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Martins FE, Lumen N, Holm HV. Management of the Devastated Bladder Outlet after Prostate CANCER Treatment. Curr Urol Rep 2024; 25:149-162. [PMID: 38750347 DOI: 10.1007/s11934-024-01206-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE OF REVIEW Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion. RECENT FINDINGS The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.
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Affiliation(s)
- Francisco E Martins
- Department of Urology, University of Lisbon, School of Medicine, Centro Hospitalar Universitário, Lisboa Norte (CHULN), Lisbon, Portugal
| | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, 9000, Ghent, Belgium
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Daskivich TJ, Naser-Tavakolian A, Gale R, Luu M, Friedrich N, Venkataramana A, Khodyakov D, Posadas E, Sandler H, Spiegel B, Freedland SJ. Variation in communication of side effects in prostate cancer treatment consultations. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00806-2. [PMID: 38396054 PMCID: PMC11341774 DOI: 10.1038/s41391-024-00806-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Effective communication of treatment side effects (SE) is critical for shared decision-making (SDM) in localized prostate cancer. We sought to qualitatively characterize how physicians communicate SE in consultations. METHODS We transcribed 50 initial prostate cancer treatment consultations across nine multidisciplinary providers (Urologists, Radiation Oncologists, Medical Oncologists) at our tertiary referral, academic center. Coders identified quotes describing SE and used an inductive approach to establish a hierarchy for granularity of communication: (1) not mentioned, (2) name only, (3) generalization("high"), (4) average incidence without timepoint, (5) average incidence with timepoint, and (6) precision estimate. We reported the most granular mode of communication for each SE throughout the consultation overall and across specialty and tumor risk. RESULTS Among consultations discussing surgery (n = 40), erectile dysfunction (ED) and urinary incontinence (UI) were omitted in 15% and 12%, not quantified (name only or generalization) in 47% and 30%, and noted as average incidence without timeline in 8% and 8%, respectively. In only 30% and 49% were ED and UI quantified with timeline (average incidence with timeline or precision estimate), respectively. Among consultations discussing radiation (n = 36), irritative urinary symptoms, ED, and other post-radiotherapy SE were omitted in 22%, 42%, and 64-67%, not quantified in 61%, 33%, and 23-28%, and noted as average incidence without timeline in 8%, 22%, and 6-8%, respectively. In only 3-8% were post-radiotherapy SE quantified with timeline. Specialty concordance (but not tumor risk) was associated with higher granularity of communication, though physicians frequently failed to quantify specialty-concordant SE. CONCLUSIONS SE was often omitted, not quantified, and/or lacked a timeline in treatment consultations in our sample. Physicians should articulate, quantify, and assign a timeline for SE to optimize SDM.
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Affiliation(s)
- Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | | | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nadine Friedrich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Abhi Venkataramana
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | | | - Edwin Posadas
- Department of Medicine, Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, Divisions of Gastroenterology and Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Section of Urology, Durham VA Medical Center, Durham, NC, USA
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Kaba M, Binbay M, Erbin A, Tefekli AH, Verep S, Muslumanoglu AY. Evaluating the Oncological and Functional Outcomes in 167 Patients Undergoing Laparoscopic Radical Prostatectomy: Could Laparoscopy Still be a Viable Option in Suitable Patients? J Laparoendosc Adv Surg Tech A 2024; 34:19-24. [PMID: 37751192 DOI: 10.1089/lap.2023.0337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023] Open
Abstract
Aim: To evaluate the oncological and functional outcomes of 167 patients who underwent laparoscopic radical prostatectomy (LRP). Materials and Methods: The retrospective study included 167 patients who were treated with LRP due to clinically localized prostate cancer between January 2007 and April 2012. Most of the patients were treated with the extraperitoneal approach. Preoperative evaluations included age, serum prostate-specific antigen (PSA) level, and biopsy Gleason score. Perioperative evaluations included duration of operative time and anastomosis time, blood loss (milliliter), and complications. Postoperative evaluations included length of hospital stay and catheterization time. Continence and erectile function were evaluated both pre- and postoperatively. The patients who used no pads or no more than one pad daily and the ones who had only a few urine leakages on effort or exertion were accepted as continent. Postoperative potency was defined as the ability to achieve sexual intercourse with or without the use of PDE-5 inhibitors. Results: Mean age and mean operative time were 62.4 ± 6.0 years and 220.5 ± 45.6 minutes, respectively. Mean anastomosis time was 35.6 ± 9.8 minutes. Mean serum PSA level and mean Gleason score were 17.5 ± 9.97 ng/mL and 6.16 ± 0.42, respectively. Pelvic lymphadenectomy was performed in 94 patients and nerve-sparing procedures in 61 patients. The pathological analysis revealed positive surgical margin in 35 patients (20.9%). Bilateral and unilateral nerve-sparing LRP procedures were performed in 51 (30.5%) and 10 (6%) patients, respectively. At 12 months after surgery, 3 (1.8%) patients were using 2 or more pads per day, 19 (26.4%) patients were satisfied with erection, hardness, and duration of intercourse, and 9 (12.5%) patients had an erection with insufficient hardness and duration. Conclusion: LRP is an acceptable method in localized prostate cancer due to its perioperative and early postoperative results.
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Affiliation(s)
- Mehmet Kaba
- Department of Urology, Private Yuzyil Gebze Hospital, Kocaeli, Turkey
| | - Murat Binbay
- Department of Urology, Bahcesehir University Medical Faculty, Istanbul, Turkey
| | - Akif Erbin
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | | | - Samed Verep
- Department of Urology, Private Yuzyil Gebze Hospital, Kocaeli, Turkey
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Rodier S, Henning J, Kukreja J, Mohammedi T, Shah P, Damani T. Robotic Primary and Revisional Hiatal Hernia Repair is Safe and Associated with Favorable Perioperative Outcomes: A Single Institution Experience. J Laparoendosc Adv Surg Tech A 2023; 33:932-936. [PMID: 37417969 DOI: 10.1089/lap.2023.0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Background: Robotic hiatal hernia (HH) repair has been demonstrated to be feasible and safe. Recent conflicting reports have emerged on the higher incidence of perioperative complications with robotic HH repair when compared with laparoscopic repair. Materials and Methods: A retrospective review of a prospective database at an academic medical center for all robotic HH repairs performed by a high-volume foregut surgeon from 2018 to 2021 was performed. Outcome measures included operative time, estimated blood loss (EBL), length of stay (LOS), conversion rate, need for esophageal lengthening procedure, intra- and perioperative complications, and 30-day in-hospital mortality. Results: One hundred four patients were included in the analysis. Fifteen percent of patients had a type I HH, 2% had a type II, 73% had a type III, and 10% had a type IV HH. Eighty-four percent of cases were primary and 16% were revisional. Fifty-four percent of patients had mesh placed and 4.4% had an esophageal lengthening procedure. Mean EBL was 15 mL and mean operative time was 151 minutes. Median LOS was 2 days (interquartile range 1-2 days). There were zero conversions. Intraoperative complication rate was 1% and 30-day complication rate was 4%. The 30-day in-hospital mortality was zero. Conclusion: In this retrospective analysis of 114 consecutive robotic HH repairs performed, with 83% type III or IV HHs and 16% revisional hiatal cases, our results demonstrate favorable perioperative outcomes, with lower EBL, shorter LOS, lower complication rate, zero conversions, and comparable operative times compared with historical laparoscopic data.
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Affiliation(s)
- Simon Rodier
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Justin Henning
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Janvi Kukreja
- Division of the Biological Sciences, University of Chicago, Chicago, Illinois, USA
| | - Taher Mohammedi
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Paresh Shah
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Tanuja Damani
- Department of Surgery, NYU Langone Health, New York, New York, USA
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Nyame YA, Holt SK, Etzioni RD, Gore JL. Racial inequities in the quality of surgical care among Medicare beneficiaries with localized prostate cancer. Cancer 2023; 129:1402-1410. [PMID: 36776124 DOI: 10.1002/cncr.34681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/21/2022] [Accepted: 01/19/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND US Black men are twice as likely to die from prostate cancer as men of other races. Lower quality care may contribute to this higher death rate. METHODS Sociodemographic and clinical data were obtained for men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with clinically localized prostate cancer (cT1-4N0/xM0/x) and managed primarily by radical prostatectomy (2005-2015). Surgical volume was determined for facility and surgeon. Relationships between race, surgeon and/or facility volume, and characteristics of treating facility with survival (all-cause and cancer-specific) were assessed using multivariable Cox regression and competing risk analysis. RESULTS Black men represented 6.7% (n = 2123) of 31,478 cohort. They were younger at diagnosis, had longer time from diagnosis to surgery, lower socioeconomic status, higher prostate-specific antigen (PSA), and higher comorbid status compared with men of other races (p < .001). They were less likely to receive care from a surgeon or facility in the top volume percentile (p < .001); less likely to receive surgical care at a National Cancer Institute-designated cancer center and more likely seen at a minority-serving hospital; and less likely to travel ≥50 miles for surgical care. On multivariable analysis stratified by surgical volume, Black men receiving care from a surgeon or facility with lower volumes demonstrated increased risk of prostate cancer mortality (hazard ratio, 1.61; 95% confidence interval, 1.01-2.69) adjusting for age, clinical stage, PSA, and comorbidity index. CONCLUSIONS Black Medicare beneficiaries with prostate cancer more commonly receive care from surgeons and facilities with lower volumes, likely affecting surgical quality and outcomes. Access to high-quality prostate cancer care may reduce racial inequities in disease outcomes, even among insured men. PLAIN LANGUAGE SUMMARY Black men are twice as likely to die of prostate cancer than other US men. Lower quality care may contribute to higher rates of prostate cancer death. We used surgical volume to evaluate the relationship between race and quality of care. Black Medicare beneficiaries with prostate cancer more commonly received care from surgeons and facilities with lower volumes, correlating with a higher risk of prostate cancer death and indicating scarce resources for care. Access to high-quality prostate cancer care eases disparities in disease outcomes. Patient-centered interventions that increase access to high-quality care for Black men with prostate cancer are needed.
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Affiliation(s)
- Yaw A Nyame
- Department of Urology, University of Washington Medical Center, Seattle, Washington, USA.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sarah K Holt
- Department of Urology, University of Washington Medical Center, Seattle, Washington, USA
| | - Ruth D Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - John L Gore
- Department of Urology, University of Washington Medical Center, Seattle, Washington, USA.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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Lima DL, Berk R, Cavazzola LT, Malcher F. Learning Curve of Robotic Enhanced-View Extraperitoneal Approach for Ventral Hernia Repairs. J Laparoendosc Adv Surg Tech A 2023; 33:81-86. [PMID: 35736784 DOI: 10.1089/lap.2022.0270] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Introduction: The enhanced-view extraperitoneal (eTEP) technique was first described for minimally invasive inguinal hernia repairs and later for laparoscopic ventral hernia repair. The objective of this study was to report our early experience and learning curve (LC) with the robotic-assisted eTEP (R-eTEP) approach. Materials and Methods: We performed a retrospective analysis of patients undergoing R-eTEP repair for ventral hernias from December 2018 to September 2021. A single surgeon operative time (OT)-based LC was evaluated. Results: A total of 81 patients underwent an R-eTEP from December 2018 to September 2021. Sixty-five patients were ultimately included in our analysis. Fifty-seven patients underwent eTEP-Rives-Stoppa (RS) and 8 patients underwent eTEP-transversus abdominis release (TAR). The median age in the whole cohort was 57 years (interquartile range [IQR] 51.5-64.5 years) with no difference between the groups. The median body mass index (BMI) was 31 kg/m2 (IQR 27-34.7 kg/m2) in the eTEP-RS group and 29.7 kg/m2 (IQR 28.5-31 kg/m2) in the eTEP-TAR group. There were 36 incisional hernias (63%) in the eTEP-RS group and 8 (100%) in the eTEP-TAR group. There were 14 recurrent hernias (25%) in the eTEP-RS group and 2 (25%) in the eTEP-TAR group. The LC was evaluated only in the eTEP-RS cases. We divided the cohort into 3 chronological groups (G1, G2, and G3), including 19 cases each. The median OT in each group was 177 (IQR 147-200), 153 (IQR 127-187), and 125 minutes (IQR 106-152 minutes), respectively. There was no difference in the median OT between G1 and G2 (P = .390). G3 had a shorter median OT than G2 (P = .02) and G1 (P = .001). There was no difference between these groups in median age, BMI, defect area, defect width, and mesh area. Conclusions: The R-eTEP approach has been shown to be safe and feasible for ventral and incisional hernia repairs. A statistically significant decrease in OT was observed after 38 cases.
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Affiliation(s)
- Diego L Lima
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
| | - Robin Berk
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
| | - Leandro T Cavazzola
- Department of Surgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Flavio Malcher
- Department of Surgery, NYU Langone, New York, New York, USA
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Sarwahi V, Tran E, Vora R, Dowling TJ, Galina J, Fakhoury J, Lo Y, Amaral T, DiMauro JP, Hasan S. The Volume-Cost Relationship: How Does Surgical Volume Affect Cost and Value in AIS Surgery. Clin Spine Surg 2022; 35:E706-E713. [PMID: 35509023 DOI: 10.1097/bsd.0000000000001338] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/09/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE The objective of this study was to evaluate and compare distribution of hospital and operating room charges and outcomes during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) patients by high-volume (HV) and standard-volume (SV) surgeons at one institution and examine potential cost savings. SUMMARY OF BACKGROUND DATA Increased surgical volume has been associated with improved perioperative outcomes after spinal deformity correction. However, there is a lack of information on how this may affect hospital costs. METHODS Retrospective study of AIS patients undergoing posterior spinal fusion between 2013 and 2019. Demographic, x-ray, chart review and hospital costs were collected and compared between HV surgeons (≥50 AIS cases/y) and SV surgeons (<50/y). Comparative analyses were computed using Wilcoxon rank-sum, Kruskal-Wallis, and the Fisher exact tests. Average values with corresponding minimum-maximum rages were reported. RESULTS A total of 407 patients (HV: 232, SV: 175) operated by 4 surgeons (1 HV, 3 SV). Radiographic parameters were similar between the groups. HV surgeons had significantly lower estimated blood loss (385.3 vs. 655.6 mL, P <0.001), fewer intraoperative transfusions (10.8% vs. 25.1%, P <0.001), shorter surgery time (221.6 vs. 324.9 min, P <0.001), and lower radiation from intraoperative fluoroscopy (4.4 vs. 6.4 mGy, P <0.001). HV patients had a significantly lower length of stay (4.3 vs. 5.3, P <0.001) and complication rate (0.4% vs. 4%, P =0.04).HV surgeons had significantly lower total costs ($61,716.24 vs. $72,745.93, P <0.001). This included lower transfusion costs ( P <0.001), operative time costs ( P <0.001), screw costs ( P <0.001), hospital stay costs ( P <0.001), and costs associated with 30-day emergency department returns ( P <0.001). CONCLUSION HV surgeons had significantly lower operative times, lower estimated blood loss and transfusion rates and lower perioperative complications requiring readmission or return to emergency department resulting in lower health care costs. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Vishal Sarwahi
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
| | - Elaine Tran
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
| | - Rushabh Vora
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
| | - Thomas J Dowling
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
| | - Jesse Galina
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
| | - Jordan Fakhoury
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Terry Amaral
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
| | - Jon-Paul DiMauro
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
| | - Sayyida Hasan
- Department of Orthopaedics, Cohen Children's Medical Center, New Hyde Park
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Moretti TBC, Magna LA, Reis LO. Surgical Results and Complications for Open, Laparoscopic, and Robot-assisted Radical Prostatectomy: A Reverse Systematic Review. EUR UROL SUPPL 2022; 44:150-161. [PMID: 36110904 PMCID: PMC9468352 DOI: 10.1016/j.euros.2022.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 11/30/2022] Open
Abstract
Context The advantages of minimally invasive surgery for radical prostatectomy (RP) have been demonstrated in a number of systematic reviews (SRs). However, the rigorous study selection process for SR means that a lot of information can be excluded, leading to a very specific clinical scenario that is often unrepresentative of real life. Our new reverse SR methodology generates a heterogeneous population database that covers a wide range of clinical scenarios. Objective To compare perioperative surgical results and complications for open retropubic RP (RRP), laparoscopic RP (LRP), and robot-assisted RP (RARP) in a reverse SR. Evidence acquisition Eight databases were searched for SRs on RRP, LRP, or RARP between 2000 and 2020 (80 SRs). All references used in these SRs were captured for analysis (1724 articles). Perioperative outcomes and complications were compared among the RRP, LRP, and RARP approaches. Evidence synthesis We identified 559 (32.4%) reports on RRP, 413 (23.9%) on LRP, and 752 (43.7%) on RARP, involving 1 353 485 patients overall. RARP showed a significantly higher annual volume of surgery per surgeon (AVSS) in comparison to RRP and LRP (mean 64.29, 43.26, and 41.47, respectively), a higher percentage of low-risk patients (prostate-specific antigen <10 ng/ml, Gleason <7, stage <cT2), and a lower rate of lymphadenectomy, culminating in a lower complication rate (12.3% for RARP, 16.3% for LRP, 20.2% for RRP). Among all outcomes, only AVSS was significantly correlated with complication rates. An AVSS of 30, 95 and 95 surgeries/yr was required for RARP, LRP, and RRP, respectively, to obtain a complication rate of 12.3% (average for RARP). RARP showed better performance for all perioperative variables studied except for operative time (operative time: 199.8 vs 214.9 vs 169.5 min; estimated blood loss: 228.2 vs 408.0 vs 852.1 ml; blood transfusion rate: 2.8% vs 6.5% vs 19.8%; length of stay: 2.9 vs 5.7 vs 6.1 d; catheter time: 7.8 vs 8.5 vs 11.0 d for RARP vs LRP vs RRP). Conclusions Our reverse SR involved a wide real-life representative sample and reference values established in the literature and revealed that minimally invasive surgery had the best perioperative and complication results, especially RARP, which was associated with less complex cases, higher annual surgeon volume, and greater performance. Patient summary We used a wide sample representative of real-life surgical practice and reference values established in the literature for three techniques for removal of the prostate to guide patients and physicians in deciding the best surgical treatment for prostate cancer according to availability.
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Damani T, Awad M. Letter to the Editor on "Complications Following Robotic Hiatal Hernia Repair Are Higher Compared to Laparoscopy". J Gastrointest Surg 2021; 25:3028-3029. [PMID: 34357531 DOI: 10.1007/s11605-021-05090-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/03/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Tanuja Damani
- Department of Surgery, NYU Grossman School of Medicine, 530 First Avenue, HCC Building, Suite 6 C, New York, NY, 10016, USA.
| | - Michael Awad
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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10
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Martins FE, Holm HV, Lumen N. Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life. J Clin Med 2021; 10:4920. [PMID: 34768438 PMCID: PMC8584541 DOI: 10.3390/jcm10214920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022] Open
Abstract
Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1-8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients' quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.
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Affiliation(s)
- Francisco E. Martins
- Department of Urology, School of Medicine, University of Lisbon, Hospital Santa Maria/CHULN, 1649-035 Lisbon, Portugal
| | | | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium;
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Miller CJ, Bichakjian CK. Mohs Micrographic Surgery for Melanoma-Do Outcomes Vary Among Treatment Facilities? JAMA Dermatol 2021; 157:513-515. [PMID: 33787822 DOI: 10.1001/jamadermatol.2021.0022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christopher J Miller
- Penn Dermatology Oncology Center, Hospital of the University of Pennsylvania, Philadelphia
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Van den Broeck T, Oprea-Lager D, Moris L, Kailavasan M, Briers E, Cornford P, De Santis M, Gandaglia G, Gillessen Sommer S, Grummet JP, Grivas N, Lam TBL, Lardas M, Liew M, Mason M, O'Hanlon S, Pecanka J, Ploussard G, Rouviere O, Schoots IG, Tilki D, van den Bergh RCN, van der Poel H, Wiegel T, Willemse PP, Yuan CY, Mottet N. A Systematic Review of the Impact of Surgeon and Hospital Caseload Volume on Oncological and Nononcological Outcomes After Radical Prostatectomy for Nonmetastatic Prostate Cancer. Eur Urol 2021; 80:531-545. [PMID: 33962808 DOI: 10.1016/j.eururo.2021.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/19/2021] [Indexed: 12/13/2022]
Abstract
CONTEXT The impact of surgeon and hospital volume on outcomes after radical prostatectomy (RP) for localised prostate cancer (PCa) remains unknown. OBJECTIVE To perform a systematic review on the association between surgeon or hospital volume and oncological and nononcological outcomes following RP for PCa. EVIDENCE ACQUISITION Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. All comparative studies for nonmetastatic PCa patients treated with RP published between January 1990 and May 2020 were included. For inclusion, studies had to compare hospital or surgeon volume, defined as caseload per unit time. Main outcomes included oncological (including prostate-specific antigen persistence, positive surgical margin [PSM], biochemical recurrence, local and distant recurrence, and cancer-specific and overall survival) and nononcological (perioperative complications including need for blood transfusion, conversion to open procedure and within 90-d death, and continence and erectile function) outcomes. Risk of bias (RoB) and confounding assessments were undertaken. Both a narrative and a quantitative synthesis were planned if the data allowed. EVIDENCE SYNTHESIS Sixty retrospective comparative studies were included. Generally, increasing surgeon and hospital volumes were associated with lower rates of mortality, PSM, adjuvant or salvage therapies, and perioperative complications. Combining group size cut-offs as used in the included studies, the median threshold for hospital volume at which outcomes start to diverge is 86 (interquartile range [IQR] 35-100) cases per year. In addition, above this threshold, the higher the caseload, the better the outcomes, especially for PSM. RoB and confounding were high for most domains. CONCLUSIONS Higher surgeon and hospital volumes for RP are associated with lower rates of PSMs, adjuvant or salvage therapies, and perioperative complications. This association becomes apparent from a caseload of >86 (IQR 35-100) per year and may further improve hereafter. Both high- and low-volume centres should measure their outcomes, make them publicly available, and improve their quality of care if needed. PATIENT SUMMARY We reviewed the literature to determine whether the number of prostate cancer operations (radical prostatectomy) performed in a hospital affects the outcomes of surgery. We found that, overall, hospitals with a higher number of operations per year have better outcomes in terms of cancer recurrence and complications during or after hospitalisation. However, it must be noted that surgeons working in hospitals with lower annual operations can still achieve similar or even better outcomes. Therefore, making hospital's outcome data publicly available should be promoted internationally, so that patients can make an informed decision where they want to be treated.
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Affiliation(s)
| | - Daniela Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, VU University, Amsterdam, The Netherlands
| | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Philip Cornford
- Department of Urology, Liverpool University Hospitals, Liverpool, UK
| | - Maria De Santis
- Department of Urology, Charité University Hospital, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Giorgio Gandaglia
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silke Gillessen Sommer
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Australia
| | - Nikos Grivas
- Department of Urology, Hatzikosta General Hospital, Ioannina, Greece
| | - Thomas B L Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Malcolm Mason
- Division of Cancer & Genetics, School of Medicine Cardiff University, Velindre Cancer Centre, Cardiff, UK
| | - Shane O'Hanlon
- Medicine for Older People, Saint Vincent's University Hospital, Dublin, Ireland
| | | | | | - Olivier Rouviere
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôspital Edouard Herriot, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Centre, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul Willemse
- Department of Oncological Urology, University Medical Centre, Utrecht Cancer Centre, Utrecht, The Netherlands
| | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, Ontario, Canada
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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Vitarelli A, Vulpi M, Divenuto L, Papapicco G, Pagliarulo V, Ditonno P. Prerectal-transperineal approach for treatment of recurrent vesico-urethral anastomotic stenosis after radical prostatectomy. Asian J Urol 2021. [DOI: 10.1016/j.ajur.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Cheraghlou S, Christensen SR, Leffell DJ, Girardi M. Association of Treatment Facility Characteristics With Overall Survival After Mohs Micrographic Surgery for T1a-T2a Invasive Melanoma. JAMA Dermatol 2021; 157:531-539. [PMID: 33787836 PMCID: PMC8014201 DOI: 10.1001/jamadermatol.2021.0023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/14/2021] [Indexed: 12/15/2022]
Abstract
Importance Early-stage melanoma, among the most common cancers in the US, is typically treated with wide local excision. However, recent advances in immunohistochemistry have led to an increasing number of these cases being excised via Mohs micrographic surgery (MMS). Although studies of resections for other cancers have reported that facility-level factors are associated with patient outcomes, it is not yet established how these factors may affect outcomes for patients treated with Mohs micrographic surgery. Objective To evaluate the association of treatment center academic affiliation and case volume with long-term patient survival after MMS for T1a-T2a invasive melanoma. Design, Setting, and Participants In a retrospective cohort study, 4062 adults with nonmetastatic, T1a-T2a melanoma diagnosed from 2004 to 2014 and treated with MMS in the National Cancer Database (NCDB) were identified. The NCDB includes all reportable cases from Commission on Cancer-accredited facilities and is estimated to capture approximately 50% of all incident melanomas in the US. Multivariable survival analyses were conducted using Cox proportional hazards models. Data analysis was conducted from February 27 to August 18, 2020. Exposures Treatment facility characteristics. Main Outcomes and Measures Overall survival. Results The study population included 4062 patients (2213 [54.5%] men; median [SD] age, 60 [16.3] years) treated at 462 centers. Sixty-two centers were top decile-volume facilities (TDVFs), which treated 1757 patients (61.9%). Most TDVFs were academic institutions (37 of 62 [59.7%]). On multivariable analysis, treatment at an academic center was associated with a nearly 30% reduction in hazard of death (hazard ratio, 0.730; 95% CI, 0.596-0.895). In a separate analysis, treatment at TDVFs was also associated with improved survival (hazard ratio, 0.795; 95% CI, 0.648-0.977). Conclusions and Relevance In this cohort study, treatment of patients with T1a-T2a invasive melanoma excised with MMS at academic and top decile-volume (≥8 cases per year) facilities was associated with improved long-term survival compared with those excised by MMS at nonacademic and low-volume facilities. Identification and protocolization of the practices of these facilities may help to reduce survival differences between centers.
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Affiliation(s)
- Shayan Cheraghlou
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | | | - David J. Leffell
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Michael Girardi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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Wah W, Papa N, Evans M, Ahern S, Earnest A. A multi-level spatio-temporal analysis on prostate cancer outcomes. Cancer Epidemiol 2021; 72:101939. [PMID: 33862413 DOI: 10.1016/j.canep.2021.101939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Geographic and temporal variation in positive surgical margins (PSM) for prostate cancer after radical prostatectomy (RP) has been observed. However, it is unclear how much of this variation could be attributed to patient, surgeon, institution, or socioeconomic-related factors and the impact of PSM on death among localized prostate cancer patients. METHODS This study aimed to assess the independent and relative contribution of the patient, surgeon, institution and area-level risk factors on geographic and temporal variation of PSM and evaluate the impact of PSM on five-year all-cause and prostate cancer-specific mortality among localized prostate cancer patients. Within the hierarchical-related regression approach, we utilised Bayesian spatial-temporal multi-level models to study individual and area-level predictors with the outcomes, while accounting for geographically structured and unstructured correlation and non-linear trends. RESULTS Individual-level data included 10,075 localized prostate cancer cases with RP reported to the Prostate Cancer Outcomes Registry Victoria between 2009 and 2018. Area-level data comprised socio-economic disadvantage and remoteness data at the local government area level in Victoria, Australia. 26 % of patients had PSM, and the rates varied across areas by years. This variation was mainly associated with NCCN risk, followed by RP techniques, surgical institution type, surgeon volume and socio-economic disadvantage. Intermediate (Odds ratio/OR = 1.21,95 % credible interval/Crl = 1.05-1.41), high/very-high risk groups (OR = 2.24,95 % Crl = 1.91-2.64) and public surgical institution (OR = 1.64, 95 % Crl = 1.46-1.84) were independently associated with a higher likelihood of PSM. Robot-assisted (OR = 0.61, 95 % Crl = 0.55-0.68), laparoscopic RP (OR = 0.76, 95 % Crl = 0.62-0.93), high-volume surgeon (OR = 0.84, 95 % Crl = 0.76-0.93) and socio-economically least disadvantaged status (OR = 0.78, 95 % Crl = 0.64-0.94) showed a lower likelihood of PSM. PSM was also independently associated with a higher five-year all-cause and prostate cancer-specific mortality. CONCLUSION Aggressive tumour characteristics and RP techniques were the main contributors to the likelihood of PSM following RP. Reducing the prevalence of PSM will generally improve prostate cancer-specific and all-cause mortality.
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Affiliation(s)
- Win Wah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Nathan Papa
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Melanie Evans
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Susannah Ahern
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Arul Earnest
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Rosenbaum CM, Fisch M, Vetterlein MW. Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy. Front Surg 2020; 7:587271. [PMID: 33324673 PMCID: PMC7725760 DOI: 10.3389/fsurg.2020.587271] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022] Open
Abstract
Vesico-urethral anastomotic stenosis is a well-known sequela after radical prostatectomy for prostate cancer and has significant impact on quality of life. This review aims to summarize contemporary therapeutical approaches and to give an overview of the available evidence regarding endoscopic interventions and open reconstruction. Initial treatment may include dilation, incision or transurethral resection. In treatment-refractory stenoses, open reconstruction via an abdominal (retropubic), transperineal or combined abdominoperineal approach is a viable option with high success rates. All of the open surgical procedures are generally accompanied by a high risk of developing de novo incontinence and patients may need further interventions. In such cases, subsequent artificial urinary sphincter implantation is the most common treatment option with the best available evidence.
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Affiliation(s)
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Kudsi OY, Bou-Ayash N, Gokcal F, Crawford AS, Chang K, Chung SK, Litwin D. Learning Curve of Robotic Rives-Stoppa Ventral Hernia Repair: A Cumulative Sum Analysis. J Laparoendosc Adv Surg Tech A 2020; 31:756-764. [PMID: 33216665 DOI: 10.1089/lap.2020.0624] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Robotic Rives-Stoppa ventral hernia repair (rRS-VHR) is a minimally invasive technique that incorporates extraperitoneal mesh placement, using either transabdominal or totally extraperitoneal access. An understanding of its learning curve and technical challenges may guide and encourage its adoption. We aim at evaluating the rRS-VHR learning curve based on operative times while accounting for adverse outcomes. Materials and Methods: We conducted a retrospective analysis of patients undergoing rRS repair for centrally located ventral and incisional hernias. A single surgeon operative time-based cumulative sum (CUSUM) analysis learning curve was created, and a composite outcome was used for risk-adjusted CUSUM (RA-CUSUM). Results: Eighty-one patients undergoing rRS-VHR were included. A learning curve was created by using skin-to-skin times. Accordingly, patients were grouped into three phases. The mean skin-to-skin time was 72.2 minutes, and there was a significant decrease in skin-to-skin times throughout the learning curve (Phase-I: 86.4 minutes versus Phase-III: 63.8 minutes; P = .001), with a gradual decrease after 29 cases. Eleven patients experienced adverse composite outcomes, which were used to create a RA-CUSUM graph. Results showed the highest adverse outcome rates in Phase-II, with a gradual decrease in risk-adjusted operative times after 51 cases. Conclusions: Consistently decreasing operative times and adverse outcome rates in rRS-VHR was observed after the completion of 29 and 51 cases, respectively. Future studies that provide group learning curves for this procedure can deliver more generalizable results in terms of its performance rates.
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Affiliation(s)
- Omar Yusef Kudsi
- Department of Surgery, Good Samaritan Medical Center, Tufts University School of Medicine, Brockton, Massachusetts, USA
| | - Naseem Bou-Ayash
- Department of Surgery, Good Samaritan Medical Center, Tufts University School of Medicine, Brockton, Massachusetts, USA
| | - Fahri Gokcal
- Department of Surgery, Good Samaritan Medical Center, Tufts University School of Medicine, Brockton, Massachusetts, USA
| | - Allison S Crawford
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Karen Chang
- Department of Surgery, Good Samaritan Medical Center, Tufts University School of Medicine, Brockton, Massachusetts, USA
| | - Sebastian K Chung
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Demetrius Litwin
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Experienced bedside-assistants improve operative outcomes for surgeons early in their learning curve for robot assisted laparoscopic radical prostatectomy. J Robot Surg 2020; 15:619-626. [DOI: 10.1007/s11701-020-01146-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022]
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Sharma G, Madenci AL, Wanis KN, Comment LA, Lotto CE, Shah SK, Ozaki CK, Subramanian SV, Eldrup-Jorgensen J, Belkin M. Association and interplay of surgeon and hospital volume with mortality after open abdominal aortic aneurysm repair in the modern era. J Vasc Surg 2020; 73:1593-1602.e7. [PMID: 32976969 DOI: 10.1016/j.jvs.2020.07.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 07/30/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Operative volume has been used as a marker of quality. Research from previous decades has suggested minimum open abdominal aortic aneurysm (AAA) repair volume requirements for surgeons of 9 to 13 open AAA repairs annually and for hospitals of 18 open AAA repairs annually to purportedly achieve acceptable results. Given concerns regarding the decreased frequency of open repairs in the endovascular era, we examined the association of surgeon and hospital volume with the 30- and 90-day mortality in the Vascular Quality Initiative (VQI) registry. METHODS Patients who had undergone elective open AAA repair from 2013 to 2018 were identified in the VQI registry. We performed a cross-sectional evaluation of the association between the average hospital and surgeon volume and 30-day postoperative mortality using a hierarchical Bayesian model. Cross-level interactions were permitted, and random surgeon- and hospital-level intercepts were used to account for clustering. The mortality results were adjusted by standardizing to the observed distribution of relevant covariates in the overall cohort. The outcomes were compared to the Society for Vascular Surgery guidelines recommended criteria of <5% perioperative mortality. RESULTS A total of 3078 patients had undergone elective open AAA repair by 520 surgeons at 128 hospitals. The 30- and 90-day risks of postoperative mortality were 4.1% (n = 126) and 5.4% (n = 166), respectively. The mean surgeon volume and hospital volume both correlated inversely with the 30-day mortality. Averaged across all patients and hospitals, we found a 96% probability that surgeons who performed an average of four or more repairs per year achieved <5% 30-day mortality. Substantial interplay was present between surgeon volume and hospital volume. For example, at lower volume hospitals performing an average of five repairs annually, <5% 30-day mortality would be expected 69% of the time for surgeons performing an average of three operations annually. In contrast, at higher volume hospitals performing an average of 40 repairs annually, a <5% 30-day mortality would be expected 96% of the time for surgeons performing an average of three operations annually. As hospital volume increased, a diminishing difference occurred in 30-day mortality between lower and higher volume surgeons. Likewise, as surgeon volume increased, a diminishing difference was found in 30-day mortality between the lower and higher volume hospitals. CONCLUSIONS Surgeons and hospitals in the VQI registry achieved mortality outcomes of <5% (Society for Vascular Surgery guidelines), with an average surgeon volume that was substantially lower compared with previous reports. Furthermore, when considering the development of minimal surgeon volume guidelines, it is important to contextualize the outcomes within the hospital volumes.
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Affiliation(s)
- Gaurav Sharma
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass
| | - Arin L Madenci
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass; Harvard T.H. Chan School of Public Health, Boston, Mass
| | | | | | - Christine E Lotto
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass
| | - Samir K Shah
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass; Harvard T.H. Chan School of Public Health, Boston, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass
| | | | | | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center, Harvard Medical School, Boston, Mass.
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Raigosa M, Avvedimento S, Descarrega J, Yuste M, Cruz-Gimeno J, Fontdevila J. Refinement Procedures for Clitorolabiaplasty in Male-to-Female Gender-Affirmation Surgery: More than an Aesthetic Procedure. J Sex Med 2020; 17:2508-2517. [PMID: 32891560 DOI: 10.1016/j.jsxm.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/19/2020] [Accepted: 08/02/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Among the various steps of a penile inversion feminizing genitoplasty, reconstruction of the clitoris and labia minora remains the most challenging procedure. AIM This study aims to evaluate surgical outcomes of neoclitoroplasty performed before and after the introduction of the labia minora's creation in our surgical technique. METHODS A retrospective analysis was carried out comparing 2 groups of patients that underwent penile inversion feminizing surgery: group A (64 patients) who had labia minora and clitoral hood creation and group B (103 patients) who did not. OUTCOMES To describe the surgical technique and outcomes of clitorolabiaplasty in male-to-female gender-affirmation surgery. RESULTS Concerning overall complication rates, there were significant differences in the incidence of hemorrhage and urethral stenosis (P < .01). Hemorrhage surrounding the urethra and labia was identified in 40 patients (group A: n = 8 [12.5%]; group B: n = 32 [31%]) (P = .006). Neomeatal stenosis occurred in 17 patients (group A: n = 1 [1.5%]; group B: n = 16 [15.5%]) (P = .003). Partial necrosis of the clitoris occurred in 2 cases (group A: n = 0; group B: n = 2 [1.9%]) (P = .52). Necrosis of the labia majora occurred in 3 cases (group A: n = 0; group B: n = 3 [2.9%]) (P = .28). 5 patients (group A: n = 2 (3.1%); group B: n = 3 [2.9%]) (P = .93) developed rectovaginal fistula. 6 patients experienced neovaginal canal stricture (group A: n = 3 [4.6%]; group B: n = 3 [2.9%]) (P = .54). 2 patients (group A: n = 0; group B: n = 2 [1.9%]) (P = .52) reported introital stenosis; Persistent granulation tissue inside the neovagina that required in-office treatments occurred in 4 cases (group A: n = 2 [3.1%]; group B: n = 2 [1.9%]) (P = .62). Wound dehiscence occurred in 23 patients (group A: n = 13 [20.3%]; group B: n = 10 [9.7%]) (P = .05). 24 patients (group A: n = 3 [4.6%]; group B: n = 21 [20.3%]) (P = .004) underwent 28 different types of aesthetic refinements. CLINICAL IMPLICATIONS Incorporating the creation of labia minora and clitoral hood in one step is a safe and viable option in patients undergoing male-to-female gender-affirmation surgery. STRENGTHS & LIMITATIONS Strength of the study is the large cohort of patients included and the consistent surgical technique. To our knowledge, this is the first study that compares with a control group, the introduction of labia minora creation in male-to-female gender-affirmation surgery. Limitations include the retrospective nature of the study and the absence of patient-reported outcomes measures. CONCLUSION Technical refinements of our technique led to a significative reduction in urethral stenosis and postoperative hemorrhage without an increased risk of major complications. Raigosa M, Avvedimento S, Descarrega J, et al. Refinement Procedures for Clitorolabiaplasty in Male-to-Female Gender-Affirmation Surgery: More than an Aesthetic Procedure. J Sex Med 2020;17:2508-2517.
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Affiliation(s)
- Mauricio Raigosa
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain.
| | | | - Jordi Descarrega
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain
| | - Marta Yuste
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain
| | - Juan Cruz-Gimeno
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain
| | - Joan Fontdevila
- Plastic and Maxillofacial Dept, Hospital Clinic, Barcelona, Spain
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Ferrari M, Mazzola B, Roggero E, D'Antonio E, Mestre RP, Porcu G, Stoffel F, Renard J. Current evidence between hospital volume and perioperative outcome: Prospective assessment of robotic radical prostatectomy safety profile in a regional center of medium annual caseload. Can Urol Assoc J 2020; 15:E153-E159. [PMID: 32807280 DOI: 10.5489/cuaj.6547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to present the safety profile of robotic radical prostatectomy (RARP) performed in a single center of medium surgical volume since its introduction and identify predictors of postoperative complications. METHODS We prospectively collected clinical data from 317 consecutive patients undergoing RARP between August 2011 and November 2019 in a medium-volume center. Surgical procedures were performed by a single experienced surgeon. Complications were collected according to the Martin criteria for reporting and the Clavien-Dindo classification for rating. Preoperative, intraoperative, and postoperative data were analyzed and compared with available literature. RESULTS A total of 102 complications were observed in 96 (30.3%) patients and were minor in 84.4% of cases (Clavien grade 1 and 2). Transfusion rate was 1.3%. Complications of grade 4b or 5 did not occur. The most frequent complications were urinary retention (7.3%) and anastomotic leak (5.9%). At multivariate analysis, the nerve-sparing technique was an independent predictor of complications (odds ratio [OR] 0.55, p=0.02). CONCLUSIONS The study shows that a high safety profile may be achieved in a medium-volume hospital. The nerve-sparing technique was a predictor of complications. Further studies are needed to define the current relationship between surgical volume and perioperative outcome for RARP.
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Affiliation(s)
- Matteo Ferrari
- Division of Urology, Bellinzona Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Brunello Mazzola
- Division of Urology, Bellinzona Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Enrico Roggero
- Clinic of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Eugenia D'Antonio
- Clinic of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Ricardo Pereira Mestre
- Clinic of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Giovanni Porcu
- Division of Urology, Bellinzona Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Flavio Stoffel
- Division of Urology, Bellinzona Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Julien Renard
- Division of Urology, Bellinzona Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Division of Urology, Geneva University Hospitals, Geneva, Switzerland
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Rezaee ME, Gross MS. AUTHOR REPLY. Urology 2020; 141:70. [PMID: 32591051 DOI: 10.1016/j.urology.2020.01.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael E Rezaee
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH
| | - Martin S Gross
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH.
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[Anastomosis stenosis after radical prostatectomy and bladder neck stenosis after benign prostate hyperplasia treatment: reconstructive options]. Urologe A 2020; 59:398-407. [PMID: 32055934 DOI: 10.1007/s00120-020-01143-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bladder neck stenosis (BNS) after simple prostatectomy and vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy for prostate cancer are common sequelae. However, the two entities differ in their pathology, anatomy and their surgical results. VUAS has an incidence of 0.2-28%. Commonly, VUAS occurs within the first 2 years after surgery. Initial therapy should be performed endourologically: dilatation, (laser) incision or resection. After three unsuccessful treatment attempts, open reconstruction should be considered. Different surgical approaches (abdominal, perineal, abdominoperineal) have been described. All are associated with good success rates. However, they are accompanied by high rates of urinary incontinence. Incontinence can be treated safely by implantation of an artificial urinary sphincter. The incidence of BNS is around 5% for all types of surgery for benign prostate hyperplasia. It occurs within the first 2 years after surgery. Initial treatment should be performed endourologically. In case of recalcitrant BNS, open reconstruction is indicated. The YV-plasty is an established procedure, and the T‑plasty represents a modification. Success rates of both procedures are high. Robot-assisted reconstructive procedures have been described for both VUAS and BNS.
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Dosanjh A, Harvey P, Baldwin S, Mintz H, Evison F, Gallier S, Trudgill N, James ND, Sooriakumaran P, Patel P. High-intensity Focused Ultrasound for the Treatment of Prostate Cancer: A National Cohort Study Focusing on the Development of Stricture and Fistulae. Eur Urol Focus 2020; 7:340-346. [PMID: 31924529 DOI: 10.1016/j.euf.2019.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/25/2019] [Accepted: 11/14/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND High-intensity focused ultrasound (HIFU) is a novel therapy for prostate cancer. Owing to a lack of long-term data, HIFU is recommended for use only in the context of research. OBJECTIVE To examine the trend for HIFU use nationally and rates of strictures and fistulae. DESIGN, SETTING, AND PARTICIPANTS Patients undergoing HIFU for prostate cancer between April 2007 and March 2018 were studied in an English national database (Hospital Episode Statistics). Data on complications were included for patients with a minimum of 1-yr follow-up. Analysis of complications was controlled for other interventions. OUTCOME MEASURES AND STATISTICAL ANALYSIS Descriptive analyses of HIFU rates and the incidence of strictures and fistulae were carried out. Cox and logistic regression models were built for urethral stricture incidence. RESULTS AND LIMITATIONS A total of 2320 HIFU treatments among 1990 patients were identified. The median age was 67yr (interquartile range 61-72). Some 1742 patients met the criteria for follow-up analysis. The highest-volume centre performed 1513 HIFU procedures, followed by 194 at the second highest. The number of HIFU procedures increased annually, rising from 196 to 283 per year. There were 208 patients (11.9%) who went on to have radiotherapy and 102 (5.9%) radical prostatectomy after HIFU. Following HIFU, stricture developed in 133/1290 patients (10.3%) and urinary fistula in 16/1240 (1.3%) before any further intervention. More recent years for HIFU were associated with a lower likelihood of stricture formation (2016/2017 vs 2007/2008: hazard ratio 0.30, 95% confidence interval 0.11-0.79; p=0.015). Limitations include the lack of staging information and unknown rates of HIFU outside of publicly funded health care. CONCLUSIONS HIFU is performed at a large number of low-volume centres and complication rates do not differ from those for established therapies. PATIENT SUMMARY This report highlights the trend for provision of high-intensity focused ultrasound treatment for prostate cancer in England. The results suggest that the rate of urethral structural complications may not be lower than that for established prostate cancer treatments.
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Affiliation(s)
- Amandeep Dosanjh
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Philip Harvey
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Simon Baldwin
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Harriet Mintz
- Warwick Medical School, University of Warwick, Warwick, UK
| | - Felicity Evison
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Suzy Gallier
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nigel Trudgill
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nicholas D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Prasanna Sooriakumaran
- Department of Uro-oncology, University College London Hospital, London, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Prashant Patel
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
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Tang L, Day AT, Lee R, Gordin E, Emerick K, Patel UA, Deschler DG, Richmon JD. Submental flap practice patterns and perceived outcomes: A survey of 212 AHNS surgeons. Am J Otolaryngol 2020; 41:102291. [PMID: 31732308 DOI: 10.1016/j.amjoto.2019.102291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 09/09/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To describe American Head and Neck Society (AHNS) surgeon submental flap (SMF) practice patterns and to evaluate variables associated with SMF complications. METHODS The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between 11/11/16 and 12/31/16. Surgeon demographics, training, practice patterns and techniques were characterized and evaluated for associations with frequency of SMF complications. RESULTS Among 212 AHNS surgeons, 108 (50.9%) reported performing SMFs, of whom 86 provided complete responses. Most surgeons who performed the SMF routinely reconstructed oral cavity defects with the flap (86.1%, n = 74). Thirty-seven surgeons (43.0%) experienced "very few" complications with the SMF. Surgeons who practiced in the United States versus internationally (p = 0.003), performed more total career SMFs (p = 0.02), and routinely reconstructed parotid and oropharyngeal defects (p = 0.04 and p < 0.001) with SMFs were more frequently perceived to have "very few" complications. SMF surgeons reported more perceived complications with the SMF compared to pectoralis major (p = 0.001) and radial forearm free flaps (p = 0.01). However, similar perceived complications were reported between all three flaps when surgeons performed >30 SMF. Among 94 surgeons not performing SMFs, 71.3% had interest in a SMF training course. CONCLUSIONS Practice patterns of surgeons performing SMFs are diverse, although most use the flap for oral cavity reconstruction. While 43% of surgeons performing the SMF reported "very few" complications, overall complication rates with the SMF were higher compared to other flaps, potentially due to limited experience with the SMF. Increased training opportunities in SMF harvest and inset are indicated.
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Motterle G, Morlacco A, Zanovello N, Ahmed ME, Zattoni F, Karnes RJ, Dal Moro F. Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review. J Endourol 2019; 34:113-120. [PMID: 31797684 DOI: 10.1089/end.2019.0716] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Purpose: Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. Materials and Methods: In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Results: Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Conclusion: Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.
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Affiliation(s)
- Giovanni Motterle
- Dipartimento di Scienze Oncologiche, Chirurgiche e Gastroenterologiche, UOC Urologia, Universita' degli Studi di Padova, Padova.,Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Alessandro Morlacco
- Dipartimento di Scienze Oncologiche, Chirurgiche e Gastroenterologiche, UOC Urologia, Universita' degli Studi di Padova, Padova
| | - Nicola Zanovello
- Dipartimento di Scienze Oncologiche, Chirurgiche e Gastroenterologiche, UOC Urologia, Universita' degli Studi di Padova, Padova
| | | | - Filiberto Zattoni
- Dipartimento di Scienze Oncologiche, Chirurgiche e Gastroenterologiche, UOC Urologia, Universita' degli Studi di Padova, Padova
| | | | - Fabrizio Dal Moro
- Dipartimento di Scienze Oncologiche, Chirurgiche e Gastroenterologiche, UOC Urologia, Universita' degli Studi di Padova, Padova.,Clinica Urologica di Udine, Azienda Sanitaria Universitaria Integrata di Udine, Italy
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Modig KK, Godtman RA, Bjartell A, Carlsson S, Haglind E, Hugosson J, Månsson M, Steineck G, Thorsteinsdottir T, Tyritzis S, Lantz AW, Wiklund P, Stranne J. Vesicourethral Anastomotic Stenosis After Open or Robot-assisted Laparoscopic Retropubic Prostatectomy-Results from the Laparoscopic Prostatectomy Robot Open Trial. Eur Urol Focus 2019; 7:317-324. [PMID: 31711932 DOI: 10.1016/j.euf.2019.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/25/2019] [Accepted: 10/17/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vesicourethral anastomotic stenosis is a well-known late complication after open radical retropubic prostatectomy (RRP) with previously reported incidences of 2.7-15%. There are few reports of the incidence after robot-assisted laparoscopic radical prostatectomy (RALP) compared with RRP. OBJECTIVE The aim was to compare the risk of developing symptomatic stenosis after RRP and RALP, and to explore potential risk factors and the influence of stenosis on the risk of urinary incontinence. DESIGN, SETTING, AND PARTICIPANTS Between 2008 and 2011, 4003 men were included in a prospective trial comparing RRP and RALP at 14 Swedish centres. Clinical data and patient questionnaires were collected before, during, and after surgery. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Stenosis was identified by either patients' reports in questionnaires or case report forms. The primary endpoint is reported as unadjusted as well as adjusted relative risks (RRs), calculated with log-binomial regression models. Data on incontinence were analysed by means of a log-binomial regression model, with stenosis as an independent and incontinence as a dependent variable. RESULTS AND LIMITATIONS Symptomatic stenosis developed in 1.9% of 3706 evaluable men within 24 mo. The risk was 2.2 times higher after RRP than after RALP (RR 2.21, 95% confidence interval [CI] 1.38-3.53). Overall, urinary incontinence was twice as common in patients who had stenosis (RR 2.01, 95% CI 1.43-2.64). CONCLUSIONS This large prospective study found an overall low rate of vesicourethral anastomotic stenosis after radical prostatectomy, but the rate was significantly lower after robot-assisted prostatectomy. The risk of stenosis seems to be associated with the number of sutures/takes in the anastomosis, but this was statistically significant only in the RALP group. PATIENT SUMMARY We investigated the risk of developing vesicourethral anastomotic stenosis after open and robot-assisted radical prostatectomy. We found that the risk was generally lower than previously reported and lower after robot-assisted radical prostatectomy than after radical retropubic prostatectomy. Urinary incontinence was twice as common in patients with stenosis.
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Affiliation(s)
- Katarina Koss Modig
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Rebecka Arnsrud Godtman
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Bjartell
- Department of Urology, Skåne University Hospital, Malmö, Sweden; Division of Urological Cancers, Department of Translational Medicine, Faculty of Medicine, Lund University, Lund, Sweden
| | - Stefan Carlsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Scandinavian Surgical Outcomes Research Group, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marianne Månsson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gunnar Steineck
- Division of Clinical Cancer Epidemiology,Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Oncology andPathology, Division of Clinical Cancer Epidemiology, Karolinska Institute, Stockholm, Sweden
| | - Thordis Thorsteinsdottir
- Research Institute in Emergency Care, Landspitali University Hospital, Reykjavik, Iceland; Faculty of Nursing, University of Iceland, Reykjavik, Iceland
| | - Stavros Tyritzis
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden; Department of Urology, Hygeia Hospital, Athens, Greece
| | - Anna Wallerstedt Lantz
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden; Icahn School of medicine at Mount Sinai Health System, New York City, NY, USA
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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The Impact of Experience on the Risk of Surgical Margins and Biochemical Recurrence after Robot-Assisted Radical Prostatectomy: A Learning Curve Study. J Urol 2019; 202:108-113. [PMID: 30747873 DOI: 10.1097/ju.0000000000000147] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Improved cancer control with increasing surgical experience (the learning curve) has been demonstrated for open and laparoscopic prostatectomy. We assessed the relationship between surgical experience and oncologic outcomes of robot-assisted radical prostatectomy. MATERIALS AND METHODS We analyzed the records of 1,827 patients in whom prostate cancer was treated with robot-assisted radical prostatectomy. Surgical experience was coded as the total number of robotic prostatectomies performed by the surgeon before the patient operation. We evaluated the relationship of prior surgeon experience to the probability of positive margins and biochemical recurrence in regression models adjusting for stage, grade and prostate specific antigen. RESULTS After adjusting for case mix, greater surgeon experience was associated with a lower probability of positive surgical margins (p = 0.035). The risk of positive margins decreased from 16.7% to 9.6% in patients treated by a surgeon with 10 and 250 prior procedures, respectively (risk difference 7.1%, 95% CI 1.7-12.2). In patients with nonorgan confined disease the predicted probability of positive margins was 38.4% in those treated by surgeons with 10 prior operations and 24.9% in those treated by surgeons with 250 prior operations (absolute risk reduction 13.5%, 95% CI -3.4-22.5). The relationship between surgical experience and the risk of biochemical recurrence after surgery was not significant (p = 0.8). CONCLUSIONS Specific techniques used by experienced surgeons which are associated with improved margin rates need further research. The impact of experience on cancer control after robotic prostatectomy differed from that in the prior literature on open and laparoscopic radical prostatectomy, and should be investigated in larger multi-institutional studies.
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High-volume hospitals are associated with lower mortality among high-risk emergency general surgery patients. J Trauma Acute Care Surg 2019; 85:560-565. [PMID: 29787533 DOI: 10.1097/ta.0000000000001985] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION We have previously demonstrated that Emergency General Surgery (EGS) patients treated at high-volume hospitals experience lower mortality rates than those treated at low-volume hospitals. However, EGS comprises a wide spectrum of diseases. Our goal was to determine which EGS diseases had better outcomes at high-volume hospitals. METHODS We undertook a retrospective analysis of the National Inpatient Sample database for 2013 (a nationwide representative sample). Patients with EGS diseases were identified using American Association for the Surgery of Trauma definitions. A hierarchical logistic regression model was used to measure risk-adjusted probability of death, adjusting for age, sex, race, ethnicity, insurance type, and comorbidities. Patients were then grouped into 16 risk groups based upon their predicted probability of death. We then compared observed mortality rates at high- versus low-volume hospitals within each risk group. RESULTS Nationwide, 3,006,615 patients with EGS diseases were treated at 4,083 hospitals in 2013. Patients with predicted risk of death of 4% or higher (275,615 patients, 9.2%) had lower observed mortality rates at high-volume hospitals than at low-volume hospitals (7.7% vs. 10.2%, p < 0.001). We estimated that 1,002 deaths were potentially preventable if high-risk patients who were treated at low-volume hospitals were instead transferred to high-volume hospitals. CONCLUSION EGS patients with predicted risk of death of 4% or higher experience lower mortality rates at high-volume hospitals than at low-volume hospitals. A regional system of EGS care that enables rapid transfer of high-risk patients to high-volume hospitals may prevent several deaths. LEVEL OF EVIDENCE Prognostic and epidemiological, level III; Therapeutic/Case Management, level IV.
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A Contemporary Analysis of Pediatric Urology Surgical Volume at a Tertiary Care Center. Urology 2019; 125:179-183. [PMID: 30610906 DOI: 10.1016/j.urology.2018.12.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the annual volume of pediatric urology cases in an academic, tertiary care setting. METHODS A retrospective review was performed of all patients operated on by 4 pediatric urologists (total of 2.5 full-time equivalents) at an academic, tertiary care center with a free-standing children's hospital from 2016 to 2017 (24 months). Basic case information was collected from operative reports. Descriptive statistics are reported using nonparametric methods. "Uncommon" was defined a priori as occurring <10% of the time. RESULTS During the entire study period, 2718 patients underwent 4580 procedures. This equated to 1088 patients and 1832 procedures per full-time equivalent. Median age at surgery was 3.2 years (IQR 0.8-10) and 757 (16.5%) of patients were female. Most procedures were elective (4406, 96.2%) and did not require postoperative admission (3842, 83.9%). Urgent and emergent cases were uncommon (174, 3.8%). Most cases were classified as general pediatric urology (3894, 85%) with 319 (7%) classified as major reconstruction, 275 (6%) as laparoscopy/endourology and 92 (2%) as oncology. The most common cases involved the groin/scrotum (1415, 30.9%), prepuce (809, 17.7%), phallus (802, 17.5%), and endoscopy (652, 14.2%). All other case types were uncommon. CONCLUSION This description of an academic pediatric urology practice at a tertiary care center with a free-standing children's hospital noted a high volume of elective, outpatient procedures that are largely general pediatric urology. Uncommon cases include urgent/emergent interventions, major reconstruction, laparoscopy/endourology, and oncology procedures.
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Canning DA. Re: Hypospadias Surgery in England: Higher Volume Centres Have Lower Complication Rates. J Urol 2018; 200:485-487. [PMID: 30412959 DOI: 10.1016/j.juro.2018.05.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2018] [Indexed: 11/16/2022]
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McDowell B, Bremer W, Ray CE. A Complication of Ultrasound-Guided Inferior Vena Cava Filter Placement. Semin Intervent Radiol 2018; 35:356-358. [PMID: 30402019 DOI: 10.1055/s-0038-1669469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Benjamin McDowell
- Department of Radiology, University of Illinois Health, Chicago, Illinois
| | - William Bremer
- Department of Radiology, University of Illinois Health, Chicago, Illinois
| | - Charles E Ray
- Department of Radiology, University of Illinois Health, Chicago, Illinois
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Surgeon-driven variability in emergency general surgery outcomes: Does it matter who is on call? Surgery 2018; 164:1109-1116. [DOI: 10.1016/j.surg.2018.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/07/2018] [Accepted: 07/09/2018] [Indexed: 11/21/2022]
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Cheraghlou S, Agogo GO, Girardi M. Treatment of primary nonmetastatic melanoma at high-volume academic facilities is associated with improved long-term patient survival. J Am Acad Dermatol 2018; 80:979-989. [PMID: 30365997 DOI: 10.1016/j.jaad.2018.10.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/04/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Previous studies of cancer care have demonstrated improved long-term patient outcomes for those treated at high-volume centers. The influence of treatment center characteristics on outcomes for primary nonmetastatic melanoma is not currently established. OBJECTIVE We aimed to investigate the association of cancer treatment center case volume and academic affiliation with long-term patient survival for cases of primary nonmetastatic melanoma. METHODS Cases of melanoma diagnosed in US adults from 2004 to 2014 and included in the National Cancer Database were identified. Hospitals were grouped by yearly case-volume quartile: bottom quartile, 2 middle quartiles, and top quartile. RESULTS Facility case volume was significantly associated with long-term patient survival (P < .0001). The 5-year survival rates were 76.8%, 81.9%, and 86.4% for patients treated at institutions in the bottom, middle, and top quartiles of case volume, respectively. On multivariate analysis, treatment at centers in both middle quartiles (hazard ratio, 0.834; 95% confidence interval, 0.778-0.895) and in the top quartile (hazard ratio, 0.691; 95% confidence interval, 0.644-0.741) of case volume was associated with improved survival relative to that of patients treated at hospitals in the bottom quartile of case volume. Academic affiliation was associated with improved outcomes for top-quartile- but not middle-quartile-volume facilities. LIMITATIONS Disease-specific survival was not available. CONCLUSIONS Treatment at a high-volume facility is associated with improved long-term patient survival for melanoma. High-volume academic centers have improved patient outcomes compared with other high-volume centers.
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Affiliation(s)
- Shayan Cheraghlou
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - George O Agogo
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael Girardi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Jang TL, Patel N, Faiena I, Radadia K, Moore DF, Elsamra SE, Singer EA, Stein MN, Lin Y, Kim IY, Eastham JA, Scardino PT, Lu-Yao GL. Comparative effectiveness of radical prostatectomy with adjuvant radiotherapy versus radiotherapy plus androgen deprivation therapy for men with advanced prostate cancer. Cancer 2018; 124:4010-4022. [PMID: 30252932 PMCID: PMC6234085 DOI: 10.1002/cncr.31726] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/11/2018] [Accepted: 07/09/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Men with locally advanced prostate cancer (LAPCa) or regionally advanced prostate cancer (RAPCa) are at high risk for death from their disease. Clinical guidelines support multimodal approaches, which include radical prostatectomy (RP) followed by radiotherapy (XRT) and XRT plus androgen deprivation therapy (ADT). However, there are limited data comparing these substantially different treatment approaches. Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study compared survival outcomes and adverse effects associated with RP plus XRT versus XRT plus ADT in these men. METHODS SEER-Medicare data were queried for men with cT3-T4N0M0 (LAPCa) or cT3-T4N1M0 (RAPCa) prostate cancer. Propensity score methods were used to balance cohort characteristics between the treatment arms. Survival analyses were analyzed with the Kaplan-Meier method and Cox proportional hazards models. RESULTS From 1992 to 2009, 13,856 men (≥65 years old) were diagnosed with LAPCa or RAPCa: 6.1% received RP plus XRT, and 23.6% received XRT plus ADT. At a median follow-up of 14.6 years, there were 2189 deaths in the cohort, of which 702 were secondary to prostate cancer. Regardless of the tumor stage or the Gleason score, the adjusted 10-year prostate cancer-specific survival and 10-year overall survival favored men who underwent RP plus XRT over men who underwent XRT plus ADT. However, RP plus XRT versus XRT plus ADT was associated with higher rates of erectile dysfunction (28% vs 20%; P = .0212) and urinary incontinence (49% vs 19%; P < .001). CONCLUSIONS Men with LAPCa or RAPCa treated initially with RP plus XRT had a lower risk of prostate cancer-specific death and improved overall survival in comparison with those men treated with XRT plus ADT, but they experienced higher rates of erectile dysfunction and urinary incontinence.
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Affiliation(s)
- Thomas L. Jang
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Neal Patel
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Izak Faiena
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Kushan Radadia
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Dirk F. Moore
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sammy E. Elsamra
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Eric A. Singer
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Mark N. Stein
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Yong Lin
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Isaac Y. Kim
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - James A. Eastham
- Memorial Sloan-Kettering Cancer Center, Department of Surgery, Urology Service, Weill Cornell Medical College, New York, NY
| | - Peter T. Scardino
- Memorial Sloan-Kettering Cancer Center, Department of Surgery, Urology Service, Weill Cornell Medical College, New York, NY
| | - Grace L. Lu-Yao
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Department of Medical Oncology, Sidney Kimmel Medical College, Jefferson College of Population Health, Philadelphia, PA (GLY)
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Campos-Juanatey F, Portillo Martín JA. [Management of vesicourethral anastomotic stenosis after radical prostatectomy]. Rev Int Androl 2018; 17:110-118. [PMID: 30237067 DOI: 10.1016/j.androl.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/13/2018] [Accepted: 05/20/2018] [Indexed: 11/24/2022]
Abstract
Vesicourethral anastomotic stenosis is a relatively uncommon problem after radical prostatectomy, but it could become recurrent and difficult to treat. Risk factors are known, and they can help to decrease the incidence. When discussing the therapeutic plan, we must consider the stenosis risk, and also the urinary continence after the prostatectomy. Many treatment schedules are proposed, some of them with low available evidence, limited to case series with different number of patient and follow-up length, or reviews on the subject. Endoscopic options are the commonest, obtaining different success rates depending on the incision, resection or vaporization of the tissue. They could also benefit from the use of adjuvant local injections of drugs regulating tissue growth. Recurrent or obliterated cases could require surgical reconstruction using perineal, abdominal or combined approaches, or even suprapubic urinary diversions.
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Affiliation(s)
- Félix Campos-Juanatey
- Servicio de Urología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
| | - José Antonio Portillo Martín
- Servicio de Urología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España; Facultad de Medicina, Universidad de Cantabria, Santander, Cantabria, España
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Chen MM, Megwalu UC, Liew J, Sirjani D, Rosenthal EL, Divi V. Regionalization of head and neck cancer surgery may fragment care and impact overall survival. Laryngoscope 2018; 129:1413-1419. [DOI: 10.1002/lary.27440] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/31/2018] [Accepted: 06/20/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michelle M. Chen
- Department of Otolaryngology–Head and Neck SurgeryStanford University Palo Alto California
- Department of OtolaryngologyPalo Alto Veterans Administration Palo Alto California
| | - Uchechukwu C. Megwalu
- Department of Otolaryngology–Head and Neck SurgeryStanford University Palo Alto California
| | - Jazmine Liew
- New York Medical College School of Medicine Valhalla New York U.S.A
| | - Davud Sirjani
- Department of Otolaryngology–Head and Neck SurgeryStanford University Palo Alto California
- Department of OtolaryngologyPalo Alto Veterans Administration Palo Alto California
| | - Eben L. Rosenthal
- Department of Otolaryngology–Head and Neck SurgeryStanford University Palo Alto California
| | - Vasu Divi
- Department of Otolaryngology–Head and Neck SurgeryStanford University Palo Alto California
- Department of OtolaryngologyPalo Alto Veterans Administration Palo Alto California
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Clark DM. Realizing the Mass Public Benefit of Evidence-Based Psychological Therapies: The IAPT Program. Annu Rev Clin Psychol 2018; 14:159-183. [PMID: 29350997 PMCID: PMC5942544 DOI: 10.1146/annurev-clinpsy-050817-084833] [Citation(s) in RCA: 248] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Empirically supported psychological therapies have been developed for many mental health conditions. However, in most countries only a small proportion of the public benefit from these advances. The English Improving Access to Psychological Therapies (IAPT) program aims to bridge the gap between research and practice by training over 10,500 new psychological therapists in empirically supported treatments and deploying them in new services for the treatment of depression and anxiety disorders. Currently IAPT treats over 560,000 patients per year, obtains clinical outcome data on 98.5% of these individuals, and places this information in the public domain. Around 50% of patients treated in IAPT services recover, and two-thirds show worthwhile benefits. The clinical and economic arguments on which IAPT is based are presented, along with details of the service model, how the program was implemented, and recent findings about service organization. Limitations and future directions are outlined.
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Affiliation(s)
- David M Clark
- Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, OX1 1TW Oxford, United Kingdom;
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Clark DM. Realizing the Mass Public Benefit of Evidence-Based Psychological Therapies: The IAPT Program. Annu Rev Clin Psychol 2018. [PMID: 29350997 DOI: 10.1146/annurev-clinpsy-050817-084833.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Empirically supported psychological therapies have been developed for many mental health conditions. However, in most countries only a small proportion of the public benefit from these advances. The English Improving Access to Psychological Therapies (IAPT) program aims to bridge the gap between research and practice by training over 10,500 new psychological therapists in empirically supported treatments and deploying them in new services for the treatment of depression and anxiety disorders. Currently IAPT treats over 560,000 patients per year, obtains clinical outcome data on 98.5% of these individuals, and places this information in the public domain. Around 50% of patients treated in IAPT services recover, and two-thirds show worthwhile benefits. The clinical and economic arguments on which IAPT is based are presented, along with details of the service model, how the program was implemented, and recent findings about service organization. Limitations and future directions are outlined.
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Affiliation(s)
- David M Clark
- Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, OX1 1TW Oxford, United Kingdom;
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Bastawrous A, Baer C, Rashidi L, Neighorn C. Higher robotic colorectal surgery volume improves outcomes. Am J Surg 2018; 215:874-878. [DOI: 10.1016/j.amjsurg.2018.01.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 12/28/2022]
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Lee JE, Park EC, Jang SY, Lee SA, Choy YS, Kim TH. Effects of Physician Volume on Readmission and Mortality in Elderly Patients with Heart Failure: Nationwide Cohort Study. Yonsei Med J 2018; 59:243-251. [PMID: 29436192 PMCID: PMC5823826 DOI: 10.3349/ymj.2018.59.2.243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 12/13/2017] [Accepted: 12/19/2017] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Readmission and mortality rates of patients with heart failure are good indicators of care quality. To determine whether hospital resources are associated with care quality for cardiac patients, we analyzed the effect of number of physicians and the combined effects of number of physicians and beds on 30-day readmission and 1-year mortality. MATERIALS AND METHODS We used national cohort sample data of the National Health Insurance Service (NHIS) claims in 2002-2013. Subjects comprised 2345 inpatients (age: >65 years) admitted to acute-care hospitals for heart failure. A multivariate Cox regression was used. RESULTS Of the 2345 patients hospitalized with heart failure, 812 inpatients (34.6%) were readmitted within 30 days and 190 (8.1%) had died within a year. Heart-failure patients treated at hospitals with low physician volumes had higher readmission and mortality rates than high physician volumes [30-day readmission: hazard ratio (HR)=1.291, 95% confidence interval (CI)=1.020-1.633; 1-year mortality: HR=2.168, 95% CI=1.415-3.321]. Patients admitted to hospitals with low or middle bed and physician volume had higher 30-day readmission and 1-year mortality rates than those admitted to hospitals with high volume (30-day readmission: HR=2.812, 95% CI=1.561-5.066 for middle-volume beds & low-volume physicians, 1-year mortality: HR=8.638, 95% CI=2.072-36.02 for middle-volume beds & low-volume physicians). CONCLUSION Physician volume is related to lower readmission and mortality for heart failure. Of interest, 30-day readmission and 1-year mortality were significantly associated with the combined effects of physician and institution bed volume.
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Affiliation(s)
- Joo Eun Lee
- Department of Public Health, Yonsei University College of Medicine, Seoul, Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Cheol Park
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk Yong Jang
- Department of Preventive Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Sang Ah Lee
- Department of Public Health, Yonsei University College of Medicine, Seoul, Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Soo Choy
- Department of Public Health, Yonsei University College of Medicine, Seoul, Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hyun Kim
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
- Department of Hospital Administration, Graduate School of Public Health, Yonsei University, Seoul, Korea.
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Sujenthiran A, Nossiter J, Parry M, Charman SC, Aggarwal A, Payne H, Dasgupta P, Clarke NW, van der Meulen J, Cathcart P. National cohort study comparing severe medium-term urinary complications after robot-assisted vs laparoscopic vs retropubic open radical prostatectomy. BJU Int 2018; 121:445-452. [PMID: 29032582 PMCID: PMC5873443 DOI: 10.1111/bju.14054] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the occurrence of severe urinary complications within 2 years of surgery in men undergoing either robot-assisted radical prostatectomy (RARP), laparoscopic radical prostatectomy (LRP) or retropubic open radical prostatectomy (ORP). PATIENTS AND METHODS We conducted a population-based cohort study in men who underwent RARP (n = 4 947), LRP (n = 5 479) or ORP (n = 6 873) between 2008 and 2012 in the English National Health Service (NHS) using national cancer registry records linked to Hospital Episodes Statistics, an administrative database of admissions to NHS hospitals. We identified the occurrence of any severe urinary or severe stricture-related complication within 2 years of surgery using a validated tool. Multi-level regression modelling was used to determine the association between the type of surgery and occurrence of complications, with adjustment for patient and surgical factors. RESULTS Men undergoing RARP were least likely to experience any urinary complication (10.5%) or a stricture-related complication (3.3%) compared with those who had LRP (15.8% any or 5.7% stricture-related) or ORP (19.1% any or 6.9% stricture-related). The impact of the type of surgery on the occurrence of any urinary or stricture-related complications remained statistically significant after adjustment for patient and surgical factors (P < 0.01). CONCLUSION Men who underwent RARP had the lowest risk of developing severe urinary complications within 2 years of surgery.
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Affiliation(s)
| | - Julie Nossiter
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Matthew Parry
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Susan C. Charman
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ajay Aggarwal
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Heather Payne
- Department of OncologyUniversity College London HospitalsLondonUK
| | | | - Noel W. Clarke
- Department of UrologyChristie and Salford Royal NHS Foundation TrustsManchesterUK
| | - Jan van der Meulen
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Paul Cathcart
- Department of UrologyGuy's and St Thomas' NHS Foundation TrustLondonUK
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Clark DM, Canvin L, Green J, Layard R, Pilling S, Janecka M. Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data. Lancet 2018; 391:679-686. [PMID: 29224931 PMCID: PMC5820411 DOI: 10.1016/s0140-6736(17)32133-5] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 07/09/2017] [Accepted: 07/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Internationally, the clinical outcomes of routine mental health services are rarely recorded or reported; however, an exception is the English Improving Access to Psychological Therapies (IAPT) service, which delivers psychological therapies recommended by the National Institute for Health and Care Excellence for depression and anxiety disorders to more than 537 000 patients in the UK each year. A session-by-session outcome monitoring system ensures that IAPT obtains symptom scores before and after treatment for 98% of patients. Service outcomes can then be reported, along with contextual information, on public websites. METHODS We used publicly available data to identify predictors of variability in clinical performance. Using β regression models, we analysed the outcome data released by National Health Service Digital and Public Health England for the 2014-15 financial year (April 1, 2014, to March 31, 2015) and developed a predictive model of reliable improvement and reliable recovery. We then tested whether these predictors were also associated with changes in service outcome between 2014-15 and 2015-16. FINDINGS Five service organisation features predicted clinical outcomes in 2014-15. Percentage of cases with a problem descriptor, number of treatment sessions, and percentage of referrals treated were positively associated with outcome. The time waited to start treatment and percentage of appointments missed were negatively associated with outcome. Additive odd ratios suggest that moving from the lowest to highest level on an organisational factor could improve service outcomes by 11-42%, dependent on the factor. Consistent with a causal model, most organisational factors also predicted between-year changes in outcome, together accounting for 33% of variance in reliable improvement and 22% for reliable recovery. Social deprivation was negatively associated with some outcomes, but the effect was partly mitigated by the organisational factors. INTERPRETATION Traditionally, efforts to improve mental health outcomes have largely focused on the development of new and more effective treatments. Our analyses show that the way psychological therapy services are implemented could be similarly important. Mental health services elsewhere in the UK and in other countries might benefit from adopting IAPT's approach to recording and publicly reporting clinical outcomes. FUNDING Wellcome Trust.
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Affiliation(s)
- David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK; The Oxford Academic Health Sciences Network, Oxford, UK.
| | - Lauren Canvin
- Department of Experimental Psychology, University of Oxford, Oxford, UK; The Oxford Academic Health Sciences Network, Oxford, UK
| | - John Green
- Department of Clinical Health Psychology, Central and North West London National Health Service Trust, London, UK
| | - Richard Layard
- Centre for Economic Performance, London School of Economics, London, UK
| | - Stephen Pilling
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Magdalena Janecka
- Seaver Autism Center, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Jin C, Hanna T, Cook E, Miao Q, Brundage M. Variation in Radiotherapy Referral and Treatment for High-risk Pathological Features after Radical Prostatectomy: Results from a Population-based Study. Clin Oncol (R Coll Radiol) 2018; 30:47-56. [DOI: 10.1016/j.clon.2017.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 10/18/2022]
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Rocco NR, Zuckerman JM. An update on best practice in the diagnosis and management of post-prostatectomy anastomotic strictures. Ther Adv Urol 2017; 9:99-110. [PMID: 28588647 PMCID: PMC5444622 DOI: 10.1177/1756287217701391] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/06/2017] [Indexed: 12/30/2022] Open
Abstract
Postprostatectomy vesicourethral anastomotic stenosis (VUAS) remains a challenging problem for both patient and urologist. Improved surgical techniques and perioperative identification and treatment of risk factors has led to a decline over the last several decades. High-level evidence to guide management is lacking, primarily relying on small retrospective studies and expert opinion. Endourologic therapies, including dilation and transurethral incision or resection with or without adjunct injection of scar modulators is considered first-line management. Recalcitrant VUAS requires surgical reconstruction of the vesicourethral anastomosis, and in poor surgical candidates, a chronic indwelling catheter or urinary diversion may be the only option. This review provides an update in the diagnosis and management of postprostatectomy VUAS.
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Affiliation(s)
| | - Jack M Zuckerman
- Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
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Wilkinson DJ, Green PA, Beglinger S, Myers J, Hudson R, Edgar D, Kenny SE. Hypospadias surgery in England: Higher volume centres have lower complication rates. J Pediatr Urol 2017; 13:481.e1-481.e6. [PMID: 28434634 DOI: 10.1016/j.jpurol.2017.01.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/08/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Hypospadias surgery has progressed steadily over recent years. There remains considerable variation in the operative management of boys with hypospadias in the UK, and it is therefore difficult to identify acceptable standards with regards to reoperation rates. OBJECTIVE To determine the frequency of reoperations and complications from all centres performing hypospadias surgery in England and to identify variables that influence outcome. METHODS All children undergoing NHS hypospadias surgery in England between 1999 and 2009 were identified using the Hospital Episode Statistics database. Patient demographics, centre type, and associated diagnostic (ICD-10) and treatment codes (OPCS4.6) were collected for both primary repairs and postoperative complications. Centres were classed as high volume if they performed an average of 20 or more operations a year. Operative complications were split into revisions (repeat repairs), repairs of urethral fistulae, repairs of meatal stenosis, or urethral stricture repairs. Statistical analysis included logistic regression, Spearman's correlation, and Mann-Whitney U for non-parametric data, with p < 0.05 taken as significant. Data are presented as median (interquartile range) unless otherwise stated. RESULTS children underwent a total of 23,962 operations at 75 centres in England during the study period. The median age at primary repair was 21 (15-38) months. The overall complication rate was 18.1%. The median complication rate for individual centres was 20.0% (13.9-27.4%) overall; 10.8% (4.7-15.9%) for revision procedures, 8.1% (5.5-11.7%) for urethral fistulae, 2.3% (1.1-3.7%) for meatal stenosis repairs, and 1.8% (0-2.8%) for urethral strictures. High volume centres had significantly lower complication rates than low volume centres (17.5% vs. 25%, p = 0.01) (Figure), and this was proven to be an independent predictor of outcomes (p = 0.01). Staged repairs were associated with more complications (p < 0.001); however, patient age and centre type were not. Median time to repair of complication was 13 (8-22) months. DISCUSSION This national population-based study used hospital episode statistics data. While accuracy is high and it has been validated for use in research, it has intrinsic limitations which affect our study. We are unable to fully account for the severity of hypospadias or the number of operating surgeons within institutions. CONCLUSIONS This study has found a clear relationship between caseload volume and complications following hypospadias surgery. Furthermore, there is significant variability between centres in terms of their surgical outcomes. Taken together these results suggest that surgeons, particularly those in centres with small caseloads should assess their results against such benchmarks when evaluating the service they provide.
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Affiliation(s)
- David J Wilkinson
- University of Liverpool, Liverpool, UK; Department of Paediatric Surgery, Alder Hey Children's Hospital, NHS Foundation Trust, Liverpool, UK
| | - Patrick A Green
- University of Liverpool, Liverpool, UK; Royal Liverpool Hospital, Prescott Street, Liverpool, UK
| | | | | | | | | | - Simon E Kenny
- University of Liverpool, Liverpool, UK; Department of Paediatric Surgery, Alder Hey Children's Hospital, NHS Foundation Trust, Liverpool, UK.
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Kranz J, Reiss PC, Salomon G, Steffens J, Fisch M, Rosenbaum CM. Differences in Recurrence Rate and De Novo Incontinence after Endoscopic Treatment of Vesicourethral Stenosis and Bladder Neck Stenosis. Front Surg 2017; 4:44. [PMID: 28848735 PMCID: PMC5554361 DOI: 10.3389/fsurg.2017.00044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/24/2017] [Indexed: 12/19/2022] Open
Abstract
Objectives The objective of this study was to compare the recurrence rate and de novo incontinence after endoscopic treatment of vesicourethral stenosis (VUS) after radical prostatectomy (RP) and for bladder neck stenosis (BNS) after transurethral resection of the prostate (TURP). Methods Retrospective analysis of patients treated endoscopically for VUS after RP or for BNS after TURP at three German tertiary care centers between March 2009 and June 2016. Investigated endpoints were recurrence rate and de novo incontinence. Chi-squared tests and t-tests were used to model the differences between groups. Results A total of 147 patients underwent endoscopic therapy for VUS (59.2%) or BNS (40.8%). Mean age was 68.3 years (range 44–86), mean follow-up 27.1 months (1–98). Mean time to recurrence after initial therapy was 23.9 months (1–156), mean time to recurrence after prior endoscopic therapy for VUS or BNS was 12.0 months (1–159). Patients treated for VUS underwent significantly more often radiotherapy prior to endoscopic treatment (33.3 vs. 13.3%; p = 0.006) and the recurrence rate was significantly higher (59.8 vs. 41.7%; p = 0.031). The overall success rate of TUR for VUS was 40.2%, success rate of TUR for BNS was 58.3%. TUR for BNS is significantly more successful (p = 0.031). The mean number of TUR for BNS vs. TUR for VUS in successful cases was 1.5 vs. 1.8, which was not significantly different. The rate of de novo incontinence was significantly higher in patients treated for VUS (13.8 vs. 1.7%; p = 0.011). After excluding those patients with radiotherapy prior to endoscopic treatment, the recurrence rate did not differ significantly between both groups (60.3% for VUS vs. 44.2% for BNS; p = 0.091), whereas the rate of de novo incontinence (13.8 for VUS vs. 0% for BNS; p = 0.005) stayed significantly higher in patients treated for VUS. Conclusion Most patients with BNS are successfully treated endoscopically. In patients with VUS, the success rate is lower. Both stenoses differ with respect to de novo incontinence. Patients must be counseled regarding the increased risk of de novo incontinence after endoscopic treatment of VUS, independent of prior radiotherapy. Longer follow-up is warranted to address long-term outcomes.
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Affiliation(s)
- Jennifer Kranz
- Department for Urology and Pediatric Urology, St. Antonius Hospital, Eschweiler, Germany
| | - Philipp C Reiss
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Georg Salomon
- Martini Klinik Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Steffens
- Department for Urology and Pediatric Urology, St. Antonius Hospital, Eschweiler, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clemens M Rosenbaum
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Aikoye AA, Khushal A, Parkin C, Bates T. Laparoscopic colectomy in a district hospital: the single surgeon can be safe. Acta Chir Belg 2017. [PMID: 28636471 DOI: 10.1080/00015458.2017.1284422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Several outcome measures have been identified for colorectal surgery and published in the literature. This study sought to compare outcomes of high volume laparoscopic colectomy by a single surgeon in a district hospital with outcomes from tertiary referral centres. METHODS This was a retrospective review of elective laparoscopic colectomy by a single laparoscopic general surgeon in a district hospital over a 51-month period using a prospectively maintained database. The key outcome measures studied were length of hospital stay, conversion to open, anastomotic leak, wound infection, re-admission and 30-day mortality. RESULTS 187 elective laparoscopic colectomies were performed at the Kent and Canterbury Hospital between July 2008 and October 2012. The median patient age was 69 years (range 22-90 years). Median length of hospital stay was 4 days (range 1-48 days). Anastomotic leak occurred in 4 (2.1%) patients. Seven (3.7%) patients underwent conversion to open surgery. Re-admission occurred in 4 (2.1%) patients for small bowel obstruction (1), wound infection (1), anastomotic leak (1) and colo-vaginal fistula (1). There was one post-operative death from severe chest infection (0.5%). These results are similar to those published by tertiary referral centres. CONCLUSIONS This study of outcomes at a district hospital shows that the outcome reported from laparoscopic colorectal surgery in tertiary referral centres is reproducible at the district hospital level by a single surgeon with a high operative volume.
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Affiliation(s)
- A. A. Aikoye
- Department of Surgery, William Harvey Hospital, East Kent Hospitals NHS Trust, Ashford, Kent, UK
| | - A. Khushal
- Department of Surgery, Kent and Canterbury Hospital, East Kent Hospitals NHS Trust, Canterbury, Kent, UK
| | - C. Parkin
- Centre for Professional Practice, University of Kent, Canterbury, Kent, UK
| | - T. Bates
- Centre for Professional Practice, University of Kent, Canterbury, Kent, UK
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Kann BH, Park HS, Yeboa DN, Aneja S, Girardi M, Foss FM, Roberts KB, Wilson LD. Annual Facility Treatment Volume and Patient Survival for Mycosis Fungoides and Sézary Syndrome. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:520-526.e2. [PMID: 28655598 DOI: 10.1016/j.clml.2017.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/30/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Management of mycosis fungoides and Sézary syndrome (MF/SS) is complex, and randomized evidence to guide treatment is lacking. The institutional treatment volumes for MF/SS might vary widely nationally and influence patient survival. PATIENTS AND METHODS Using the National Cancer Database, we identified patients with a diagnosis of MF/SS from 2004 to 2011 in the United States who had received treatment at a reporting facility. The patients were grouped into quintiles according to their treatment facility's average annual treatment volume (ATV). The characteristics associated with ATV were identified and compared using χ2 tests. Overall survival (OS) was compared among the ATV quintiles using the Kaplan-Meier method with log-rank tests and multivariable Cox regression with hazard ratios (HRs). OS was also analyzed using the annual patient volume as a continuous variable. RESULTS A total of 2205 patients treated at 374 facilities were included for analysis. The ATV quintile cutoffs were 1, 3, 6, and 9 patients. With a median follow-up period of 59 months, the 5-year estimated OS survival increased with ATV from 56.7% in the lowest quintile (≤ 1 patient annually) to 83.8% in the highest quintile (> 9 patients annually; P < .001). On multivariable analysis, greater ATV was associated with improved survival when analyzed as a continuous variable (HR, 0.96 per patient per year; 95% confidence interval, 0.94-0.98; P < .001) and when comparing the highest quintile to the lowest quintile (HR, 0.46; 95% confidence interval, 0.39-0.55). CONCLUSION The present national database analysis demonstrated that higher facility ATV is associated with improved OS for patients with MF/SS. Further study is needed to determine the underlying reasons for improved survival with higher facility ATV.
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Affiliation(s)
- Benjamin H Kann
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT.
| | - Henry S Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Debra N Yeboa
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Sanjay Aneja
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Michael Girardi
- Department of Dermatology, Yale School of Medicine, New Haven, CT
| | - Francine M Foss
- Department of Hematology and Oncology, Yale School of Medicine, New Haven, CT
| | - Kenneth B Roberts
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Lynn D Wilson
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
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Pincus D, Morrison S, Gargan MF, Camp MW. Informal regionalization of pediatric fracture care in the Greater Toronto Area: a retrospective cross-sectional study. CMAJ Open 2017; 5:E468-E475. [PMID: 28619746 PMCID: PMC5498182 DOI: 10.9778/cmajo.20160156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Operative management of pediatric fractures is an expected competency in the specialty of Orthopedic Surgery. However, specialized pediatric centres may be providing care for increasing numbers of patients with fractures previously treated at community hospitals. The primary objective of this study was to examine trends in presentation of children with fractures to a specialized pediatric centre. METHODS We performed a detailed chart review to examine trends in presentation of children aged 14 years or less with supracondylar humerus or femur fractures to a specialized pediatric centre (Hospital for Sick Children, Toronto) from anywhere in the Greater Toronto Area between Apr. 1, 2008, and Mar. 31, 2015. Consecutive patients admitted to hospital and requiring operative intervention for a supracondylar humerus or femur fracture were considered. We calculated changes in operation incidence rates per year using multivariable negative binomial regression models. RESULTS A total of 945 children with supracondylar humerus fractures and 421 with femur fractures underwent operative intervention during the study period. The baseline characteristics of the 2 groups were similar irrespective of which year fixation occurred. The annual incidence rate of supracondylar humerus fractures increased from 108 to 169 (56.5%) over the study period, at an adjusted rate of 7.5% per year (adjusted incidence rate ratio [IRR] 1.075, 95% confidence interval [CI] 1.072-1.079, p < 0.001). The annual incidence rate of femur fractures increased from 49 to 69 (40.8%), at an adjusted rate of 5.3% per year (adjusted IRR 1.053, 95% CI 1.044-1.062, p < 0.001). Significant increases were observed independent of fracture classification, stabilization method, whether patients were transferred from an outside hospital or presented directly, patient geographic location or the season in which the fracture occurred. INTERPRETATION Adjusted annual incidence rates of supracondylar humerus and femur fractures increased significantly over the study period. Further work is needed to assess the clinical impact of informal regionalization of care and to determine whether the phenomenon occurs in other specialties.
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Affiliation(s)
- Daniel Pincus
- Affiliations: Division of Orthopaedic Surgery (Pincus, Gargan, Camp), Department of Surgery, University of Toronto; Institute for Clinical Evaluative Sciences (Pincus); Institute of Health Policy, Management and Evaluation (Pincus), University of Toronto; The Hospital for Sick Children (Morrison, Gargan, Camp), Toronto, Ont
| | - Steven Morrison
- Affiliations: Division of Orthopaedic Surgery (Pincus, Gargan, Camp), Department of Surgery, University of Toronto; Institute for Clinical Evaluative Sciences (Pincus); Institute of Health Policy, Management and Evaluation (Pincus), University of Toronto; The Hospital for Sick Children (Morrison, Gargan, Camp), Toronto, Ont
| | - Martin F Gargan
- Affiliations: Division of Orthopaedic Surgery (Pincus, Gargan, Camp), Department of Surgery, University of Toronto; Institute for Clinical Evaluative Sciences (Pincus); Institute of Health Policy, Management and Evaluation (Pincus), University of Toronto; The Hospital for Sick Children (Morrison, Gargan, Camp), Toronto, Ont
| | - Mark W Camp
- Affiliations: Division of Orthopaedic Surgery (Pincus, Gargan, Camp), Department of Surgery, University of Toronto; Institute for Clinical Evaluative Sciences (Pincus); Institute of Health Policy, Management and Evaluation (Pincus), University of Toronto; The Hospital for Sick Children (Morrison, Gargan, Camp), Toronto, Ont
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