Fellowship and Subspecialization in Urology: An Analysis of Robotic-assisted Partial Nephrectomy

The Role of Experience: How Case Volume and Endourology-Fellowship Training Impact Surgical Outcomes for Ureteroscopy

Introduction: Surgical experience is associated with superior outcomes in complex urologic cases, such as prostatectomy, nephrectomy, and cystectomy. The question remains whether experience is predictive of outcomes for less complex procedures, such as ureteroscopy (URS). Our study examined how case volume and endourology-fellowship training impacts URS outcomes. Methods: We retrospectively reviewed URS cases from 2017 to 2019 by high ureteroscopy volume urologists (HV), low ureteroscopy volume urologists (LV), endourology-fellowship trained (FT), and non-endourology FT (NFT) urologists. Surgical outcomes including stone-free rate (SFR), complication and reoperation rates, and postoperative imaging follow-up were analyzed between groups. Results: One thousand fifty-seven cases were reviewed across 23 urologists: 6 HV, 17 LV, 3 FT, and 20 NFT. Both FT and HV operated on more complex cases with lower rates of pre-stented patients. HV also operated on patients with higher rates of renal stones, lower pole involvement, and prior failed procedures. Despite this, FT and HV showed between 11.7% and 14.4% higher SFR, representing 2.7- to 3.6-fold greater odds of stone-free outcomes for primary and secondary stones. Additionally, HV and FT had a 4.9% to 7.8% lower rate of postoperative complications and a 3.3% to 4.3% lower rate of reoperations, representing 1.9- to 4.0-fold lower odds of complications. Finally, their patients had a 1.6- to 2.1-fold higher odds of postoperative imaging follow-up with a greater proportion receiving postoperative imaging within the recommended 3-month postoperative period. Conclusions: More experienced urologists, as defined by higher case volume and endourology-fellowship training, had higher SFR, lower complication and reoperation rates, and better postoperative imaging follow-up compared with less experienced urologists. Although less experienced urologists had outcomes in-line with clinical and literature standards, continued training and experience may be a predictor of better outcomes across multiple URS modalities.

Impact of diverticular disease on prostate cancer risk among hypertensive men

INTRODUCTION

Prostate cancer (PCa) is a heterogenous disease with multiple etiological factors playing a role in its development. Recently, chronic and systemic inflammatory conditions such as inflammatory bowel disease were identified as key risk factors influencing its development. The study aimed to evaluate the relationship between diverticular disease (DD) (local and acute inflammation) and PCa.

METHODS

Hypertensive patients with DD and hypertensive controls were identified between 1995 and 2010 from the Statewide Planning and Research Cooperative System database. Cohorts were queried for PCa incidence through 2015. Univariable and multivariable logistic regression analyses were used for determining independent predictors of PCa diagnosis.

RESULTS

A total of 51,353 patients with DD and 111,541 controls were identified. In all, 6.26% of DD developed PCa, and 3.71% of controls developed PCa (p < 0.01). DD was a significant risk factor for PCa (OR: 1.27 CI: 1.19-1.34, p < 0.01). On subgroup analysis, the patients diagnosed with DD <50 years old had an OR of 3.39 for PCa (CI: 2.52-4.56, p < 0.01), age 50-59 had an OR of 2.12 (CI: 1.86-2.15, p < 0.01), and age 60-69 had an OR of 1.20 (CI: 1.10-1.31, p < 0.01). Finally, age and race stratification showed that white patients <50 had an OR of 2.56 (CI: 1.75-3.76, p < 0.01), while black patients <50 had an OR of 3.98 (CI: 2.61-6.07, p < 0.01). The trend in differing odds between these populations was the same for age groups 50-59 and 60-69.

CONCLUSION

Our analysis shows that DD is associated with diagnosis of PCa in hypertensive men. Importantly, the earlier the diagnosis of DD, the higher the odds for development of PCa, particularly in black men.

Evaluation of Peri-operative Outcomes Associated With Resident Involvement on Tumor Resection and Renorrhaphy During Robotic-assisted Partial Nephrectomy

OBJECTIVE

To evaluate perioperative outcomes of resident trainee involvement in tumor resection and renorrhaphy during robotic assisted partial nephrectomy (RAPN).

MATERIALS AND METHODS

We analyzed 500 consecutive RAPN in a single surgeon prospectively maintained database. Cases with resident performed tumor resection and renorrhaphy (N = 71) were case matched on R.E.N.A.L. score and RAPN year using a greedy matching algorithm. Perioperative variables were compared to attending cases.

RESULTS

There were no statistically significant differences in high grade postoperative complications (resident: 3% vs attending: 6%, P = .68), positive margins (resident: 1% vs attending: 3%, P = .31), length of stay (resident: 2.0 vs attending: 2.0 days, P = .73), and 30 day readmission (resident: 7% vs attending: 11%, P = .56). However, residents had a statistically significant longer warm ischemia time (median 21 vs 15 minutes, P <.001), thus less likely to achieve trifecta (66% vs 85%, P = .02). Resident involvement had longer median operative time (197 vs 184 minutes, P = .03). No statistically significant difference in functional volume loss (P = .12) or surface intermediate base margin score (P = .66) between residents and attending was found. No difference in post-operative creatinine change was found at 1 day and 1 month (resident: 0.2 vs attending: 0.1 mg/dL, P = .4 and resident: 0.1 vs attending: 0.1 mg/dL, P = .6, respectively).

CONCLUSION

Supervised resident console involvement in tumor resection and renorrhaphy during RAPN is safe and does not increase rates of complications. Residents have longer median warm ischemia time compared to attending only cases, but this does not appear to impact post-operative renal function.