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Chu CE, Law L, Zuniga K, Lin TK, Tsourounis C, Rodriguez-Monguio R, Lazar A, Washington SL, Cooperberg MR, Greene KL, Carroll PR, Pruthi RS, Meng MV, Chen LL, Porten SP. Liposomal Bupivacaine Decreases Postoperative Length of Stay and Opioid Use in Patients Undergoing Radical Cystectomy. Urology 2020; 149:168-173. [PMID: 33278460 DOI: 10.1016/j.urology.2020.11.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To analyze differences in length of stay, opioid use, and other perioperative outcomes in patients undergoing radical cystectomy with urinary diversion who received either liposomal bupivacaine (LB) or epidural analgesia. METHODS This was a single center, retrospective cohort study of patients undergoing open radical cystectomy with urinary diversion from 2015-2019 in the early recovery after surgery (ERAS) pathway. Patients received either LB or epidural catheter analgesia for post-operative pain control. LB was injected at the time of fascial closure to provide up to 72 hours of local analgesia. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative opioid use, time to solid food, time to ambulation, and direct hospitalization costs. Multivariable Cox proportional hazards regression was used to determine associations between analgesia type and discharge. RESULTS LB use was independently associated with shorter post-operative length of stay compared to epidural use (median (IQR) 4.9 days (3.9-5.8) vs 5.9 days (4.9-7.9), P<.001), less total opioid use (mean 188.3 vs 612.2 OME, P <.001), earlier diet advancement (mean 1.6 vs 2.4 days, P <.001), and decreased overall direct costs ($23,188 vs $29,628, P <.001). 45% of patients who received LB were opioid-free after surgery, none in the epidural group. On multivariable Cox proportional hazards regression modeling, LB use was independently associated with earlier discharge (HR 2.1, IQR 1.0-4.5). CONCLUSION Use of LB in open radical cystectomy is associated with reduced LOS, less opioid exposure, and earlier diet advancement.
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Affiliation(s)
- Carissa E Chu
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA.
| | - Lauren Law
- Department of Clinical Pharmacy, Medication Outcomes Center, University of California, San Francisco, CA
| | - Kyle Zuniga
- Department of Urology, University of California, Los Angeles, CA
| | - Tracy Kuo Lin
- Department of Clinical Pharmacy, Medication Outcomes Center, University of California, San Francisco, CA
| | - Candy Tsourounis
- Department of Clinical Pharmacy, Medication Outcomes Center, University of California, San Francisco, CA
| | - Rosa Rodriguez-Monguio
- Department of Clinical Pharmacy, Medication Outcomes Center, University of California, San Francisco, CA
| | - Ann Lazar
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Samuel L Washington
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Matthew R Cooperberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Kirsten L Greene
- Department of Urology, University of Virginia, Charlottesville, VA
| | - Peter R Carroll
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Raj S Pruthi
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Maxwell V Meng
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Lee-Lynn Chen
- Department of Anesthesia, University of California, San Francisco, CA
| | - Sima P Porten
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
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Joice GA, Tema G, Semerjian A, Gupta M, Bell M, Walker J, Kates M, Bivalacqua TJ. Evaluation of Incisional Negative Pressure Wound Therapy in the Prevention of Surgical Site Occurrences After Radical Cystectomy: A New Addition to Enhanced Recovery After Surgery Protocol. Eur Urol Focus 2020; 6:698-703. [PMID: 31704281 DOI: 10.1016/j.euf.2019.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/16/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgical site infection (SSI) remains a significant complication after radical cystectomy (RC). Enhanced recovery after surgery (ERAS) focuses on interventions to decrease length of stay, but few address wound-related complications directly. OBJECTIVE To determine the impact that prophylactic incisional negative pressure wound therapy (iNPWT) will have to reduce the rate of surgical site occurrences (SSOs = SSI + seroma + superficial dehiscence) after RC. DESIGN, SETTINGS, AND PARTICIPANTS We retrospectively reviewed patients undergoing RC by a single surgeon from 2012 to 2017. As part of our ERAS pathway, we employed prophylactic iNPWT during abdominal closure and compared it with a contemporary cohort of standard wound closure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We compared 90-d SSIs, SSOs, and readmissions between iNPWT and standard skin staple closure. Univariate and multivariate regressions were used to compare the two groups. RESULTS AND LIMITATIONS We identified 158 (104 iNPWT, 54 standard) patients from 2012 to 2017. The rates of SSIs and SSOs were 9.7% and 19.0%, respectively. The overall readmission rate for the cohort was 21.5%, with 4.4% of patients requiring readmission for SSI. The iNPWT group had lower rates of SSIs (5.8% vs 16.7%, p = 0.03) and SSOs (11.5% vs 33.3%, p < 0.01). There was no difference between the groups for readmission (21.1% vs 22.2%, p = 0.5). The iNPWT protected against both SSI (odds ratio [OR] 0.89, 95% confidence interval [CI]: 0.81-0.98) and 90-d SSO (OR 0.77, 95% CI: 0.68-0.87). CONCLUSIONS Prophylactic iNPWT is feasible after RC with a modest decrease in both 90-d SSIs and 90-d SSOs, but not readmissions. Wound closure assisted by iNPWT should be considered in RC ERAS pathways. PATIENT SUMMARY In this report, we looked at the impact of new vacuum suction dressing on the prevention of surgical infections after radical cystectomy (RC). We found that this wound dressing can decrease the impact of surgical infections and aid in recovery after RC.
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Affiliation(s)
- Gregory A Joice
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, USA.
| | - Giorgia Tema
- Department of Urology, "Sant'Andrea" Hospital, "La Sapienza" University, Rome, Italy
| | - Alice Semerjian
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Mohit Gupta
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michael Bell
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Joanne Walker
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Max Kates
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, USA
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Leow JJ, Catto JWF, Efstathiou JA, Gore JL, Hussein AA, Shariat SF, Smith AB, Weizer AZ, Wirth M, Witjes JA, Trinh QD. Quality Indicators for Bladder Cancer Services: A Collaborative Review. Eur Urol 2020; 78:43-59. [PMID: 31563501 DOI: 10.1016/j.eururo.2019.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/03/2019] [Indexed: 12/14/2022]
Abstract
CONTEXT There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer. OBJECTIVE To evaluate the optimal management of bladder cancer and propose quality indicators (QIs). EVIDENCE ACQUISITION A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs. EVIDENCE SYNTHESIS For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, bacillus Calmette-Guerin [BCG] unresponsive). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care. CONCLUSIONS We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Although there is currently a lack of level 1 evidence for the benefit of implementing these QIs, we believe that the measurement of these QIs could aid in the improvement and benchmarking of optimal care for bladder cancer. PATIENT SUMMARY After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care.
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Affiliation(s)
- Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James W F Catto
- Academic Urology Unit, The University of Sheffield, Sheffield, UK
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John L Gore
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
| | - Ahmed A Hussein
- Department of Urology, Cairo University, Cairo, Egypt; Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Departments of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Angela B Smith
- Department of Urology, Lineberger Comprehensive Cancer Center, UNC-Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Alon Z Weizer
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Manfred Wirth
- Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - J Alfred Witjes
- Department of Urology, Radboud University, Nijmegen, The Netherlands
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Syed JS, Abello A, Nguyen J, Lee AJH, Desloges JJ, Leapman MS, Kenney PA. Outcomes for urologic oncology procedures: are there differences between academic and community hospitals? World J Urol 2019; 38:1187-1193. [PMID: 31420696 DOI: 10.1007/s00345-019-02902-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/02/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To compare the rate of hospital-based outcomes including costs, 30-day readmission, mortality, and length of stay in patients who underwent major urologic oncologic procedures in academic and community hospitals. METHODS We retrospectively reviewed the Vizient Database (Irving, Texas) from September 2014 to December 2017. Vizient includes ~ 97% of academic hospitals (AH) and more than 60 community hospitals (CH). Patients aged ≥ 18 with urologic malignancies who underwent surgical treatment were included. Chi square and Student t tests were used to compare categorical and continuous variables, respectively. RESULTS We identified a total of 37,628 cases. There were 33,290 (88%) procedures performed in AH and 4330 (12%) in CH. These included prostatectomy (18,540), radical nephrectomy (rNx) 8059, partial nephrectomy (pNx) (5287), radical cystectomy (4421), radical nephroureterectomy (rNu) (1006), and partial cystectomy (321). There were no significant differences in 30-day readmission rates or mortality for any procedure between academic and community hospitals (Table 1), p > 0.05 for all. Length of stay was significantly lower for radical cystectomy and prostatectomy in AH (p < 0.01 for both) and lower for rNx in CH (p = 0.03). The mean direct cost for index admission was significantly higher in AH for rNx, pNx, rNu, and prostatectomy. Case mix index was similar between the community and academic hospitals. CONCLUSION Despite academic and community hospitals having similar case complexity, direct costs were lower in community hospitals without an associated increase in readmission rates or deaths. Length of stay was shorter for cystectomy in academic centers.
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Affiliation(s)
- Jamil S Syed
- Department of Urology, Yale School of Medicine, PO Box 208058, New Haven, CT, 06520-8058, USA.
| | - Alejandro Abello
- Department of Urology, Yale School of Medicine, PO Box 208058, New Haven, CT, 06520-8058, USA
| | - Justin Nguyen
- Department of Urology, Yale School of Medicine, PO Box 208058, New Haven, CT, 06520-8058, USA
| | - Aidan J H Lee
- Department of Urology, Yale School of Medicine, PO Box 208058, New Haven, CT, 06520-8058, USA
| | - Juan-Javier Desloges
- Department of Urology, Yale School of Medicine, PO Box 208058, New Haven, CT, 06520-8058, USA
| | - Michael S Leapman
- Department of Urology, Yale School of Medicine, PO Box 208058, New Haven, CT, 06520-8058, USA
| | - Patrick A Kenney
- Department of Urology, Yale School of Medicine, PO Box 208058, New Haven, CT, 06520-8058, USA
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Abstract
PURPOSE OF REVIEW The purpose of the study is to review and summarize major additions to the literature as pertains to enhanced recovery protocols after radical cystectomy in the past year. RECENT FINDINGS Enhanced recovery after surgery protocols is multimodal pathways that include elements to optimize all stages of care including preoperative, intraoperative and postoperative measures. Several authors have recently presented their results with initial implementation of an enhanced recovery protocol after radical cystectomy, while others have begun to examine outcomes beyond the index admission and to refine the various targeted components of the protocol. Enhanced recovery after surgery protocols has revolutionized patient care following radical cystectomy, a procedure still burdened by high complication rates and lengthy hospital stay. Although still lacking in universal implementation and standardization of the protocol, significant advancements are made each year as we move towards best practice.
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