Performing urological inpatient procedures as same-day procedures during the COVID pandemic A retrospective feasibility study

INTRODUCTION

In line with Canadian provincial directives due to the COVID-19 pandemic, certain elective urologic surgical cases that are normally performed as inpatient procedures were performed as same-day discharge procedures to reduce hospitalization and the usage of scarce healthcare resources. Since the pandemic, we began performing laser enucleation of the prostate (LEP), robotic-assisted radical prostatectomy (RARP), and percutaneous nephrolithotomy (PCNL ) as outpatient surgeries. This was supported by recent evidence demonstrating the safety and feasibility of performing these minimally invasive surgeries as same-day procedures. As such, we sought to retrospectively evaluate the clinical outcomes and safety during the COVID-19 era at our institution for same-day discharge LEP, RARP, and PCNL procedures.

METHODS

All patients operated for LEP, RARP, or PCNL between May 2020 and March 2022 at two academic institutions were included. Surgeries were classified as planned same-day discharge or inpatient surgery. Same-day discharge patients were compared to inpatients for each procedure type. This comparison assessed the occurrence of same-day failure, postoperative complications, and re-admission rates at 30 days. This study was approved by the scientific ethics committee of the Centre de Recherche de l'Université de Montréal (CRCHUM).

RESULTS

A total of 413 subjects were included in this study. Among LEP patients (n=169), 104 (62%) were identified as same-day procedures and 65 (38%) were inpatient. Among RARP patients (n=194), 46 (24%) were identified as same-day procedures and 148 (76%) inpatient. Among PCNL patients (n=50), 38 (76%) were identified as same-day procedures and 12 (24%) were inpatient. Of the patients who underwent planned same-day LEP, RARP, and PCNL, 77.9%, 73.9%, and 71.1% were successfully discharged home, respectively. Patients who underwent LEP as inpatients had a higher incidence of overall postoperative complications compared to same-day LEP (23.1% vs. 8.7%, p=0.017). The rates of 30-day emergency department (ED ) visits and hospital re-admission were similar between inpatient and same-day LEP (9.2% vs. 3.8%, p=0.27; and 4.6% vs. 1.0%, p=0.32, respectively). Inpatient RARP, however, was associated with more 30-day ED visits compared to same-day procedures (17.4% vs. 4.1%, p<0.01). No statistically significant differences were found for postoperative complications (15.2% vs. 6.1%, p=0.097) and re-admission rates (1.4% vs. 4.3%, p=0.51). There were no significant differences on overall postoperative complications, 30-day ED visits, and re-admission rates in inpatient vs. same-day PCNL.

CONCLUSIONS

Our results suggest that same-day discharge for LEP, RARP, and PCNL is safe and feasible in select patients, with an acceptable complication rate. These results should be validated in a larger, prospective clinical trial comparing same-day and inpatient procedures.

Evaluation of Canadian urology residency and fellowship program websites

Introduction: There is growing use of online resources in the postgraduate medical education application process to provide applicants program-specific details, thus allowing for informed decision-making. Given the variability and non-standardized electronic training descriptions and objectives, our goal was to assess the availability of program information through program websites for both residency and fellowship urology programs across Canada. Methods: Using the Canadian Residency Matching Service (CaRMS) and the Canadian Urological Association (CUA) websites, we compiled a list of all Canadian urology residency and fellowship programs. We reviewed all programs’ website using a 40-item tool based on seven subcategories, including education, application process, faculty information, trainee/fellow information, research and extra-curricular activities, wellness, and both benefits and career planning. Each website was reviewed by two trained reviewers. Any inter-reviewer discrepancy was resolved by a third-party reviewer. Results: Among 13 Canadian urology residency programs, all had program websites and met 48% of the criteria evaluated. None of the residency program websites reported information on work hours, surgical caseload statistics, or equity diversity and inclusion/community initiatives. Among 37 Canadian urology fellowship programs, 10 programs did not have websites, and the remaining 27 program websites met 28% of the criteria evaluated. Scores were highest for the application process subcategory, while scores were lowest for the wellness and benefits/career planning subcategories among both residency and fellowship programs. Conclusions: With growing reliance and dependence on web resources to access residency and fellowship program information, there is a clear need to standardize and improve Canadian training websites for prospective applicants.

Temporal trends, tumor characteristics and stage-specific survival in penile non-squamous cell carcinoma vs. squamous cell carcinoma

PURPOSE

To compare Cancer-specific mortality (CSM) in patients with Squamous cell carcinoma (SCC) vs. non-SCC penile cancer, since survival outcomes may differ between histological subtypes.

METHODS

Within the Surveillance, Epidemiology and End Results database (2004-2016), penile cancer patients of all stages were identified. Temporal trend analyses, cumulative incidence and Kaplan-Meier plots, multivariable Cox regression and Fine and Gray competing-risks regression analyses tested for CSM differences between non-SCC vs. SCC penile cancer patients.

RESULTS

Of 4,120 eligible penile cancer patients, 123 (3%) harbored non-SCC vs. 4,027 (97%) SCC. Of all non-SCC patients, 51 (41%) harbored melanomas, 42 (34%) basal cell carcinomas, 10 (8%) adenocarcinomas, eight (6.5%) skin appendage malignancies, six (5%) epithelial cell neoplasms, two (1.5%) neuroendocrine tumors, two (1.5%) lymphomas, two (1.5%) sarcomas. Stage at presentation differed between non-SCC vs. SCC. In temporal trend analyses, non-SCC diagnoses neither decreased nor increased over time (p > 0.05). After stratification according to localized, locally advanced, and metastatic stage, no CSM differences were observed between non-SCC vs. SCC, with 5-year survival rates of 11 vs 11% (p = 0.9) for localized, 33 vs. 37% (p = 0.4) for locally advanced, and 1-year survival rates of 37 vs. 53% (p = 0.9) for metastatic penile cancer, respectively. After propensity score matching for patient and tumor characteristics and additional multivariable adjustment, no CSM differences between non-SCC vs. SCC were observed.

CONCLUSION

Non-SCC penile cancer is rare. Although exceptions exist, on average, non-SCC penile cancer has comparable CSM as SCC penile cancer patients, after stratification for localized, locally invasive, and metastatic disease.

Evidence from Human and Animal Studies: Pathological Roles of CD8(+) T Cells in Autoimmune Peripheral Neuropathies

Autoimmune peripheral neuropathies such as Guillain-Barre Syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) affect millions of people worldwide. Despite significant advances in understanding the pathology, the molecular and cellular mechanisms of immune-mediated neuropathies remain elusive. T lymphocytes definitely play an important role in disease pathogenesis and CD4⁺ T cells have been the main area of research for decades. This is partly due to the fact that the most frequent animal model to study autoimmune peripheral neuropathy is experimental allergic neuritis (EAN). As it is induced commonly by immunization with peripheral nerve proteins, EAN is driven mainly by CD4⁺ T cells. However, similarly to what has been reported for patients suffering from multiple sclerosis, a significant body of evidence indicates that CD8⁺ T cells may play a pathogenic role in GBS and CIDP disease development and/or progression. Here, we summarize clinical studies pertaining to the presence and potential role of CD8⁺ T cells in autoimmune peripheral neuropathies. We also discuss the findings from our most recent studies using a transgenic mouse line (L31 mice) in which the T cell co-stimulator molecule B7.2 (CD86) is constitutively expressed in antigen presenting cells of the nervous tissues. L31 mice spontaneously develop peripheral neuropathy, and CD8⁺ T cells are found accumulating in peripheral nerves of symptomatic animals. Interestingly, depletion of CD4⁺ T cells accelerates disease onset and increases disease prevalence. Finally, we point out some unanswered questions for future research to dissect the critical roles of CD8⁺ T cells in autoimmune peripheral neuropathies.