Predicting Peak Productivity in Urologic Medicare Practice via Work-Relative Value Units

OBJECTIVE

To explore factors associated with productivity in urologic practice. Work-relative value units (wRVUs), the basis for Center for Medicare & Medicaid Services (CMS) and private payer reimbursements, commonly serve to estimate physician productivity. Limited data describes which practice factors predict increased wRVU productivity.

METHODS

The 2017 and 2018 CMS databases were retrospectively queried for urologic Medicare provider demographics and procedural/service details. Medical school graduation year was used to estimate years in practice and generation (Millennial, Gen X, Baby Boomer, or Post-War). Treated patients' demographics were obtained. Adjusted and unadjusted linear mixed models were performed to predict wRVU production.

RESULTS

Included were 6773 Medicare-participating urologists across the United States. Millennials produced 1115 wRVUs per year, while Gen X and Baby Boomers produced significantly more (1997 and 2104, respectively, P <.01). Post-War urologists produced numerically more (1287, P = .88). In adjusted analyses, predictors of Medicare wRVU productivity included female and pelvic medicine and reconstructive surgery (exponentiated beta estimate (β) 1.46, 95% CI 1.32-1.60), men's health (β 1.22, 95% CI 1.13-1.32), and oncologic subspecialization (β 1.08, 95% CI 1.02-1.14), female gender (β 0.87, 95% CI 0.82-0.92), wRVUs generated from inpatient procedures (β 1.08, 95% CI 1.06-1.09) and office visits (β 0.88, 95% CI 0.87-0.89), and the level of education (β 1.10, 95% CI 1.07-1.14) and percent impoverished patients (β 0.85, 95% CI 0.83-0.88) in provider's practice zip code.

CONCLUSION

Urologic experience, specialization, demographics, practice patterns, and patient demographics are significantly associated with wRVU productivity in Medicare settings. Further work should incorporate quality metrics into wRVUs and ensure patient demographics do not affect reimbursement.

Single-Port vs Multiport Robot-Assisted Partial Nephrectomy: A Meta-Analysis

Background: Several centers have reported their experience with single-port robot-assisted partial nephrectomy (SP-RAPN); however, it is uncertain if utilization of this platform represents an improvement in outcomes compared to multiport robot-assisted partial nephrectomy (MP-RAPN). To evaluate this, we performed a meta-analysis to compare the perioperative, oncological, and functional outcomes between SP-RAPN and MP-RAPN. Methods: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until January 1, 2023. A meta-analysis has been reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and assessing the methodological quality of systematic reviews (AMSTAR) guidelines. The odds ratio (OR) and weighted mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI). Results: Of the 374 retrieved abstracts, 29 underwent full-text review, and 8 studies were included in the final analysis, comprising a total cohort of 1007 cases of RAPN (453 SP-RAPN cases and 554 MP-RAPN cases). Compared to MP-RAPN, the SP-RAPN group had a significantly longer ischemia time (MD = 4.6 minutes, 95% CI 2.8 to 6.3, p < 0.001), less estimated blood loss (MD = -12.4 mL, 95% CI -24.6 to -0.3, p = 0.045), higher blood transfusion rate (OR = 2.97, 95% CI 1.33 to 6.65, p = 0.008), and higher postoperative estimated glomerular filtration rate (eGFR) at 6 months (MD = 4.9 mL/min, 95% CI 0.2 to 9.7, p = 0.04). There was no significant difference in other outcomes between the two approaches, including the intraoperative complication, overall postoperative complication, minor postoperative complication (Clavien-Dindo I - II), major postoperative complication (Clavien-Dindo III-V), conversion to radical nephrectomy, pain score on day #1, pain score on discharge, morphine milligram equivalent usage, hospital stay, positive surgical margins, and postoperative eGFR. Conclusions: SP-RAPN represents an emerging technique using a novel platform. Initial studies have demonstrated that SP-RAPN is a safe and feasible approach to performing partial nephrectomy, although with inferior outcomes for ischemia time and blood transfusion rates. Further studies will be necessary to define the best usage of SP-RAPN within the surgeon's armamentarium.

Ablative minimally invasive surgical therapies for benign prostatic hyperplasia: A review of Aquablation, Rezum, and transperineal laser prostate ablation

INTRODUCTION

Benign prostatic hyperplasia (BPH) is one of the most common diseases affecting men and can present with bothersome lower urinary tract symptoms (LUTS). Historically, transurethral resection of the prostate (TURP) has been considered the gold standard in the treatment of LUTS due to BPH. However, TURP and other traditional options for the surgical management of LUTS secondary to BPH are associated with high rates of sexual dysfunction. In the past decade, several novel technologies, including Aquablation therapy, convective water vapor therapy (Rezum), and transperineal prostate laser ablation (TPLA), have demonstrated promising evidence to be safe and effective while preserving sexual function.

METHODS

In this review, we discuss three ablative minimally invasive surgeries: Aquablation, Rezum, and TPLA. We review their techniques, safety, as well as perioperative and functional outcomes. We go into further detail regarding sexual function after these ablative minimally invasive surgical therapies.

RESULTS

Aquablation is a surgeon-guided, robot-executed, heat-free ablative waterjet procedure with sustained functional outcomes at 5 years while having no effect on sexual activity. Rezum is an innovative office-based, minimally invasive surgical option for BPH that delivers convective water vapor energy into prostate adenoma to ablate obstructing tissue. Rezum leads to significant improvements in Qmax, IPSS while preserving sexual function. TPLA is another office-based technology which uses a diode laser source to produce thermoablation. It leads to improvement in Qmax, IPSS, and QoL while preserving ejaculatory function.

CONCLUSIONS

Overall, ablative minimally invasive surgical therapies have demonstrated excellent safety and efficacy profiles while preserving sexual function. These modalities should be discussed with patients to ensure informed and shared decision-making. Ablative minimally invasive surgical therapies may be particularly interesting to patients who value the preservation of their sexual function.

Prospective Multicenter Evaluation of Pain Before and After Removal of Nonobstructing Renal Calculi: A CoRE Initiative

PURPOSE

Flank pain associated with stone disease is typically caused by a stone that obstructs urine flow. However, it is plausible that nonobstructing kidney stones may still cause pain. We performed a multicenter, observational trial to evaluate whether treatment of small nonobstructing calyceal stones improves pain and kidney stone-specific health-related quality of life.

MATERIALS AND METHODS

Patients aged 18 years or older with nonobstructing renal stone(s) up to 10 mm in longest diameter and moderate to severe pain were recruited. All participants completed 3 questionnaires: the Brief Pain Inventory (BPI), the Patient-Reported Outcomes Measurement Information System pain interference form 6a, and the Wisconsin Stone Quality of Life questionnaire. Thereafter, all participants underwent ureteroscopy for renal stone treatment. All 3 questionnaires were repeated at 2, 6 to 8, and at 12 weeks postprocedure. The primary outcomes were change in preoperative to 12-week postoperative mean BPI score and worst BPI pain score.

RESULTS

A total of 43 patients with nonobstructing kidney stones and associated flank pain were recruited. All stones were removed. Preoperatively, BPI scores for mean pain and worst pain were 5.5 and 7.2, respectively which decreased to 1.8 and 2.8 respectively at 12 weeks postoperatively. Wisconsin Stone Quality of Life questionnaire mean score increased from 70.4 to 115.3 at 12 weeks postoperatively. A total of 86% and 69% of patients had at least a 20% and 50% reduction in their mean pain scores, respectively.

CONCLUSIONS

This study determined that patients benefit significantly from the removal of calyceal nonobstructing kidney stones for at least 12 weeks with a reduction in pain and an increase in quality of life. Therefore, surgical removal of these stones in this patient population should be offered as a treatment option.

A scoping review of office-based prostatic stents: past, present, and future of true minimally invasive treatment of benign prostatic hyperplasia

PURPOSE

To conduct a scoping review of the existing literature and recent developments on prostatic stents for the treatment of benign prostatic hyperplasia (BPH).

METHODS

A comprehensive search was performed on Embase, MEDLINE, and Web of Science to identify English literature on prostatic stents for the treatment of BPH. Additional studies and upcoming devices were identified through grey literature search and expert consultation. Study characteristics and stent information were extracted and tabulated narratively.

RESULTS

Of the 1171 search results, 64 studies were included in this review. iTiND was the prostatic stent with the most long-term evidence. iTiND is a safe and effective minimally invasive treatment for BPH that preserves sexual function. Adverse events are mild and transitory. Emerging stents (e.g. Zenflow, Butterfly, Urocross, and Exime) had 7/64 eligible studies, where no studies had long-term follow-up. These newer stents show promising results for quality of life and BPH symptom management; however, long-term monitoring and head-to-head comparisons are needed.

CONCLUSION

Over the last 50 years, prostatic stents have evolved and demonstrated improved clinical efficacy. iTiND provides a safe and effective outpatient treatment of LUTS secondary to BPH preserving erectile and ejaculatory function. Emerging prostatic stents are a promising, effective, and safe intervention in well-selected patients interested in its benefits.

Aquablation in Patients on Antithrombotics: Assessment of Safety, Postoperative Bleeding Rates and Clinical Outcomes

OBJECTIVE

To analyze the impact of perioperative antithrombotic use on the bleeding outcomes following Aquablation.

METHODS

One hundred sixteen men with who underwent Aquablation as part of the WATER prospective trial (NCT02505919) were assigned to 2 groups based on perioperative antithrombotic status. Antithrombotic cessation and restart timing were based on the surgeon's discretion. Methods of achieving intraoperative hemostasis consisted of no-cautery balloon tamponade or cautery. Primary endpoints included immediate postoperative hematuria rates and changes in hemoglobin. Secondary endpoints included 90-day bleeding complications and nonbleeding postoperative adverse events.

RESULTS

Forty-one men took antithrombotic medications in the perioperative period while 75 men had no antithrombotic medication. Preoperative hemoglobin levels were comparable between both groups. Postoperative hemoglobin change from baseline (drop of 1.8 ± 1.5 g/dL among the antithrombotic group vs 1.8 ± 1.7 g/dL among the antithrombotic-naïve group) did not differ between both groups (P = .896). In total, 4 (9.8%) men in the antithrombotic group and 4 (5.3%) patients in the antithrombotic-naïve group experienced a Clavien-Dindo grade 1 complication (P = .451) in the 3-month postoperative period. Eight (19.5%) patients in the antithrombotic group and 11 (14.7%) patients in the antithrombotic-naïve group experienced a Clavien-Dindo grade 2 complication (P = .601), none of which is associated with bleeding in both groups. No men in either group demonstrated de novo erectile dysfunction. One patient (2.4%) in the antithrombotic group and none in the antithrombotic-naïve group required blood products (P = .353).

CONCLUSION

Aquablation demonstrates comparable postoperative bleeding outcomes and other adverse effects for men with benign prostatic hypertrophy who are on antithrombotic therapy.

Aquablation versus TURP: 5-year outcomes of the WATER randomized clinical trial for prostate volumes 50-80 mL

INTRODUCTION

To report the 5-year efficacy and safety of Aquablation compared with transurethral resection of the prostate for the management of lower urinary tract symptoms secondary to benign prostatic hyperplasia in men with prostate volumes 50-80 mL.

MATERIALS AND METHODS

In a large double-blinded, multicenter, and prospective randomized controlled trial, 96 randomized men with 50-80 mL prostates who underwent Aquablation or transurethral prostate resection were prospectively identified for subgroup analysis. Follow up was performed for up to 5 years. The primary efficacy endpoint was the reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety endpoint was the occurrence of Clavien-Dindo (CD) postoperative complications grade 1 persistent and grade 2 or higher at 3 months.

RESULTS

Both groups had comparable baseline characteristics. Reduction in IPSS score was significantly higher in the Aquablation group across 5 years of follow up (-14.1 vs. -10.8, p = 0.02). The Aquablation group achieved a significantly lower rate of CD1P and CD2 or higher events at 3 months follow up (risk difference of -23.1%). Among recorded adverse events, de novo postoperative ejaculatory dysfunction was notably lower in Aquablation (risk difference of -21.9%), while the risk of bleeding remained similar after 6 months. The surgical and medical retreatment rate at 6 months was also lower in Aquablation (risk difference of -14.4%).

CONCLUSIONS

In the 50-80 mL prostate volume subgroup, Aquablation yields superior long-term symptom relief and lower complication rates than standard transurethral resection, with notably lower rates of ejaculatory dysfunction. This further supports the adoption of Aquablation for men with medium-sized prostates.

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.

Treating LUTS in Men with Benign Prostatic Obstruction: A Review Article

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life.

Evaluating the perceptions of Canadian urology residents and program directors regarding the current training in genitourinary imaging

INTRODUCTION

Competency in interpreting genitourinary (GU) imaging is an important skill for urologists; however, no nationally accredited GU imaging curriculum exists for Canadian urology residency training programs. The main objectives of our study were to 1) characterize GU imaging training in Canada; (2) evaluate residents' self-perceived competencies in interpreting GU imaging; (3) explore program directors' (PD) and residents' perceptions regarding the current imaging curriculum and suggestions for future directions.

METHODS

From November to December 2022, a survey examining current imaging education in residency, perceived resident imaging knowledge, avenues for improvement in imaging education, and the role of point-of-care ultrasound within urology was distributed to all Canadian urology PDs and residents.

RESULTS

All PDs (13/13) and 40% (72/178) of residents completed the survey. Only two programs had a formal GU imaging curriculum. PDs and residents reported trainees were least comfortable interpreting Doppler ultrasound of renal, gonadal, and penile vessels. PDs reported that residents were most comfortable with non-contrast computed tomography (CT) scans (9.5/10), CT urogram (9.3/10), and retrograde pyelography (9.3/10). All but one PD favored increasing imaging training in their program. PDs highlighted the lack of time in the curriculum (n=3) and lack of educators (n=3) as the primary barriers to increasing imaging training in their program.

CONCLUSIONS

Most PDs and residents believe there needs to be more imaging training offered at their institution; however, addressing this is challenging due to the limited time in the curriculum and the need for available educators.

Disparities in Travel-Related Barriers to Accessing Health Care From the 2017 National Household Travel Survey

Importance

Geographic access, including mode of transportation, to health care facilities remains understudied.

Objective

To identify sociodemographic factors associated with public vs private transportation use to access health care and identify the respondent, trip, and community factors associated with longer distance and time traveled for health care visits.

Design, Setting, and Participants

This cross-sectional study used data from the 2017 National Household Travel Survey, including 16 760 trips or a nationally weighted estimate of 5 550 527 364 trips to seek care in the United States. Households that completed the recruitment and retrieval survey for all members aged 5 years and older were included. Data were analyzed between June and August 2022.

Exposures

Mode of transportation (private vs public transportation) used to seek care.

Main Outcomes and Measures

Survey-weighted multivariable logistic regression models were used to identify factors associated with public vs private transportation and self-reported distance and travel time. Then, for each income category, an interaction term of race and ethnicity with type of transportation was used to estimate the specific increase in travel burden associated with using public transportation compared a private vehicle for each race category.

Results

The sample included 12 092 households and 15 063 respondents (8500 respondents [56.4%] aged 51-75 years; 8930 [59.3%] females) who had trips for medical care, of whom 1028 respondents (6.9%) were Hispanic, 1164 respondents (7.8%) were non-Hispanic Black, and 11 957 respondents (79.7%) were non-Hispanic White. Factors associated with public transportation use included non-Hispanic Black race (compared with non-Hispanic White: adjusted odds ratio [aOR], 3.54 [95% CI, 1.90-6.61]; P < .001) and household income less than $25 000 (compared with ≥$100 000: aOR, 7.16 [95% CI, 3.50-14.68]; P < .001). The additional travel time associated with use of public transportation compared with private vehicle use varied by race and household income, with non-Hispanic Black respondents with income of $25 000 to $49 999 experiencing higher burden associated with public transportation (mean difference, 81.9 [95% CI, 48.5-115.3] minutes) than non-Hispanic White respondents with similar income (mean difference, 25.5 [95% CI, 17.5-33.5] minutes; P < .001).

Conclusions and Relevance

These findings suggest that certain racial, ethnic, and socioeconomically disadvantaged populations rely on public transportation to seek health care and that reducing delays associated with public transportation could improve care for these patients.

Posterior urethral valves, pressure pop-offs, and kidney function: systematic review and meta-analysis

PURPOSE

To determine the role of pressure pop-off mechanisms, including vesicoureteral reflux and renal dysplasia (VURD) syndrome, in determining long-term kidney outcomes in boys with posterior urethral valves (PUV).

METHODS

A systematic search was performed in December 2022. Descriptive and comparative studies with a defined pressure pop-off group were included. Assessed outcomes included end-stage renal disease (ESRD), kidney insufficiency (defined as chronic kidney disease [CKD] stage 3 + or SCr > 1.5 mg/dL), and kidney function. Pooled proportions and relative risks (RR) with 95% confidence intervals (CI) were extrapolated from available data for quantitative synthesis. Random-effects meta-analyses were performed according to the study design and techniques. The risk of bias was assessed with the QUIPS tool and GRADE quality of evidence. The systematic review was prospectively registered on PROSPERO (CRD42022372352).

RESULTS

A total of 15 studies describing 185 patients with a median follow-up of 6.8 years were included. By the last follow-up, overall effect estimates demonstrate the prevalence of CKD and ESRD to be 15.2% and 4.1%, respectively. There was no significant difference in the risk of ESRD in patients with pop-off compared to no pop-off patients [RR 0.34, 95%CI 0.12, 1.10; p = 0.07]. There was a significantly reduced risk for kidney insufficiency in boys with pop-off [RR 0.57, 95%CI 0.34, 0.97; p = 0.04], but this protective effect was not re-demonstrated after excluding studies with inadequate reporting of CKD outcomes [RR 0.63, 95%CI 0.36, 1.10; p = 0.10]. Included study quality was low, with 6 studies having moderate risk and 9 having a high risk of bias.

CONCLUSIONS

Pop-off mechanisms may be associated with reducing the risk of kidney insufficiency, but current certainty in the evidence is low. Further research is warranted to investigate sources of heterogeneity and long-term sequelae in pressure pop-offs.

Litigation associated with 5-alpha-reductase-inhibitor use: A Canadian legal database review

INTRODUCTION

5α-reductase inhibitors (5ARI) are commonly prescribed medications. There is ongoing controversy about the adverse events of these medications. The aim of this study is to characterize lawsuits in Canada involving medical complications of 5ARIs use.

MATERIALS AND METHODS

Legal cases were queried from CanLII. Cases were included if they involved a party taking a 5ARI who alleged an adverse event. Relevant full cases were retained, and pertinent characteristics were extracted with the help of a legal expert.

RESULTS

Our deduplicated search yielded 67 unique legal documents from December 2013 to February 2019. Twelve of these documents met the inclusion criteria (representing 3 cases, considering each case had several hearings). The medical complaints filed by the plaintiffs were all related to medication side effects (n = 3, 100%). The plaintiffs were commonly patients themselves. Defendants were exclusively pharmaceutical companies. Persistent erectile dysfunction after stopping the medication was cited as a side effect in all complaints. The prescriptions were made for male pattern hair loss (n = 3, 100%) in all cases. All cases represent class actions brought by the plaintiffs, and they have been certified by their respective court. However, the cases are still ongoing.

CONCLUSION

While 5ARI use has been linked to undesired sexual side effects, there have been few litigations on this issue in Canada. Persisting sexual dysfunction after stopping the medication is the only complaint presented in legal action. To date, no judgment against a physician or pharmaceutical company was identified. Cases are still ongoing.

Urologic Oncology Survivorship Guidelines: An Overview of the Evidence and the Current Implementation Gap

Cancer survivorship is particularly significant for patients with urologic malignancies, who account for >25% of cancer survivors. The American Cancer Society has a guideline on survivorship care in prostate cancer and the American Urological Association has published a core curriculum on cancer survivorship in urologic cancers. However, there is a lack of high-quality evidence on survivorship strategies to inform guideline recommendations. Future efforts need to focus on producing high-quality survivorship research and on increasing appropriate resources to improve the implementation of survivorship care. PATIENT SUMMARY: There are few guidelines on survivorship care for patients with prostate, bladder, penile, or kidney cancer. More funding is needed for research into care for cancer survivors.

Financial Disclosures Reported by Industry Among Authors of the American Academy of Ophthalmology Clinical Practice Guidelines

Importance

Recommendations of clinical guidelines affect physicians' care delivery. Potential bias and undeclared conflicts of interests (COIs) among guideline authors can impact clinical practice decisions.

Objective

To assess financial disclosures reported by physician authors of the American Academy of Ophthalmology (AAO) Practice Pattern Guidelines compared with those reported by industry to evaluate the disclosures' accuracy.

Design, Setting, and Participants

In this cross-sectional study, all clinical guidelines in the AAO Preferred Practice Patterns (PPP) since 2013 (first year with publicly available industry payment reports) were reviewed on May 1, 2022. Guideline physician authors' name and their reported COI disclosure were extracted from the guideline publication. Payments to physician authors reported by industry were retrieved from the US Centers for Medicare & Medicaid Open Payments database. Physician authors serving on the AAO guideline committee were included.

Main Outcomes and Measures

The primary outcome measure was the accuracy of authors' COIs disclosure. Secondary outcome measures were payments to physician authors reported by industry, the types of payments, and authors' gender.

Results

A total of 24 AAO guidelines released between 2016 and 2020 were included. Per guideline, there was a mean (SD) of 7.83 (2.24) physician authors. After removing 14 nonphysician authors, 188 physician author names remained, including 83 names assigned as women (44.1%) and 105 names assigned as men (55.9%). Authors could be counted multiple times in these 188 names. According to the Open Payments database, industry reported that 112 of 188 physician authors (59.6%) had at least received 1 payment while serving on the guideline committee, with a payment mean (SD) of $29 849.35 ($54 131.56). According to AAO guidelines, 149 authors (79.3%) had no financial disclosures while serving on the guideline committee. Among these 149 authors, most authors (81 [54.4%]) had payments reported by industry on the Open Payments database not disclosed within the guideline reports. Women physicians were paid significantly more than men for total payments (median [IQR] payments, $15 265 [$598.47-$41 104.67] vs $301.48 [$218.85-$14 615.09]; difference, $14 963.52; P = .003).

Conclusions and Relevance

Industry reported physician guideline authors to have received significant industry payments, some of which were not disclosed within information of the guidelines. To strengthen author transparency regarding these reported disclosures, the authors may want to review and resolve such potential discrepancies during the review and subsequent publication of guidelines.

The impact of 5-ARI on perioperative and functional outcomes of GreenLight PVP: an analysis of the Global GreenLight Group database

INTRODUCTION

  In this study, we sought to investigate the impact of 5-alpha reductase inhibitors (5-ARI) on the perioperative and functional outcomes of 180-Watt XPS GreenLight photovaporization of the prostate (PVP) using a large international database.

MATERIALS AND METHODS

  Data were obtained from the Global GreenLight Group (GGG) database, which includes eight high-volume, experienced surgeons from seven international centers.  All men with established benign prostatic hyperplasia (BPH) with known 5-ARI status who underwent GreenLight PVP using the XPS-180W system between 2011 and 2019 were eligible for the study.  Patients were assigned to two groups based on the preoperative use of 5-ARI.  Analyses were adjusted for patient age, prostate volume, and American Society of Anesthesia (ASA) score.

RESULTS

  We included 3,500 men, of which 1,246 (36%) had preoperative 5-ARI use.  Patients in both groups were similar with regards to age and prostate size.  On multivariable analysis, total operative time was slightly shorter (-3.26 min 95% CI: 1.20 - 5.32, p < 0.01) and required 35.6kJ less laser energy (95% CI: -48.0kJ - -23.3kJ, p < 0.01) for patients on 5ARI compared to those without 5-ARI.  However, no clinically significant difference was appreciated regarding postoperative transfusion rates [OR 0.048 (95% CI -0.82-0.91; p = 0.91)], hematuria rates [OR 0.96 (95% CI 0.72-1.3; p = 0.81)], 30-day readmission rates [OR 0.98 (95% CI 0.71-1.4; p = 0.90)], or overall functional outcomes.

CONCLUSION

  Our findings suggest that preoperative 5-ARI is not associated with any clinically significant different perioperative or functional outcomes for GreenLight PVP using the XPS-180W system.  There is no role for the initiation or discontinuation of 5-ARI prior to GreenLight PVP.

Safety and efficacy of GreenLight PVP in octogenarians: evaluation of the Global GreenLight Group database

INTRODUCTION

The present study analyzes the largest international GreenLight database, the Global GreenLight Group (GGG), to evaluate the functional and safety profile of GreenLight photoselective vaporization of the prostate (PVP) in octogenarians.

METHODS

The GGG is a database comprised of patients that underwent GreenLight PVP from 2011 to 2019 performed by 8 experienced urologists at 7 international hospitals. Patients 80 years or older at the time of surgery were categorized as octogenarians. They were compared to a similar group of PVP patients below the age of 80.

RESULTS

Among 3,648 patients, 586 men were above the age of 80. Compared to patients under the age of 80, octogenarians had larger prostates (76.0 vs 71.9 ml, p = 0.02) and a lower BMI (25.6 vs 26.7, p = 0.045). Operative time was not significantly longer in octogenarians. The improvement in functional outcomes between 80-year-old patients and control patients was not significantly different at one-year follow-up, with the exception of maximum urinary flow (Q_max) that favoured younger patients (10.3 vs 12.6 ml/s, p = 0.02). The odds of transfusion were greater for older patients [OR 8.2 (95% CI 3.6-18.9, p < 0.01)], but they were not at increased risk of hematuria. Octogenarians had higher readmission rates (23.0 vs 11.9%, p < 0.01).

CONCLUSIONS

GreenLight PVP is a safe option in well-selected octogenarians in a cohort of patients treated by surgeons experienced with the technology. The odds of transfusion were higher in patients over 80, but the absolute risk remains low. The 30-day hospital readmission rate was higher in octogenarians.

Is Segmental Ureterectomy Associated with Inferior Survival for Localized Upper-Tract Urothelial Carcinoma of the Ureter Compared to Radical Nephroureterectomy?

Segmental ureterectomy (SU) is an alternative to radical nephroureterectomy (RNU) in the treatment of upper-tract urothelial carcinoma (UTUC) of the ureter. SU generally preserves renal function, at the expense of less intensive cancer control. We aim to assess whether SU is associated with inferior survival compared to RNU. Using the National Cancer Database (NCDB), we identified patients diagnosed with localized UTUC of the ureter between 2004-2015. We used a propensity-score-overlap-weighted (PSOW) multivariable survival model to compare survival following SU vs. RNU. PSOW-adjusted Kaplan-Meier curves were generated and we performed a non-inferiority test of overall survival. A population of 13,061 individuals with UTUC of the ureter receiving either SU or RNU was identified; of these, 9016 underwent RNU and 4045 SU. Factors associated with decreased likelihood of receiving SU were female gender (OR, 0.81; 95% CI, 0.75-0.88; p < 0.001), advanced clinical T stage (cT4) (OR, 0.51; 95% CI, 0.30-0.88; p = 0.015), and high-grade tumor (OR, 0.76; 95% CI, 0.67-0.86; p < 0.001). Age greater than 79 years was associated with increased probability of undergoing SU (OR, 1.18; 95% CI, 1.00-1.38; p = 0.047). There was no statistically significant difference in OS between SU and RNU (HR, 0.98; 95% CI, 0.93-1.04; p = 0.538). SU was not inferior to RNU in PSOW-adjusted Cox regression analysis (p < 0.001 for non-inferiority). In weighted cohorts of individuals with UTUC of the ureter, the use of SU was not associated with inferior survival compared to RNU. Urologists should continue to utilize SU in appropriately selected patients.

UroBOT: A national survey of Canadian urology residents and fellows on robot-assisted surgery

INTRODUCTION

Robot-assisted surgery (RAS) has a positive impact on the quality of care given to patients. Its increasing adoption in Canadian urology practice also influences the surgical training of residents and fellows. Currently, the lack of clear objectives makes RAS education challenging. The main objective of our study is to highlight how urology trainees perceive the importance of RAS and the standardization of its training.

METHODS

In 2021, we conducted a survey of all the residents and fellows enrolled in a Canadian urology program. The questions assessed their opinion on the importance of RAS and on their robotic surgery training.

RESULTS

The response rate was 29%. The majority of participants (67%) wished that they would have a better exposure to RAS during their surgical training. Only 7% of respondents reported that their program had clear criteria to help them progress through the steps of RAS, and most trainees (81%) felt their residency program should provide them with a formal RAS training program. Seventy-six percent of respondents believed that RAS would become a core skill required by the Royal College in the future, although 32% feared it would hinder their ability to learn other important techniques, such as open surgery.

CONCLUSIONS

Our study revealed that, although most respondents are interested in RAS, their training lacks standardization. Moreover, the potential integration of RAS as a core skill of the Royal College faces some important challenges, mostly due to the perceived lack of time to learn a new surgical technique.

Age-stratified potency outcomes of bilateral nerve sparing robotic-assisted radical prostatectomy

INTRODUCTION

This study aims to report age-stratified potency outcomes in men undergoing robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

A retrospective review was performed on a database of 1737 patients who underwent RARP for localized prostate cancer between 2007 and 2019. Inclusion criteria consisted of patients undergoing bilateral nerve-sparing RARP. Exclusion criteria were preoperative Sexual Health Inventory for Men (SHIM) score < 17 and postoperative androgen deprivation therapy or radiotherapy. Patients were divided into four cohorts based on age: ≤ 54 years (group 1); 55-59 years (group 2); 60-64 years (group 3) and ≥ 65 years (group 4). Functional outcomes were measured up to 36 months. Kaplan-Meier analysis was performed to compare the time to recovery of potency stratified by age groups using log-rank testing.

RESULTS

A total of 542 patients met the selection criteria. Potency rates were significantly different between groups. Groups 1 through 4 demonstrated potency recovery rates of 64.2%, 52.3%, 36.6% and 20.7% at 1-year follow up, respectively. After 3 years, groups 1 through 4 had potency rates of 77.9%, 67.0%, 50.5% and 35.0%, respectively. Recovery of potency was achieved at a median time after surgery of 199, 340 and 853 days for groups 1-3, respectively. The Cox proportional hazard model showed that older age, higher body mass index (BMI), and lower preoperative SHIM score were associated with significantly higher rates of impotence.

CONCLUSION

This study shows that RARP has acceptable potency outcomes, regardless of age. However, patient factors, including older age and preoperative SHIM were significantly associated with poorer functional recovery. This data is valuable in prognostic evaluation and patient counseling.

Effect of Surgeon and Facility Volume on Outcomes of Benign Prostatic Hyperplasia Surgery: Implications of Disparities in Access to Care at High-Volume Centers

OBJECTIVE

To report the effect of surgeon and facility volume on outcomes of transurethral resection of the prostate (TURP) and laser treatment of benign prostatic hyperplasia (BPH). We also investigate disparities in access to care by identifying demographic predictors of receipt of treatment at high-volume facilities.

METHODS

We used New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) data. We included 18,041 (41.4%) and 25,577 (58.6%) adult patients that underwent TURP and laser procedures in the outpatient setting between January 2005 and December 2018, respectively. Average annual surgeon and facility volumes were broken down by tertile. The effect of volume on short-term outcomes (30-day and 90-day readmission) was examined using mixed-effect logistic regression models. Cox-proportional-hazard models were used to assess the association between volume and long-term stricture development and reoperation. Demographic predictors of treatment at high-volume facilities were assessed using multinomial logistic regression.

RESULTS

High-volume facilities were more likely to offer laser procedures compared to low-volume facilities. Higher facility and surgeon volume were associated with lower odds of 30 and 90-day readmissions compared to low-volume facilities. There was no difference in reoperation and stricture development between surgeon volume groups. Medicaid insurance, Hispanic ethnicity, and Black race were inversely associated with treatment at high-volume facilities.

CONCLUSION

Higher surgeon and facility volumes were associated with lower odds of readmission. Higher facility volume was associated with lower hazards of reoperation and developing strictures. Medicaid insurance and non-white race were associated with lower odds of treatment at high-volume facilities, highlighting racial and socioeconomic disparities in access to high-volume BPH surgery facilities.

Racial Differences in Germline Genetic Testing for Prostate Cancer: A Systematic Review

PURPOSE

Testing for pathogenic variants can aid in oncologic risk stratification and identification of targeted therapies. Despite known disparities in access to prostate cancer (PCa) care, little has been written about access to germline genetic testing (GGT) for Black men and other historically marginalized populations. This systematic review sought to delineate racial/ethnic disparities in GGT for PCa.

METHODS

This systematic review identified articles published from January 1996 through May 2021 in PubMed, Web of Science, and Embase. We included studies that reported rates of GGT in men with PCa in the United States by race/ethnicity as reflective of routine clinical care or research. A narrative synthesis was performed.

RESULTS

Of 4,309 unique records, 91 studies examining 50 unique study populations met inclusion criteria. Of these, four populations included men who received GGT through routine clinical care, accounting for 4,415 men (72.6% White and 7.2% Black). The other 46 populations included men who received GGT as part of a research study, accounting for 30,824 men (64.3% White and 21.6% Black). Of these 46 research populations, 19 used targeted methods to increase recruitment from a specific demographic.

CONCLUSION

Most studies that report GGT rates by race/ethnicity are in research settings. Many of these studies used targeted recruitment methods and subsequently have a greater proportion of Black men than clinical and US population-based studies. Other historically marginalized populations are not well represented. There remains a knowledge gap regarding the extent of racial disparities in the use of GGT, particularly in the clinical setting.

Long-Term Impact of Medicaid Expansion on Colorectal Cancer Screening in Its Targeted Population

INTRODUCTION

Colorectal cancer screening continuously decreased its mortality and incidence. In 2010, the Affordable Care Act extended Medicaid eligibility to low-income and childless adults. Some states elected to adopt Medicaid at different times while others chose not to. Past studies on the effects of Medicaid expansion on colorectal cancer screening showed equivocal results based on short-term data following expansion.

AIMS

To examine the long-term impact of Medicaid expansion on colorectal cancer screening among its targeted population at its decade mark.

METHODS

Behavioral Risk Factor Surveillance System data were extracted for childless adults below 138% federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were stratified into very early expansion states, early expansion states, late expansion states, and non-expansion states. Colorectal cancer screening prevalence was determined for eligible respondents. Difference-in-differences analyses were used to examine the effect of Medicaid expansion on colorectal cancer screening in states with different expansion statuses.

RESULTS

Colorectal cancer screening prevalence in very early, early, late, and non-expansion states all increased during the study period (40.45% vs. 48.14%, 47.52% vs 61.06%, 46.06% vs 58.92%, and 43.44% vs 56.70%). Difference-in-differences analysis showed significantly increased CRC screening prevalence in very early expansion states during 2016 compared to non-expansion states (Crude difference-in-differences + 16.45%, p = 0.02, Adjusted difference-in-differences + 15.9%, p = 0.03). No statistical significance was observed among other years and groups.

CONCLUSIONS

Colorectal cancer screening increased between 2012 and 2020 in all states regardless of expansion status. However, Medicaid expansion is not associated with long-term increased colorectal cancer screening prevalence.

What is the prevalence of hepatic steatosis on ultrasonography in patients followed for nephrolithiasis?

INTRODUCTION

Patients with non-alcoholic fatty liver disease (NAFLD) have higher prevalence of nephrolithiasis. The aim of the present study was to determine prevalence of hepatic steatosis on ultrasonography in nephrolithiasis patients.

METHODS

Charts of 318 consecutive nephrolithiasis patients seen in stone clinic between January and February 2018 were retrospectively reviewed. Ultrasound reports were reviewed for hepatic steatosis. Subsequent liver investigations were noted. Patients' demographic predictors of hepatic steatosis were identified using univariable logistic regression models.

RESULTS

A total of 162 patients was included, of which 76 (46.9%) were found to have hepatic steatosis and 22 (13.6%) were found to have moderate-to-severe hepatic steatosis. Median followup was 2.03 years. Predictors of hepatic steatosis included higher body mass index and smoking (both p<0.05). Progression of fatty liver on ultrasound was noted for 13 (17.1%) and regression was noted for two (2.6%). Of the 16 patients with a Fibrosis-4 (FIB-4) score, four (25.0%) patients required further investigation and 12 (75.0%) were unlikely to have advanced fibrosis. Of 12 patients who underwent fibroscan, one (8.3%) had both fibrosis and cirrhosis, two (16.7%) fibrosis only, and two (16.7%) moderate-to-severe steatosis.

CONCLUSIONS

Hepatic steatosis on ultrasound followup of nephrolithiasis patients is common, especially in smokers and overweight patients. Current recommendations suggest that primary care physicians calculate a FIB-4 score upon the detection of hepatic steatosis on ultrasound. The decision to refer to hepatology for a corroborative fibroscan is then based on the FIB-4 score.

Simulation-based prostate enucleation training: Initial experience using 3D-printed organ phantoms

INTRODUCTION

Anatomical endoscopic enucleation of the prostate (AEEP) is an effective treatment for benign prostatic hyperplasia (BPH); however, there is controversy regarding the difficulty of learning such a technique. Simulation-based training can mimic real-life surgeries and help surgeons develop skills they can transfer to the operating room, thereby improving patient safety. This study aimed to evaluate the validity of a novel organ phantom for use in AEEP simulation training.

METHODS

Participants performed AEEP on organ phantom simulators during a Masterclass using one of three energy modalities: holmium:YAG laser, thulium fiber laser, or bipolar energy. The organ phantom is composed of hydrogels and uses 3D molds to recreate prostatic tissue. Participants completed a questionnaire assessing content validity, face validity, feasibility, and acceptability of using the prostate organ phantom.

RESULTS

The novice group consisted of 13 urologists. The median number of AEEP previously performed was 0 (interquartile range [IQR] 0-2). Two experts in AEEP (surgeons having performed over 100 AEEP interventions) also participated. All participants agreed or strongly agreed that there is a role for simulators in AEEP training. Participants positively rated the overall operative experience (7.3/10). Morcellation (4.7/10) and hemostasis (3.1/10) were deemed the least realistic steps. All participants considered it feasible to incorporate this organ phantom into training programs and 92.9% agreed that it teaches skills transferrable to the operating room.

CONCLUSIONS

This study has established content and face validity for AEEP with three different energy sources for an organ phantom. Participants considered its use both feasible and appropriate for AEEP training purposes.

Clinical Applications of Machine Learning for Urolithiasis and Benign Prostatic Hyperplasia: A Systematic Review

INTRODUCTION

Previous systematic reviews related to machine learning (ML) in urology often overlooked the literature related to endourology. Therefore, we aim to conduct a more focused systematic review examining the use of ML algorithms for benign prostatic hyperplasia (BPH) or urolithiasis. In addition, we are the first group to evaluate these articles using the STREAM-URO framework.

METHODS

Searches of MEDLINE, Embase, and the Cochrane CENTRAL databases were conducted from inception through July 12, 2021. Keywords included those related to ML, endourology, urolithiasis, and BPH. Two reviewers screened the citations that were eligible for title, abstract and full-text screening, with conflicts resolved by a third reviewer. Two reviewers extracted information from the studies, with discrepancies resolved by a third reviewer. The data collected was then qualitatively synthesized by consensus. Two reviewers evaluated each article according to the STREAM-URO checklist with discrepancies resolved by a third reviewer.

RESULTS

After identifying 459 unique citations, 63 articles were retained for data extraction. Most articles consisted of tabular (n=32) and computer vision (n=23) tasks. The two most common problem types were classification (n=40) and regression (n=12). In general, most studies utilized neural networks as their ML algorithm (n=36). Among the 63 studies retrieved, 58 were related to urolithiasis and five focused on BPH. The urolithiasis studies were designed for outcome prediction (n=20), stone classification (n=18), diagnostics (n=17), and therapeutics (n=3). The BPH studies were designed for outcome prediction (n=2), diagnostics (n=2), and therapeutics (n=1). On average, the urolithiasis and BPH articles met 13.8 (SD 2.6), and 13.4 (4.1) of the 26 STREAM-URO framework criteria, respectively.

CONCLUSIONS

The majority of the retrieved studies successfully helped with outcome prediction, diagnostics, and therapeutics for both urolithiasis and BPH. While ML shows great promise in improving patient care, it is important to adhere to the recently developed STREAM-URO framework to ensure the development of high-quality ML studies.

Top 100 Urology Influencers on Twitter: Is Social Media Influence Associated with Academic Impact?

BACKGROUND

Social media use in medicine has exploded, with uptake by most physicians and patients. There is a risk of dissemination of inaccurate information about urological conditions on social media. Physicians, as key opinion leaders, must play a role in sharing evidence-based information through social media.

OBJECTIVE

To identify and describe the top 100 urology influencers on the Twitter social media platform and to correlate Twitter influence with academic impact in urology.

DESIGN, SETTING, AND PARTICIPANTS

Twitter influence scores for the search topic "urology" were collected in April 2022 using published methodology. The top 100 personal accounts with the highest computed scores were linked to individuals' names, all-time h index, geographic location, specialty, attributed sex, and board certification status in this cross-sectional study.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We examined the correlation between influence rank and h index.

RESULTS AND LIMITATIONS

Of the top 100 Twitter influencers on the topic of urology, the majority are from the USA (64%), male (85%), and practicing urologists (91%). Some 93% of US urology influencers are board-certified. Only 22 of the 50 US states are represented. The second most frequent country is the UK, with ten urology influencers. The median all-time h index is 42 (interquartile range 28.25-58). There is a weak positive correlation between influence rank and h index (r = 0.23; p = 0.02). Limitations of the study include the inability to validate the accuracy of the proprietary ranking algorithm and investigation of just one social media platform.

CONCLUSIONS

The top Twitter influencers in urology are mostly board-certified US urologists. Collectively, influencers have a relatively greater academic impact in comparison to the average urologist, although there is a weak positive correlation between Twitter influence and h index among top Twitter influencers.

PATIENT SUMMARY

Given the explosion of medical information on Twitter, we report the personal accounts with the greatest impact for the topic of "urology". We found that most urology influencers on Twitter are US board-certified urologists with a strong research history.

Age-stratified continence outcomes of robotic-assisted radical prostatectomy

INTRODUCTION

Incontinence after robot-assisted radical prostatectomy (RARP) significantly impacts quality of life. This study aims to compare the age-stratified continence outcomes in Canadian men undergoing RARP.

MATERIALS AND METHODS

A retrospective review was performed on a prospectively maintained database of 1737 patients who underwent RARP for localized prostate cancer between 2007 and 2019. Patients were stratified into five groups based on age: group 1, ≤ 54 years (n = 245); group 2, 55-59 years (n = 302) ; group 3, 60-64 years (n = 386); group 4, 65-69 years (n = 348); and group 5, ≥ 70 years (n = 116). Functional outcomes were assessed up to 36 months. Log-rank and multivariable Cox regression analyses were performed to compare the time to recovery of pad-free continence by age group.

RESULTS

Continence rates of groups 1 to 5 were respectively 90.2%, 79.1%, 80.4%, 71.4%, and 59.8% at 1-year follow up (p < 0.001). After 3 years, groups 1 through 5 had continence rates of 97%, 91.7%, 89.3%, 81.4%, and 77.6%, respectively (p < 0.001). Median time to recovery of continence was 58, 135, 140, 152 and 228 days, respectively. Among men who remained incontinent, older patients consistently required more pads. In Cox proportional hazard model, groups 2, 3, 4 and 5 were respectively 33% (p < 0.001), 34% (p < 0.001), 33% (p = 0.001), and 41% (p = 0.005) more likely to remain incontinent compared to group 1.

CONCLUSIONS

Age is associated with significantly lower rates of continence recovery, longer time to recovery of continence, and more severe cases of incontinence after RARP.

Does the 5-item Frailty Index predict surgical complications of endoscopic surgical management for benign prostatic obstruction? An analysis of the ACS-NSQIP

PURPOSE

To assess whether the 5-item Frailty Index (5i-FI) predicts surgical complications of endoscopic surgery for benign prostatic obstruction (BPO) and examine the rates of these complications across BPO surgical modalities adjusting for patient frailty.

METHODS

The ACS-NSQIP registry was queried for patients who underwent transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), and laser enucleation of the prostate (LEP) between 2009 and 2019. Patients' frailties were estimated using the 5i-FI. We assessed the association between 5i-FI and the following endpoints: all complications, major complications (Clavien-Dindo ≥ 3), length of stay (LOS) ≥ 2 days, and 30-day postoperative readmission. Inverse probability of treatment weighting (IPTW) was used to account for selection bias in treatment allocation. IPTW-adjusted rates for 30-day complications were compared between surgical modalities.

RESULTS

The cohort included 38,399 (62.6%) TURP, 19,121 (31.2%) PVP, and 3797 (6.2%) LEP. Men with 5i-FI score ≥ 2 were more likely to receive TURP (22.7%) and PVP (22.5%) than LEP (18.8%). 5i-FI ≥ 2 was associated with higher odds of all complications (OR 1.50), major complications (OR 1.63), LOS ≥ 2 (OR 1.31), and readmission (OR 1.65). After IPTW, LEP had the lowest rates for all complications (6.29%; 95%CI 5.48-7.20), major complications (2.30%; 95%CI 1.83-2.89), and readmission (3.80%; 95%CI 3.18-4.53).

CONCLUSION

The 5i-FI score is an independent predictor of 30-day postoperative surgical complications after endoscopic BPO surgery. After IPTW, LEP and PVP were associated with lower rates of complications than TURP. However, frail patients were less likely to undergo PVP and LEP. Preoperative frailty assessment could improve risk stratification before BPO surgery.

Access to definitive treatment and survival for intermediate-risk and high-risk prostate cancer at hospital systems serving health disparity populations

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Background: Socioeconomic and racial disparities in prostate cancer (PCa) can be attributed to patient-level and physician-level factors. However, there is growing interest in investigating the role of the facility of care in driving cancer disparities. Therefore, we sought to examine receipt of guideline-concordant definitive treatment, time to treatment initiation (TTI), and survival for men with PCa receiving care at hospital systems serving health disparity populations (HSDPs). Methods: We conducted a retrospective analysis of the National Cancer Database (2004-2016) among men with intermediate-risk or high-risk PCa eligible for definitive treatment. The primary outcomes were receipt of definitive treatment and TTI within 90 days of diagnosis. The secondary outcome was survival. We defined HSDPs as minority-serving hospitals – facilities in the highest decile of proportion of Non-Hispanic Black (NHB) or Hispanic cancer patients – and/or high-burden safety-net hospitals – facilities in the highest quartile of proportion of underinsured patients. We used mixed-effect models with facility-level random intercept to compare outcomes between HSDPs and non-HSDPs among the entire cohort and among men who received definitive treatment. We evaluated interactions between HSDP status and race for each of the outcomes. Results: The cohort included 821,931 men with intermediate-risk or high-risk PCa. We included 968 non-HSDPs (72.2%) and 373 HSDPs (27.8%) facilities. Treatment at HSDPs was associated with lower odds of receipt of definitive treatment (aOR 0.64; 95% CI 0.57-0.71; p < 0.001), lower odds of TTI within 90 days of diagnosis (aOR 0.74; 95% CI 0.68-0.79; p < 0.001), and worse survival (aHR 1.05; 95% CI 1.02-1.09; p = 0.003). However, no difference was found in survival among patients who received definitive treatment. NHB men at HSDPs had also worse outcomes than NHB men treated at non-HSDPs as well as NHW men treated at HSDPs (Table). Conclusions: Patients treated at HSDPs were less likely to receive timely definitive treatment and had worse survival. NHB men have worse outcomes than NHW at HSDPs. NHB men with PCa remain largely disadvantaged since they are more likely to be treated at hospitals with worse outcomes and have worse outcomes than other patients at those same institutions. [Table: see text]

Global experience and progress in GreenLight-XPS 180-Watt photoselective vaporization of the prostate

PURPOSE

To evaluate changes in global perioperative data of GreenLight-XPS 180-Watt photo-selective vaporization of the prostate (GL-XPS) of the Global Greenlight Group (GGG) database.

METHODS

3441 men, who underwent GL-XPS for symptomatic BPH between 2011 and 2019 at seven high volume international centers, were included. Primary outcome measurements were operative time (OT; min), effective laser time (LT; min of OT), as well as intraoperative and postoperative adverse events (AEs), all analyzed by year of surgery (2011-2019) and prostate volume (PV) group (< 80 ml vs. 80-150 ml vs. > 150 ml).

RESULTS

The median age was 70 years (interquartile range 64-77), the median PV was 64 ml (IQR 47-90). The OT and LT slightly increased but stayed highly efficient all in all. Median OT was 60 min (IQR 45-83) and LT was 33 min (IQR 23-46). Median energy use was 253 kJ (IQR 170-375) with an energy density of 3.94 kJ/ml (IQR 2.94-5.02). The relative probability of perioperative AEs decreased by 17% each year (p < 0.001). The relative probability of perioperative transfusion dropped significantly from 2% in 2011 to 0% in 2019 (p = 0.007). The early postoperative complications (within 30 days after surgery) decreased significantly from 48.8% (n = 106) in 2011 to 24.7% (n = 20) in 2019 (p > 0.001).

CONCLUSION

These findings from the GGG demonstrate significant improvement secondary to growing experience with GL-XPS between 2011 and 2019 in intraoperative AEs, including transfusions, and postoperative AEs. While staying highly efficient in OT and LT of GL-XPS within a 9-year period of experience.

Risk and predictors of ipilimumab-associated cardiac adverse events among patients treated for melanoma: A national cohort analysis

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Background: Ipilimumab is a CTLA-4 inhibitor widely used to treat advanced melanoma. While ipilimumab-induced cardiac immune-related adverse events (irAE) have been reported, there is a paucity of data from large cohorts. We investigated the risk and predictors of ipilimumab-associated cardiac irAE in a national cohort of patients with cutaneous melanoma. Methods: Using SEER-Medicare linked data, we compared the risk of cardiac irAE between patients treated with ipilimumab with or without concomitant treatment for cutaneous melanoma and controls not treated with ipilimumab following a primary diagnosis of cutaneous melanoma. We excluded patients ≤65 years and patients with cardiac comorbidities diagnosed within one year prior to the initiation of melanoma treatment. The primary endpoint was the incidence of at least one cardiac irAE after ipilimumab initiation including acute pericarditis, myocarditis, cardiomyopathy, conduction disorders, cardiac dysthymias, acute heart failure, and takotsubo syndrome. To estimate the risk of cardiac irAE, we conducted a multivariable competing-risk analysis adjusting for death of any cause within one year of treatment as a competing event. Then, we constructed a stepwise logistic regression to assess the predictors of having at least one cardiac irAE within one year of ipilimumab initiation. Subgroup analysis was conducted among patients who received ipilimumab only. The models were adjusted for patient demographics, disease stage, Charlson comorbidity index (CCI), history of hypertension, autoimmune disease, end stage renal disease (ESRD), chronic anticoagulant, and steroid use. Results: The cohort included 715 patients treated with ipilimumab and 22,070 controls. In the ipilimumab arm, 23.4% had metastatic disease, 9.5% had a history of autoimmune disease, and 2.2% had CCI≥2. The incidence rates of cardiac irAE among patients who received ipilimumab and among the control group were 23.3 and 13.6 per 1,000 person-years, respectively. We found that patients who received ipilimumab had a higher risk of cardiac irAE compared to controls (adjusted hazard ratio 1.87; 95%CI 1.50-2.32; p < 0.001). In addition to ipilimumab treatment, other predictors of cardiac irAE included male gender, older age, patients with metastatic disease, history of autoimmune disease, hypertension, ESRD, anticoagulant use, and CCI≥2. The predictors of cardiac irAE were also consistent in the subgroup analysis of patients who received ipilimumab only. Conclusions: Patients who received ipilimumab with or without concomitant treatment for cutaneous melanoma had a higher risk for cardiac irAE. Predictors of cardiac irAE help tailor therapy according to patients’ risk profiles.

Digital technologies in cancer care: a review from the clinician's perspective

Physicians are increasingly utilizing digital health technologies (DHT) such as smartphone applications, network-enabled wearable devices, web-based communication platforms, videoconferencing, chatbots, artificial intelligence and virtual reality to improve access to, and quality of, care. DHT aid in cancer screening, patient education, shared decision-making, promotion of positive health habits, symptom monitoring and intervention, patient-provider communication, provision of psychological support and delivery of effective survivorship care. This narrative review outlines how physicians may utilize digital health to improve or augment their delivery of cancer care. For the full potential of DHT to be realized, experts must develop appropriate solutions to issues surrounding the regulation, liability, quality, security, equity and reimbursement of DHT.

GreenLight photovaporization of the prostate in high-medical-risk patients: an analysis of the Global GreenLight Group (GGG) database

PURPOSE

We sought to characterize the adjusted outcomes of GreenLight photoselective vaporization of the prostate (PVP) in high-medical-risk (HMR) patients using data from the largest international database.

METHODS

Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. Eligible study participants underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019. HMR patients were defined as patients with ASA III or greater and were compared to non-HMR patients. Analyses were adjusted for patient age and prostate volume.

RESULTS

In the HMR group, patients on average were older and had smaller prostates than the non-HMR control group. Compared to non-HMR patients, transfusions occurred more frequently (2.6% vs. 0.14%, p < 0.01) and the odds of readmission were elevated [OR 2.0, (95% CI 1.4-2.8, p < 0.01)] among HMR patients. Twelve months postoperatively, HMR patients experience greater improvement in QoL than the control group [+ 0.54 (95% CI 0.07-1.0, p = 0.02)]. PVR also decreased 93.1 ml more in HMR than in non-HMR patients after 12 months (95% CI 33.6-152.6, p < 0.01).

CONCLUSION

We found that GreenLight PVP is safe and effective in improving functional outcomes in higher-risk patients with severe systemic disease compared to their lower-risk counterparts. Though absolute risks remain low, GreenLight PVP is associated with higher odds of transfusion and readmission in the high-risk cohort. The findings of our study reaffirm current guidelines that propose PVP as a viable treatment option for HMR patients.