoscopic, and robotic skills over 4 years: is there a trend?

BACKGROUND AND PURPOSE: Tracking the progression of technical skill acquisition during urology residency training is an essential yet challenging task that has been mostly based on anecdotal and subjective performance assessment. We evaluated five surgical tasks used at our institution to assess skill acquisition among residents over 4 consecutive years in an effort to determine appropriate skill testing for resident proficiency relative to level of training for future performance testing. METHODS: Urology residents were tested yearly throughout the course of their residency with five surgical tasks in an open, laparoscopic, and robotic format. The five tasks were: (1) rings on a peg, (2) thread the rings, (3) cut the line, (4) hexagonal suturing, and (5) suture and knot tying. Evaluation was performed by a trained instructor to assess quantity and quality of the skill task performance. RESULTS: The highest scores were obtained on all open tasks regardless of training level. Residents performed second best on robotic and lowest on the laparoscopic skill tasks. The score difference among surgery platforms was statistically significant P<0.0005 across all tasks. It was Tasks 2 and 5, however, that showed a statistically significant difference in overall quantity×quality score between different postgraduate year (PGY) residents (P=0.03 and P=0.02). In addition, the quantity score for Task 5 also showed a statistically significant difference among PGY residents (P=0.04). There was no statistically significant difference in time to perform tasks among PG years. CONCLUSIONS: The high-level Tasks 2 and 5 were the most useful in differentiating different levels of skill task competency among urology residents and appear to be most useful in assessing the degree of improvement among residents during training. These tasks have subsequently been worked into our institution's testing curriculum.