Comparison of 1-Year Health Care Costs and Use Associated With Open vs Robotic-Assisted Radical Prostatectomy.

Importance: With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer. Objective: To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP). Design, Setting, and Participants: This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020. Exposures: Type of surgical procedure: ORP vs RARP. Main Outcomes and Measures: Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use. Results: Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits. Conclusions and Relevance: Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.

Robot-Assisted Radical Prostatectomy Associated with Decreased Persistent Postoperative Opioid Use.

Introduction: Minimally invasive surgery offers reduced pain and opioid use postoperatively compared with open surgery, but large-scale comparative studies are lacking. We assessed the incidence of persistent opioid use after open and robot-assisted radical prostatectomy (RARP). Materials and Methods: We performed a retrospective claims database cohort study of opioid-naive (i.e., no opioid prescriptions 30-180 days before index surgery) adult males who underwent radical prostatectomy for prostate cancer from July 2013 to June 2017. For patients who filled a perioperative opioid prescription (30 days before to 14 days after surgery), we calculated the incidence of new persistent postoperative opioid use (≥1 prescription 90-180 days after surgery). Multivariable logistic regression was performed to investigate the association between the surgical approach, patient risk factors, and persistent opioid use. Results: Twelve thousand two hundred seventy-eight radical prostatectomy patients filled an opioid prescription perioperatively (1510 [12%] open and 10,768 [88%] robot assisted). Of these, 846 (6.9%) patients continued to fill opioid prescription(s) 90 to 180 days after surgery. Patients undergoing RARP were 35% less likely to develop new persistent opioid use compared with those undergoing open radical prostatectomy (6.5% vs 9.7%; adjusted odds ratio 0.65; 95% confidence interval 0.54, 0.79). Other independent risk factors included living in the southern, western, or north central United States; preoperative comorbidity; and tobacco use. Conclusions: Approximately 6.9% of opioid-naive patients continued to fill opioid prescriptions 90 days after radical prostatectomy. The risk of persistent opioid use was significantly lower among patients undergoing a robot-assisted vs open approach. Further efforts are needed to develop postoperative opioid prescription protocols for patients undergoing radical prostatectomy.

Primer: cognitive motor learning for teaching surgical skill--how are surgical skills taught and assessed?

As the practice of surgery evolves, the modalities by which future surgeons are trained must also develop. Traditionally, surgical trainees have learned through a mentorship model, with the majority of cognitive motor learning for surgical skill being initiated and practiced within the operating room. This, however, is no longer the ideal environment in which to acquire surgical skills and, subsequently, many surgical training programs are incorporating the use of other surgical models within their curricula. Training on simulators, ranging from low-fidelity bench models to complex, high-fidelity virtual reality models, seems to be transferable and might prove to be a crucial supplement to the traditional curriculum. Models that are reliable and valid, coupled with objective instruments that measure technical skill, might prove to be useful for evaluation. For a simulator to provide a good assessment of competency, it should either correlate to or predict the person's technical performance in the operating room. More research is, therefore, needed regarding the validity and transferability of various training models, particularly if they are to become a form of assessment for certification or licensure.

Progression to metastatic disease from a small renal cell carcinoma prospectively followed with an active surveillance protocol.

With the widespread use of abdominal imaging to evaluate other medical conditions, many renal tumours are being diagnosed at earlier stages. Older patients have experienced the most significant increase in the incidence of renal cell carcinoma (RCC). This age group frequently has significant medical comorbidities. This has led to the concept of active surveillance for select patients with renal lesions that may not affect their mortality. However, the ultimate risk of active surveillance is the potential for developing metastases. This case report presents the development of metastatic disease from a small, incidentally detected and prospectively followed RCC with asymptomatic progression.

Prevalence and prognostic factors for erectile dysfunction in renal transplant recipients.

INTRODUCTION: The purpose of this study was to determine the prevalence of erectile dysfunction (ED) at our institution in the postrenal transplant population and to compare those patients who had ED with those who did not have ED, with respect to several patient characteristics. METHODS: We conducted a cross-sectional study of male renal transplant recipients who were in attendance at the transplant clinic from April 1, 2004, to March 31, 2006. Erectile function was evaluated using the International Index of Erectile Function short form questionnaire. Patients were also screened for depression using the Beck Depression Inventory. We performed a chart review to obtain various patient characteristics. RESULTS: This study involved 55 patients. Their average age was 50 years old and the mean duration of the current transplant was 7.9 years. ED was identified in 28 of the patients (51%). More patients with ED were over age 50 years (64% v. 26%, p = 0.004). There was a higher prevalence of diabetes mellitus (39% v. 11%, p = 0.02) in patients with ED compared with those patients without ED. More patients with ED were depressed compared with those patients who did not have ED (29% v. 7%, p = 0.04). These 3 factors were significantly associated with ED and this relationship was confirmed on multivariate analysis. CONCLUSION: ED remains a common problem in the renal transplant population. The cause of ED is multifactorial, with increasing age and the presence of diabetes mellitus and depression increasing the risk of ED.

Radical nephrectomy with en bloc resection of liver, diaphragm, and lung for locally invasive sarcomatoid renal cell carcinoma.

Despite the widespread use of abdominal imaging, some patients with renal cell carcinoma still present with advanced disease. We report 1 case of locally invasive sarcomatoid renal cell carcinoma requiring resection of the kidney, adrenal glands, liver, diaphragm, and lung, with diaphragmatic reconstruction with a polytetrafluoroethylene patch. The patient was alive and well 5 years postoperatively. However, we acknowledge that the success experienced with this case does not represent the typical outcome for a patient with such advanced disease.

Pamidronate distribution in pediatric renal and rheumatologic patients.

OBJECTIVE: To evaluate the distribution and elimination of pamidronate in a population of pediatric patients with renal and rheumatologic disease. METHODS: Pamidronate whole blood levels were collected for the first 4 h after first exposure in 7 patients. The relationship between the rate of urinary excretion of pamidronate and bone formation or resorption was examined in 18 patients while receiving pamidronate at a total dose of 1 mg/kg/dose infused intravenously over a 4-h period. The urinary pamidronate clearances were correlated with renal function, calcium levels and measures of bone formation and resorption. RESULTS: Pamidronate levels reached steady state concentrations of 0.9-1.5 microg/ml within 30 min and the clearance of the drug (mean+/-SE) from blood was 180.0+/-64.2 ml/kg/h with an elimination half-life of less than 1 h. The mean urinary excretion of 31.5+/-2.2% of the administered dose indicated that about 68% of the drug was incorporated into bone, confirming the uptake of pamidronate into bone was similar in pediatric patients compared to that previously reported for adults. Bone specific alkaline phosphatase, which is a marker for bone growth and formation, had significant correlation with the uptake of pamidronate into bone (p=0.002). No correlation was demonstrated with a marker for bone resorption (urinary N-telopeptide/creatinine ratio), or with creatinine clearance or calciuria when assessed 2 months after treatment. CONCLUSION: Pamidronate at a dose of 1 mg/kg/dose every 2 months appears safe in the short term for pediatric patients, achieves relatively low whole blood pamidronate levels, and has similar skeletal uptake of pamidronate compared to adults.

Sarcoid of the testis.

Sarcoidosis is a chronic disease that rarely manifests in the male reproductive tract. Due to its infrequent nature, treatment for sarcoid of the male reproductive tract is controversial. We report a case of incidentally discovered sarcoid of the testis in a white male managed with a testis sparing approach.

Primary malignant melanoma of the prostate: case report and review of the literature.

Primary malignant melanoma of the prostate is very rare. Most cases attributed to the prostate actually originate from the prostatic urethra. Due to its infrequency, primary malignant melanoma of the genitourinary tract presents a difficult diagnostic and management challenge. We report a case of primary malignant melanoma of the prostate found incidentally following transurethral resection of the prostate (TURP).

Pamidronate treatment of pediatric fracture patients on chronic steroid therapy.

Pediatric nephrology and rheumatology patients with steroid-induced osteopenia are at risk of skeletal fracture. Bisphosphonate therapy has not been routinely advocated as a primary or secondary intervention for steroid-associated fractures in this population. This case control study evaluates the role of pamidronate therapy as a secondary fracture intervention. Children with symptomatic pathological fractures of the axial spine or ribs were treated with pamidronate 1 mg/kg/dose (n=17) IV at 60-day intervals for 1 yr (n=15) or 2 yr (n=2). Bone mineral density of L1-L4 (BMD) was assessed prior to treatment and at six-month intervals, and compared to 17 disease-age-gender-steroid dose-matched control patients. Alkaline phosphatase, calcium, phosphate, PTH, renal biochemistry, and 24-hr urine collections for CrCl, N-telopeptide/creatinine ratio, phosphate excretion, and calcium excretion were obtained every two months in the pamidronate population. Pamidronate caused a first exposure transient flu-like illness lasting <24 h in three patients and one patient had a new pathological fracture. No adverse events of hypocalcemia, allergic reaction or thrombophlebitis were noted. All patients reported improvement of skeletal pain. Despite ongoing steroid treatment, pamidronate significantly increased L1-L4 BMD Z-scores (mean+/-SE) relative to baseline (pamidronate vs control: 0-6 months: 0.27+/-0.14 vs -0.82+/-0.31; 0-12 months: 0.63+/-0.17 vs -0.46+/-0.27; 0-18 months: 0.55+/-0.32 vs 0.17+/-0.27; 0-24 months: 0.15+/-0.21 vs -0.23+/-0.22; 0-30 or 36 months: 0.77+/-0.71 vs -0.68+/-0.25) with repeated measures ANOVA assessment (F=11.27, p=0.0057). This study supports the safety and efficacy of pamidronate in steroid-induced fractures in pediatric nephrology and rheumatology patients.

Determination of pamidronate in human whole blood and urine by reversed-phase HPLC with fluorescence detection.

Pamidronate is a bisphosphonate that is effective in treating bone disease including osteopenia and osteoporosis in adults. A sensitive and reliable method for the analysis of pamidronate in whole blood and urine is key to the development of this drug for use in children. A previously described method for pamidronate analysis serum and urine did not consistently detect the drug at satisfactory levels in whole blood. The procedure involves co-precipitation of the bisphosphonates with calcium phosphate, pre-column derivitization with fluorescamine, HPLC utilizing a Nucleosil C(18) column, and fluorescence detection with excitation at 395 nm and emission at 480 nm. Changes to the original protocol included the use of a new internal standard (alendronate), the optimization of the concentration of ethylenediaminetetraacetic acid (EDTA) for dissolving the precipitate, and the elimination of the acidification step prior to deproteinization. The optimum EDTA concentration, which had a significant effect on the labeling capability of fluorescamine, was determined to be 20 mm.A good separation between pamidronate and alendronate was achieved using a heated (40 degrees C ) Nucleosil C(18), 10 micro m particle size column. The mobile phase was an aqueous solution of 1 mm Na(2)EDTA-methanol (97:3, v/v) adjusted to pH 6.5 using a fl ow-rate of 1 mL/min. Fluorescence detection was set at 395 nm for excitation and at 480 nm for emission. The limit of quantitation for pamidronate was 0.5 micro g/mL in whole blood and 0.1 micro g/mL in urine. The method was applied to both whole blood and urine samples from pediatric patients.