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1.
Urology ; 116: 130, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29703531
2.
Urology ; 116: 125-130, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29545042

RESUMO

OBJECTIVE: To determine whether an enhance recovery protocol for radical cystectomy patient affected the length of stay or the number and type of readmissions that occurred after hospital discharge. MATERIALS AND METHODS: We prospectively assessed 152 cystectomy patients after initiation of the pathway. These patients were compared with the previous 147 patient operated on before the pathway initiation. Eligible patients were those undergoing radical cystectomy with any diversion at our institution. Univariate tests were performed using Wilcoxon sum-rank and chi-square tests. Multivariate analyses were performed using logistic regression models to assess for patient factors related to readmissions. RESULTS: With institution of the pathway, length of stay decreased from 10 to 7.1 days. Our readmission rates did not change significantly. Patients were readmitted for different reasons after pathway implementation, with the rate of urinary tract infection-related readmissions increasing from 14.3% to 40.4%, but with a concomitant decrease in the rate of readmissions for wound and deep space infections from 42.9% to 23.4%. Our venous thromboembolism rate decreased from 6.8% to 3.3% with implementation of the protocol. CONCLUSION: Implementation of a cystectomy care pathway significantly decreased length of stay without an increased rate of readmissions at 30 days. No patient factors predisposed to an increased rate of readmission. Pathway implementation led to a decrease in wound and deep space infection readmissions, but was associated with an increase in urinary tract infection readmissions. Further studies are examining if early intervention can further decrease readmission rates.


Assuntos
Cistectomia/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/epidemiologia , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Cistectomia/métodos , Humanos , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Fatores de Tempo , Infecções Urinárias/epidemiologia , Infecções Urinárias/etiologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia
3.
Asian J Urol ; 5(1): 28-32, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29379733

RESUMO

Benign prostatic hyperplasia (BPH) is characterized by an enlarged prostate, lower urinary tract symptoms (LUTS), and a decreased urinary flow rate. Common in older men, BPH is a progressive disease that can eventually lead to complications including acute urinary retention (AUR) and the need for BPH-related surgery. Both normal and abnormal prostate growth is driven by the androgen dihydrotestosterone (DHT), which is formed from testosterone under the influence of 5-alpha reductase. Thus, 5-alpha reductase inhibitors (5-ARIs) effectively reduce the serum and intraprostatic concentration of DHT, causing an involution of prostate tissue. Two 5-ARIs are currently available for the treatment of BPH-finasteride and dutasteride. Both have been demonstrated to decrease prostate volume, improve LUTS and urinary flow rates, which ultimately reduces the risk of AUR and BPH-related surgery. Therefore, either alone or in combination with other BPH medications, 5-ARIs are a mainstay of BPH management.

4.
Int Braz J Urol ; 42(3): 464-71, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27286108

RESUMO

INTRODUCTION: The use of multi-parametric (MP) MRI to diagnose prostate cancer has been the subject of intense research, with many studies showing positive results. The purpose of our study is to better understand the accessibility, role, and perceived accuracy of MP-MRI in practice by surveying practicing urologists. MATERIALS AND METHODS: Surveys were sent to 7,400 practicing American Urological Association member physicians with a current email address. The survey asked demographic information and addressed access, accuracy, cost, and role of prostate MRI in clinical practice. RESULTS: Our survey elicited 276 responses. Respondents felt that limited access and prohibitive cost of MP-MRI limits its use, 72% and 59% respectively. Academic urologists ordered more MP-MRI studies per year than those in private practice (43.3% vs. 21.1%; p<0.001). Urologists who performed more than 30 prostatectomies a year were more likely to feel that an MP-MRI would change their surgical approach (37.5% vs. 19.6%, p-value=0.002). Only 25% of respondents agreed or strongly agreed that MP-MRI should be used in active surveillance. For patients with negative biopsies and elevated PSA, 39% reported MP-MRI to be very useful. CONCLUSIONS: Our study found that MP-MRI use is most prominent among practitioners who are oncology fellowship-trained, practice at academic centers, and perform more than 30 prostatectomies per year. Limited access and prohibitive cost of MP-MRI may limit its utility in practice. Additionally, study participants perceive a lack of accuracy of MP-MRI, which is contrary to the recent literature.


Assuntos
Imageamento por Ressonância Magnética , Padrões de Prática Médica/estatística & dados numéricos , Próstata/diagnóstico por imagem , Neoplasias da Próstata/diagnóstico por imagem , Urologistas/estatística & dados numéricos , Biópsia , Humanos , Imageamento por Ressonância Magnética/economia , Imageamento por Ressonância Magnética/normas , Masculino , Próstata/patologia , Prostatectomia/estatística & dados numéricos , Neoplasias da Próstata/patologia , Inquéritos e Questionários , Estados Unidos
5.
Int. braz. j. urol ; 42(3): 464-471, tab
Artigo em Inglês | LILACS | ID: lil-785732

RESUMO

ABSTRACT Introduction The use of multi-parametric (MP) MRI to diagnose prostate cancer has been the subject of intense research, with many studies showing positive results. The purpose of our study is to better understand the accessibility, role, and perceived accuracy of MP-MRI in practice by surveying practicing urologists. Materials and Methods Surveys were sent to 7,400 practicing American Urological Association member physicians with a current email address. The survey asked demographic information and addressed access, accuracy, cost, and role of prostate MRI in clinical practice. Results Our survey elicited 276 responses. Respondents felt that limited access and prohibitive cost of MP-MRI limits its use, 72% and 59% respectively. Academic urologists ordered more MP-MRI studies per year than those in private practice (43.3% vs. 21.1%; p<0.001). Urologists who performed more than 30 prostatectomies a year were more likely to feel that an MP-MRI would change their surgical approach (37.5% vs. 19.6%, p-value=0.002). Only 25% of respondents agreed or strongly agreed that MP-MRI should be used in active surveillance. For patients with negative biopsies and elevated PSA, 39% reported MP-MRI to be very useful. Conclusions Our study found that MP-MRI use is most prominent among practitioners who are oncology fellowship-trained, practice at academic centers, and perform more than 30 prostatectomies per year. Limited access and prohibitive cost of MP-MRI may limit its utility in practice. Additionally, study participants perceive a lack of accuracy of MP-MRI, which is contrary to the recent literature.


Assuntos
Humanos , Masculino , Próstata/diagnóstico por imagem , Neoplasias da Próstata/diagnóstico por imagem , Padrões de Prática Médica/estatística & dados numéricos , Imageamento por Ressonância Magnética/economia , Imageamento por Ressonância Magnética/normas , Urologistas/estatística & dados numéricos , Próstata/patologia , Prostatectomia/estatística & dados numéricos , Neoplasias da Próstata/patologia , Estados Unidos , Biópsia , Inquéritos e Questionários
6.
J Robot Surg ; 10(2): 129-34, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27039192

RESUMO

The objective of this study was to evaluate surgical outcomes with respect to the experience level of the bedside assistant during robot-assisted partial nephrectomy. A retrospective review was conducted of a prospectively maintained database of 414 consecutive robot-assisted laparoscopic partial nephrectomies performed by experienced robotic surgeons at our institution from April 2011 to September 2014. A senior-level assistant was defined as a resident in his or her post-graduate year (PGY) 4 or 5, or a fellow. Junior-level assistants were considered to be PGY-2, PGY-3, or a nurse first assistant. Multivariate analyses were performed using linear, Poisson, and logistic regression models. There were 115 junior-level cases and 299 senior-level cases. On univariate analysis, the experience level of the assistant had no impact on operative time (168 for junior level vs. 163 min for senior level, p = 0.656). Likewise, there were no differences between the junior- and senior-level groups with regard to warm ischemia time (21.3 vs. 20.9 min, p = 0.843), negative margin status (111/115 (96.5 %) vs. 280/299 (93.6 %), p = 0.340), or postoperative complications (17/115 (14.8 %) vs. 35/299 (11.7 %), p = 0.408). After multivariate analysis, operative time was associated with increased body mass index and tumor size (both p < 0.001), but not with resident experience level (p = 0.051). Estimated blood loss and postoperative complications were also not associated with the PGY of the assistant (p = 0.488 and p = 0.916, respectively). Despite common concern, the PGY status of a physician trainee serving as the bedside assistant does not appear to influence the outcomes of robot-assisted partial nephrectomy at a high-volume center.


Assuntos
Neoplasias Renais/cirurgia , Nefrectomia/métodos , Assistentes Médicos/normas , Papel do Médico , Procedimentos Cirúrgicos Robóticos/métodos , Perda Sanguínea Cirúrgica , Competência Clínica/normas , Educação de Pós-Graduação em Medicina/normas , Feminino , Humanos , Internato e Residência/normas , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento , Isquemia Quente
7.
Int. braz. j. urol ; 41(6): 1126-1131, Nov.-Dec. 2015. tab
Artigo em Inglês | LILACS | ID: lil-769771

RESUMO

Purpose: To evaluate the overall prognosis of post-stem cell transplant inpatients who required continuous bladder irrigation (CBI) for hematuria. Materials and Methods: We performed a retrospective analysis of adult stem cell transplant recipients who received CBI for de novo hemorrhagic cystitis as inpatients on the bone marrow transplant service at Washington University from 2011-2013. Patients who had a history of genitourinary malignancy and/or recent surgical urologic intervention were excluded. Multiple variables were examined for association with death. Results: Thirty-three patients met our inclusion criteria, with a mean age of 48 years (23-65). Common malignancies included acute myelogenous leukemia (17/33, 57%), acute lymphocytic leukemia (3/33, 10%), and peripheral T cell lymphoma (3/33, 10%). Median time from stem cell transplant to need for CBI was 2.5 months (0 days-6.6 years). All patients had previously undergone chemotherapy (33/33, 100%) and 14 had undergone prior radiation therapy (14/33, 42%). Twenty-eight patients had an infectious disease (28/33, 85%), most commonly BK viremia (19/33, 58%), cytomegalovirus viremia (17/33, 51%), and bacterial urinary tract infection (8/33, 24%). Twenty-two patients expired during the same admission as CBI treatment (22/33 or 67% of total patients, 22/28 or 79% of deaths), with a 30-day mortality of 52% and a 90-day mortality of 73% from the start of CBI. Conclusions: Hemorrhagic cystitis requiring CBI is a symptom of severe systemic disease in stem cell transplant patients. The need for CBI administration may be a marker for mortality risk from a variety of systemic insults, rather than directly attributable to the hematuria.


Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Cistite/mortalidade , Cistite/terapia , Transplante de Células-Tronco Hematopoéticas/mortalidade , Hematúria/mortalidade , Hematúria/terapia , Transplante de Medula Óssea/efeitos adversos , Transplante de Medula Óssea/mortalidade , Cistite/etiologia , Mortalidade Hospitalar , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Hematúria/etiologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Irrigação Terapêutica/métodos , Estados Unidos/epidemiologia
8.
Eur Urol ; 67(6): 1160-1167, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25301759

RESUMO

BACKGROUND: The natural history of prostate-specific antigen (PSA)-defined biochemical recurrence (BCR) of prostate cancer (PCa) after definitive local therapy is highly variable. Validated prediction models for PCa-specific mortality (PCSM) in this population are needed for treatment decision-making and clinical trial design. OBJECTIVE: To develop and validate a nomogram to predict the probability of PCSM from the time of BCR among men with rising PSA levels after radical prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: Between 1987 and 2011, 2254 men treated by radical prostatectomy at one of five high-volume hospitals experienced BCR, defined as three successive PSA rises (final value >0.2 ng/ml), single PSA >0.4 ng/ml, or use of secondary therapy administered for detectable PSA >0.1 ng/ml. Clinical information and follow-up data were modeled using competing-risk regression analysis to predict PCSM from the time of BCR. INTERVENTION: Radical prostatectomy for localized prostate cancer and subsequent PCa BCR. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: PCSM. RESULTS AND LIMITATIONS: The 10-yr PCSM and mortality from competing causes was 19% (95% confidence interval [CI] 16-21%) and 17% (95% CI 14-19%), respectively. A nomogram predicting PCSM for all patients had an internally validated concordance index of 0.774. Inclusion of PSA doubling time (PSADT) in a nomogram based on standard parameters modestly improved predictive accuracy (concordance index 0.763 vs 0.754). Significant parameters in the models were preoperative PSA, pathological Gleason score, extraprostatic extension, seminal vesicle invasion, time to PCa BCR, PSA level at PCa BCR, and PSADT (all p<0.05). CONCLUSIONS: We constructed and validated a nomogram to predict the risk of PCSM at 10 yr among men with PCa BCR after radical prostatectomy. The nomogram may be used for patient counseling and the design of clinical trials for PCa. PATIENT SUMMARY: For men with biochemical recurrence of prostate cancer after radical prostatectomy, we have developed a model to predict the long-term risk of death from prostate cancer.


Assuntos
Recidiva Local de Neoplasia/sangue , Nomogramas , Antígeno Prostático Específico/sangue , Próstata/cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/mortalidade , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/epidemiologia , Prognóstico , Próstata/patologia , Neoplasias da Próstata/sangue , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Fatores de Risco
9.
Int Braz J Urol ; 41(6): 1126-31, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26742970

RESUMO

PURPOSE: To evaluate the overall prognosis of post-stem cell transplant inpatients who required continuous bladder irrigation (CBI) for hematuria. MATERIALS AND METHODS: We performed a retrospective analysis of adult stem cell transplant recipients who received CBI for de novo hemorrhagic cystitis as inpatients on the bone marrow transplant service at Washington University from 2011-2013. Patients who had a history of genitourinary malignancy and/or recent surgical urologic intervention were excluded. Multiple variables were examined for association with death. RESULTS: Thirty-three patients met our inclusion criteria, with a mean age of 48 years (23-65). Common malignancies included acute myelogenous leukemia (17/33, 57%), acute lymphocytic leukemia (3/33, 10%), and peripheral T cell lymphoma (3/33, 10%). Median time from stem cell transplant to need for CBI was 2.5 months (0 days-6.6 years). All patients had previously undergone chemotherapy (33/33, 100%) and 14 had undergone prior radiation therapy (14/33, 42%). Twenty-eight patients had an infectious disease (28/33, 85%), most commonly BK viremia (19/33, 58%), cytomegalovirus viremia (17/33, 51%), and bacterial urinary tract infection (8/33, 24%). Twenty-two patients expired during the same admission as CBI treatment (22/33 or 67% of total patients, 22/28 or 79% of deaths), with a 30-day mortality of 52% and a 90-day mortality of 73% from the start of CBI. CONCLUSIONS: Hemorrhagic cystitis requiring CBI is a symptom of severe systemic disease in stem cell transplant patients. The need for CBI administration may be a marker for mortality risk from a variety of systemic insults, rather than directly attributable to the hematuria.


Assuntos
Cistite/mortalidade , Cistite/terapia , Transplante de Células-Tronco Hematopoéticas/mortalidade , Hematúria/mortalidade , Hematúria/terapia , Adulto , Idoso , Transplante de Medula Óssea/efeitos adversos , Transplante de Medula Óssea/mortalidade , Cistite/etiologia , Feminino , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Hematúria/etiologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Irrigação Terapêutica/métodos , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
10.
Patient Saf Surg ; 8(1): 39, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25309624

RESUMO

BACKGROUND: Continuous bladder irrigation (CBI) is a long-standing treatment used in the setting of gross hematuria and other acute bladder issues. Its use has traditionally been reserved for patients under direct urologic care, but with the constraints of modern large-hospital healthcare, many patients have CBI administered by providers unfamiliar with its use and potential complications. FINDINGS: There were 136 CBI orders placed in 2013 by non-urologic providers. The biggest hazard found in our analysis was the requirement for entering a rate of irrigation administration. Nurses with no experience with CBI viewed this order as an indication to administer via an infusion pump, which can easily exceed the mechanical integrity of the bladder and increase the risk of bladder perforation. Our panel also found that due to lack of experience by nurses and non-urologic providers, that signs and symptoms of CBI dysfunction were not common knowledge. Also we found that non-urologic providers were unfamiliar with administration and dosing of medications for CBI patients to help with the intrinsic discomfort with CBI administration. CONCLUSIONS: In our revised order set we found that removing the requirement for an infusion rate, along with placing warnings in the CPOE, helped staff better understand this possible complication. We created a best practice alert in our CPOE to strongly recommend the urology service be consulted. Communication text boxes were added to the order set to help staff be aware of the signs and symptoms of CBI dysfunction, along with a guide for trouble shooting.

12.
JAMA ; 308(2): 133; author reply 136, 2012 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-22782405
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