Radiologic indicators prior to renal cell cancer thrombectomy: Implications for vascular reconstruction and mortality.

BACKGROUND: Renal cancer may invade the inferior vena cava (IVC) creating more complex surgical intervention. We investigate radiologic findings that may predict vascular reconstruction prior to surgery and future renal cancer-specific mortality. MATERIALS AND METHODS: Radiologic findings included Mayo Clinic risk factors for vascular reconstruction: Right-sided tumor, anteroposterior diameter of the IVC at the ostium of the renal vein ≥24.0 mm, and radiologic identification of complete occlusion of the IVC. Additional factors included thrombus in the lumen of the hepatic veins and metastasis. Along with other demographic factors, analysis included Chi-squared analysis for vascular reconstruction and logistic regression for mortality. A Kaplan-Meier curve was created for the most significant radiologic factor. RESULTS: Thirty-seven patients underwent IVC tumor thrombectomy at two institutions from April 2007 to February 2015. We found that Mayo risk factors of 0, 1, 2, and 3 and the proportions of vascular reconstruction of 0%, 0%, 12.5%, and 13.6%, respectively (P = 0.788). Hepatic vein involvement was the most significant determinate of renal cell carcinoma-specific mortality in multivariable analysis, controlling for the size of IVC at the hepatic veins, pulmonary metastasis, and Fuhrman grade (P = 0.02, Log-rank P = 0.002). CONCLUSION: Mayo risk factors did not predict vascular reconstruction in our small cohort of Level II-Level IV IVC thrombus undergoing IVC thrombectomy. Tumor thrombus traveling into the lumen of the hepatic veins was a significant risk factor for accelerated mortality.

Medicaid Patient Access to Urological Care in the Era of the Patient Protection and Affordable Care Act: A Baseline to Measure Policy Effectiveness.

INTRODUCTION: Medicaid expansion under PPACA (Patient Protection and Affordable Care Act) sought to increase access to health care by expanding access to insurance. The association between access to Medicaid and access to urological health care, however, has not been tested to our knowledge. To test this association we performed a prospective, survey based analysis of Medicaid acceptance rates and new appointment wait times for a patient seeking urological care. This study presents baseline data collected prior to Medicaid expansion in 2014. METHODS: A primary cohort representing 20% of all urological surgeons in a nationwide database was surveyed using a simulated patient script. The data were collected in November 2013 prior to Medicaid expansion. The primary outcome measures were Medicaid acceptance and new patient appointment wait times. A practice level, secondary cohort was also analyzed. RESULTS: A total of 650 urological surgeons were successfully sampled in the primary cohort, of whom 271 (41.7%) did not accept any Medicaid, 205 (31.5%) accepted some but not all Medicaid and 174 (26.8%) accepted all Medicaid insurance plans. The median wait time for a new patient appointment was 18 days. Medicaid acceptance rates were similar in the secondary cohort. The percentage of urologists accepting all forms of Medicaid varied by state, ranging from 10% to 90%. CONCLUSIONS: Medicaid patient access to urological care is restricted, suggesting that access to Medicaid insurance coverage may not translate into access to urological care. Subsequent data collection will assess trends in Medicaid patient access to urological care following Medicaid expansion.

A Randomized Controlled Trial for Pain Control in Laparoscopic Urologic Surgery: 0.25% Bupivacaine Versus Long-Acting Liposomal Bupivacaine.

BACKGROUND AND PURPOSE: Liposomal bupivacaine is a delayed-release preparation providing up to 72 hours of local analgesia. It costs much more than standard bupivacaine, however. A prospective, randomized, patient-blinded, controlled trial was performed to assess the efficacy of liposomal bupivacaine versus 0.25% bupivacaine when injected into surgical incisions during laparoscopic and robot-assisted urologic surgery. METHODS: A total of 206 adults were randomized to receive liposomal bupivacaine or 0.25% bupivacaine. All surgical incisions were injected with liposomal bupivacaine or 0.25% bupivacaine with systematic dosing. The primary outcome was total opioid consumption during the postoperative hospital stay. All opioid doses were converted to morphine equivalents. Secondary end points included pain scores using visual analog pain scales, duration of hospital stay, and the time to first opioid use. A subgroup analysis was performed for renal surgery patients. RESULTS: There was no significant difference in median total opioid use during the hospital stay between those who received liposomal bupivacaine (15 [interquartile range (IQR) 6.7-27] mg) and 0.25% bupivacaine (17.3 [IQR 8.3-30.5] mg) (P=0.39). Furthermore, pain scores, length of hospital stay, and time to first opioid use did not differ between groups. Subgroup analysis of laparoscopic renal surgery revealed no difference between liposomal bupivacaine and 0.25% bupivacaine. CONCLUSIONS: For laparoscopic and robot-assisted urologic surgery, there is no significant difference between liposomal bupivacaine and 0.25% bupivacaine for local analgesia at the incision sites.

Active Surveillance is an Appropriate Management Strategy for a Proportion of Men Diagnosed with Prostate Cancer by Prostate Specific Antigen Testing.

PURPOSE: The purpose of this study was to determine the fraction of men who would qualify for active surveillance in a population based cohort diagnosed with prostate cancer. In those who qualified and subsequently underwent primary treatment with radical prostatectomy, we assessed the rate of upgrading and up staging. MATERIALS AND METHODS: SABOR is a Clinical and Epidemiologic Center of the EDRN (Early Detection Research Network), NCI (National Cancer Institute), with 3,828 men enrolled at the time of review. Of these men 320 were diagnosed with prostate cancer, of whom 281 had sufficient data for review. These 281 cases were reviewed to determine suitability for active surveillance using 2 sets of criteria. Criteria 1 were prostate specific antigen density less than 15%, 2 or fewer cores involved with cancer, Gleason score 6 or less and cancer involving 50% or less of biopsy volume. Criteria 2 were 4 or fewer cores with Gleason 3 + 3 cancer and only 1 core of Gleason 3 + 4 cancer with up to 15% of core involved with Gleason 3 + 4 disease. For those undergoing radical prostatectomy, we examined rates of up staging and upgrading. RESULTS: Of the 281 patients, 187 (67%) qualified for active surveillance under criteria 1 and/or 2. Treatment data were available on 178 patients, and 74 underwent radical prostatectomy. Using the initial biopsy, 14 men (33.1%) who met criteria 1 and 9 (25%) who met criteria 2 were upgraded and/or up staged on final pathological review. By comparison, 38% of those who did not qualify for active surveillance were upgraded and/or up staged. CONCLUSIONS: In a population based cohort, two-thirds of men diagnosed with prostate cancer qualify for active surveillance. Less restricted criteria for surveillance may be appropriate based on similar rates of upgrading/up staging at radical prostatectomy.