To assess the reliability of peer-review of TURBT videos as a means to evaluate surgeon skill and its relationship to detrusor sampling.
Urologists from an academic health system submitted TURBT ...videos in 2019. Ten blinded peers evaluated each surgeon's performance using a 10-item scoring instrument to quantify surgeon skill. Normalized composite skill scores for each surgeon were calculated using peer ratings. For surgeons submitting videos, we retrospectively reviewed all TURBT pathology results (2018-2019) to assess surgeon-specific detrusor sampling. A hierarchical logistic regression model was fit to evaluate the association between skill and detrusor sampling, adjusting for patient and surgeon factors.
Surgeon skill scores and detrusor sampling rates were determined for 13 surgeons performing 245 TURBTs. Skill scores varied from -6.0 to 5.1 mean: 0; standard deviation (SD): 2.40. Muscle was sampled in 72% of cases, varying considerably across surgeons (mean: 64.5%; SD: 30.7%). Among 8 surgeons performing >5 TURBTs during the study period, adjusted detrusor sampling rate was associated with sending separate deep specimens (odds ratio OR: 1.97; 95% confidence interval CI: 1.02-3.81, P = .045) but not skill (OR: 0.81; 95% CI: 0.57-1.17, P = .191).
Surgeon skill was not associated with detrusor sampling, suggesting there may be other drivers of variability of detrusor sampling in TURBT.
Active surveillance (AS) has emerged as the preferred management strategy for many men with prostate cancer (PC); however, insufficient longitudinal monitoring may increase the risk of poor outcomes. ...We sought to determine rates of patients becoming lost to follow-up (LTFU) and associated risk factors in a large AS cohort. The Michigan Urologic Surgery Improvement Collaborative (MUSIC) maintains a prospective registry of PC patients from 44 academic and community urology practices. Over a 6-yr period (2011–2017), we identified patients managed with AS. LTFU was defined as any 18-mo period where no pertinent surveillance testing was entered in the registry. With a median surveillance period of 32 mo, the estimated 2-yr LTFU-free probability calculated by Kaplan-Meier method was 90% (95% confidence interval CI=89–92%). Both African American race (hazard ratio HR: 2.77, 95% CI=1.81–4.24) and Charlson comorbidity index ≥1 (HR: 1.55, 95% CI=1.08–2.23) were independently associated with increased risk of LTFU. There was variability in rates of estimated 2-yr LTFU-free survival across MUSIC practices, ranging from 52% (95% CI=21–100%) to 99% (95% CI=97–100%), with a median of 96% (interquartile range: 94–98%), although this did not reach statistical significance (p=0.076). These data reveal opportunities for urology practices to identify systems to reduce rates of LTFU and improve the long-term safety of AS.
With a median observation period of 32 mo, an estimated 10% of patients will be lost to follow-up at the 2 yr time point while on AS. African American men and generally unhealthy patients were at increased risk, and there was variability from one urology practice to another. There is ample opportunity to improve the quality of the performance of AS.
Almost 10% of patients in The Michigan Urologic Surgery Improvement Collaborative (MUSIC) were lost to follow-up (LTFU) within 2 yr on active surveillance, with African American patients and those with CCI ≥1 at an increased risk. Variability exists in rates of patients becoming LTFU among MUSIC contributing practices.
To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system ...to drive improvement efforts.
Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed.
We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9±33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%-66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval CI 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.65-23.45, P < .001) were associated with higher rates of opioid prescribing, while prescribing decreased with increasing patient age (OR 0.97; CI 0.95-0.99, P = 0.016). Multivariable linear regression analysis demonstrated an association between surgery at satellite facilities, having a surgeon in practice for at least 20 years, and higher surgeon volume with increased MMEs prescribed.
Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing.
Background and Objectives
Recent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. ...Our objective was to evaluate the association between surgical approach and 5‐year survival following resection of abdominopelvic malignancies.
Methods
Patients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010‐2015 were identified from the National Cancer Data Base. The association between surgical approach and 5‐year survival was assessed using propensity‐score‐matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional‐hazard models.
Results
The rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05‐1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39‐1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10‐1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44‐0.82; P = .003).
Conclusions
These results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted.
Purpose We retrospectively evaluated urologist adherence to the AUA guidelines on the management of new patients with benign prostatic hyperplasia related lower urinary tract symptoms in a large ...university urology group. Materials and Methods All first time benign prostatic hyperplasia/lower urinary tract symptom visits to the urology clinic at the Northwestern Medical Faculty Foundation between January 1, 2008 and December 31, 2012 were evaluated using an institutionally managed electronic medical record data repository. Clinical documentation and orders from each encounter were assessed to determine the rate of performance of guideline measures. Approximately 1% of all results were manually reviewed in a validation process designed to determine the reliability of the electronic medical record based system. Results A total of 3,494 eligible encounters were evaluated in the final analysis. Provider adherence rates with the 9 measures recommended in the guidelines varied by measure from 53.0% to 92.8%. The rate of performance of 5 not routinely recommended measures was 10.2% or less. Post-void residual and urinary flow measurement were optional measures, and were performed on 68.1% and 4.6% of new encounters respectively. Manual validation revealed the electronic medical record data extraction was concordant with manual review in 96.7% of cases (95% CI 94.8–98.5). Conclusions Using electronic medical record based data extraction techniques, we reliably document a baseline adherence rate with AUA guidelines on the management of benign prostatic hyperplasia. Establishing this benchmark will be important for future investigation into patient outcomes related to guideline adherence and into methods for improving provider adherence.
This study examined the relationship between stimulant medications used for the treatment of attention deficit hyperactivity disorder and semen parameters. We performed a retrospective cohort study ...at a large, academic institution between 2002 and 2020. We included men with a semen analysis without prior spermatotoxic medication use, empiric medical therapy exposure or confounding medical diagnoses (varicocele, Klinefelter's syndrome, cryptorchidism, cystic fibrosis, diabetes, cancer or cancer‐related treatment, and azoospermia). Men were stratified by stimulant exposure (methylphenidate or amphetamines). A multivariable linear regression was fit to assess the association between individual semen parameters, age, stimulant exposure and non‐stimulant medication use. Of 8,861 men identified, 106 men had active prescriptions for stimulants within 90 days prior to semen testing. After controlling for age and exposure to non‐stimulant medications, stimulant use was associated with decreased total motile sperm count (β: −18.00 mil/ejaculate and standard error: 8.44, p = 0.033) in the setting of decreased semen volume (β: −0.35 ml, and standard error: 0.16, p = 0.035), but not sperm concentration, motility and morphology. These findings suggest a role for reproductive physicians and mental health providers to consider counselling men on the potential negative impact of stimulants prescribed for attention deficit hyperactivity disorder on semen volume during fertility planning.
Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with ...the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.
Purpose
The American Urological Association (AUA) published new prostate cancer (CaP) screening guidelines in 2013. We apply the guidelines to a retrospective cohort to compare tumor characteristics ...of those no longer recommended for screening with those who remain screening candidates.
Methods
We identified cases of screening detected CaP (stage cT1c) in the Surveillance Epidemiology and End Results database from October 2005 to December 2010. The 2013 AUA Guidelines were retrospectively applied to the cohort. Men were categorized into three groups for comparison based on whether or not they would now be recommended for CaP screening (Unscreened, Young Unscreened, and Screened). We compared clinical and pathological characteristics of CaP across study groups.
Results
A total of 142,382 men were identified. Screening would no longer be recommended for 40,160. Those no longer recommended for screening had higher median PSA (6.4 vs. 5.8 ng/mL,
p
< 0.01), more Gleason 7 and ≥8 CaP on prostate biopsy (36.4 vs. 34.8 %,
p
< 0.001; 12.4 vs. 9.2 %,
p
< 0.001, respectively) and slightly more Gleason ≥8 CaP (9.0 vs. 7.5 %,
p
= 0.03), and T3 tumors (17.3 vs. 16.5 %,
p
= 0.01) at prostatectomy. Nodal and distant metastasis rates were clinically equivalent among men screened and unscreened. Subgroup analysis of young patients (40–54 years old) no longer recommended for screening identified intermediate or high-risk Gleason scores at prostatectomy 57.6 % of the time.
Conclusions
Features of CaP in men no longer recommended for routine screening are largely equivalent to if not worse than those in screened men.
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