The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

Disparities in COVID-19 Disease Incidence by Income and Vaccination Coverage - 81 Communities, Los Angeles, California, July 2020-September 2021

COVID-19 has disproportionately affected socially vulnerable communities characterized by lower income, lower education attainment, and higher proportions of minority populations, among other factors (1-4). Disparities in COVID-19 incidence and the impact of vaccination on incidence disparities by community income were assessed among 81 communities in Los Angeles, California. Median community vaccination coverage and COVID-19 incidence were calculated across household income strata using a generalized linear mixed effects model with Poisson distribution during three COVID-19 surge periods: two before vaccine availability (July 2020 and January 2021) and the third after vaccines became widely available in April 2021 (September 2021). Adjusted incidence rate ratios (aIRRs) during the peak month of each surge were compared across communities grouped by median household income percentile. The aIRR between communities in the lowest and highest median income deciles was 6.6 (95% CI = 2.8-15.3) in July 2020 and 4.3 (95% CI = 1.8-9.9) in January 2021. However, during the September 2021 surge that occurred after vaccines became widely availabile, model estimates did not identify an incidence disparity between the highest- and lowest-income communities (aIRR = 0.80; 95% CI = 0.35-1.86). During this surge, vaccination coverage was lowest (59.4%) in lowest-income communities and highest (71.5%) in highest-income communities (p<0.001). However, a significant interaction between income and vaccination on COVID-19 incidence (p<0.001) indicated that the largest effect of vaccination on disease incidence occured in the lowest-income communities. A 20% increase in community vaccination was estimated to have resulted in an additional 8.1% reduction in COVID-19 incidence in the lowest-income communities compared with that in the highest-income communities. These findings highlight the importance of improving access to vaccination and reducing vaccine hesitancy in underserved communities in reducing disparities in COVID-19 incidence.

National prevalence of IC/BPS in women and men utilizing veterans health administration data

Importance

Interstitial cystitis/bladder pain syndrome (IC/BPS) is an immense burden to both patients and the American healthcare system; it is notoriously difficult to diagnose. Prevalence estimates vary widely (150-fold range in women and >500-fold range in men).

Objectives

We aimed to create accurate national IC/BPS prevalence estimates by employing a novel methodology combining a national population-based dataset with individual chart abstraction.

Study design

In this epidemiological survey, all living patients, with ≥2 clinic visits from 2016 to 2018 in the Veterans Health Administration, with an ICD-9/10 code for IC/BPS (n = 9,503) or similar conditions that may represent undiagnosed IC/BPS (n = 124,331), were identified (other were controls n = 5,069,695). A detailed chart review of random gender-balanced samples confirmed the true presence of IC/PBS, which were then age- and gender-matched to the general US population.

Results

Of the 5,203,529 patients identified, IC/BPS was confirmed in 541 of 1,647 sampled charts with an IC/BPS ICD code, 10 of 382 charts with an ICD-like code, and 3 of 916 controls. After age- and gender-matching to the general US population, this translated to national prevalence estimates of 0.87% (95% CI: 0.32, 1.42), with female and male prevalence of 1.08% (95% CI: 0.03, 2.13) and 0.66% (95% CI: 0.44, 0.87), respectively.

Conclusions

We estimate the prevalence of IC/BPS to be 0.87%, which is lower than prior estimates based on survey data, but higher than prior estimates based on administrative data. These potentially represent the most accurate estimates to date, given the broader and more heterogeneous population studied and our novel methodology of combining in-depth chart abstraction with administrative data.

Demographic Differences and Disparities in the Misdiagnosis of Interstitial Cystitis/Bladder Pain Syndrome in a National Cohort of VA Patients

OBJECTIVE

To explore association between misdiagnosis of IC/BPS and demographics. Interstitial cystitis/bladder pain syndrome (IC/BPS) is associated with significant diagnostic uncertainty, resulting in frequent misdiagnosis as there is little known about the potential impact of key demographic factors.

METHODS

All patients in the VA system between 1999-2016 were identified by ICD-9/10 codes for IC/BPS (595.1/N30.10) (n = 9,503). ICD code accuracy for true IC/BPS (by strict criteria) was assessed by in-depth chart abstraction (n = 2,400). Associations were explored between rates of misdiagnosis and demographics.

RESULTS

IC/BPS criteria were met in only 651 (48.8%) of the 1,334 charts with an ICD code for IC/BPS reviewed in depth. There were no differences in the misdiagnosis rate by race (P=.27) or by ethnicity (P=.97), after adjusting for differences in age and gender. In IC/BPS-confirmed cases, female patients were diagnosed at a younger age than males (41.9 vs. 58.2 years, P<.001). Black and Hispanic patients were diagnosed at a younger age compared to White (41.9 vs. 50.2 years, P<.001) and non-Hispanic patients, respectively (41.1 vs. 49.1 years, P=.002).

CONCLUSION

There was a high rate of misdiagnosis of IC/BPS overall, with only 48.8% of patients with an ICD code for IC/BPS meeting diagnostic criteria. There were no significant associations between diagnostic accuracy and race/ethnicity. Black and Hispanic patients were more likely to receive a diagnosis of IC/BPS at a younger age, suggesting there may be differing natural histories or presentation patterns of IC/BPS between racial/ethnic groups.

Comorbidities in a Nationwide, Heterogenous Population of Veterans with Interstitial Cystitis/Bladder Pain Syndrome

OBJECTIVE

To examine the prevalence of comorbid conditions in a nationwide population of men and women with IC/BPS utilizing a more heterogeneous sample than most studies to date.

METHODS

Using the Veterans Affairs Informatics and Computing Infrastructure, we identified random samples of male and female patients with and without an ICD-9/ICD-10 diagnosis of IC/BPS. Presence of comorbidities (NUAS [chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, migraines], back pain, diabetes, and smoking) and psychosocial factors (alcohol abuse, post-traumatic stress disorder, sexual trauma, and history of depression) were determined using ICD-9 and ICD-10 codes. Associations between these variables and IC/BPS status were evaluated while adjusting for the potential confounding impact of race/ethnicity, age, and gender.

RESULTS

Data was analyzed from 872 IC/BPS patients (355 [41%] men, 517 [59%] women) and 558 non-IC/BPS patients (291 [52%] men, 267 [48%] women). IC/BPS patients were more likely than non-IC/BPS patients to have a greater number of comorbidities (2.72+/-1.77 vs 1.73+/-1.30, P < 0.001), experience one or more NUAS (chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and migraines) (45% [388/872] vs. 18% [101/558]; P < 0.001) and had a higher prevalence of at least one psychosocial factor (61% [529/872] v. 46% [256/558]; P < 0.001). Differences in the frequencies of comorbidities between patients with and without IC/BPS were more pronounced in female patients.

CONCLUSION

These findings validate the findings of previous comorbidity studies of IC/BPS in a more diverse population.

Payer Type, Race/Ethnicity, and the Timing of Surgical Management of Urinary Stone Disease

PURPOSE

Surgery for upper tract urinary stone disease is often reserved for symptomatic patients and those whose stone does not spontaneously pass after a trial of passage. Our objective was to determine whether payer type or race/ethnicity is associated with the timeliness of kidney stone surgery.

MATERIALS AND METHODS

A population-based cohort study was conducted using the California Office of Statewide Health Planning and Development dataset from 2010 to 2012. We identified patients who were discharged from an emergency department (ED) with a stone diagnosis and who subsequently underwent a stone surgery. Primary outcome was time from ED discharge to urinary stone surgery in days. Secondary outcomes included potential harms resulting from delayed stone surgery.

RESULTS

Over the study period, 15,193 patients met the inclusion criteria. Median time from ED discharge to stone surgery was 28 days. On multivariable analysis patients with Medicaid, Medicare, and self-pay coverage experienced adjusted mean increases of 46%, 42%, and 60% in time to surgery, respectively, when compared with those with private insurance. In addition, patients of Black and Hispanic race/ethnicity, respectively, experienced adjusted mean increases of 36% and 20% in time to surgery relative to their White counterparts. Before a stone surgery, underinsured patients were more likely to revisit an ED three or more times, undergo two or more CT imaging studies, and receive upper urinary tract decompression.

CONCLUSIONS

Underinsured and minority patients are more likely to experience a longer time to stone surgery after presenting to an ED and experience potential harm from this delay.

Care Seeking Patterns for Women Requiring a Repeat Pelvic Organ Prolapse Surgery Due to Native Tissue Repair Failure Compared to a Mesh Complication

OBJECTIVE

To explore patient migration patterns in patients requiring repeat surgery after Pelvic Organ Prolapse (POP) repair as there is a limited understanding of care seeking patterns for repeat surgery after POP repair. We hypothesized that undergoing repeat surgery for a prolapse mesh complication would be associated with an increased incidence of migration to a new facility for care compared to those undergoing repeat surgery for recurrent POP.

METHODS

In this retrospective population based study, all females who underwent an index POP repair procedure (with or without mesh) at nonfederal facilities who subsequently underwent a repeat surgery (recurrent prolapse repair or mesh complication) were identified from the Office of Statewide Health Planning and Development for the state of California (2005-2011). The location of index repair and repeat surgery were identified and factors associated with migration were explored.

RESULTS

Of the 3,930 women who underwent repeat surgery for either POP recurrence or a mesh complication, 1,331 (33.9%) had surgery at a new facility. Multivariate analysis revealed that mesh complications (odds ratio [OR] 1.28, P = 0.004) or native tissue same compartment recurrence (OR 1.19, P = 0.02) were both associated with increased odds of undergoing surgery at a new facility. Having surgery in a county with multiple centers increased the odds of migration to a new facility for care (OR = 1.33, P < 0.001), unless the initial repair was at a high volume institution (OR = 0.32, P < 0.001). Overall across indications, women changing locations for their second surgery tended to migrate toward select centers in urban areas.

CONCLUSION

Women who undergo repeat surgery after POP repair have similar patterns of migration to a new facility irrespective of the indication for surgery.

Redefining the Stone Belt: Precipitation Is Associated with Increased Risk of Urinary Stone Disease

OBJECTIVES

The American Southeast has been labeled the "Stone Belt" due to its relatively high burden of urinary stone disease, presumed to be related to its higher temperatures. However, other regions with high temperatures (e.g., the Southwest) do not have the same disease prevalence as the southeast. We seek to explore the association of stone disease to other climate-associated factors beyond temperature, including precipitation and temperature variation.

METHODS

We identified all patients who underwent a surgical procedure for urinary stone disease from the California Office of Statewide Health Planning and Development (OSHPD) databases (2010-2012). Climate data obtained from the National Oceanic and Atmospheric Administration (NOAA) were compared to population adjusted county operative stone burden, controlling for patient and county demographic data as potential confounders.

RESULTS

A total of 63,994 unique patients underwent stone procedures in California between 2010 and 2012. Multivariate modeling revealed that higher precipitation (0.019 average increase in surgeries per 1000 persons per inch, p < 0.01) and higher mean temperature (0.029 average increase in surgeries per 1000 persons per degree, p < 0.01) were both independently associated with an increased operative stone disease burden. Controlling for county-level patient factors did not change these observed effects.

CONCLUSIONS

In the state of California, higher precipitation and higher mean temperature are associated with increased rates of stone surgery. Our results appear to agree with the larger trends seen throughout the United States where the areas of highest stone prevalence have warm wet climates and not warm arid climates.

Intermittent Projectile Urethraggia: An Unusual Sequela of a Skateboarding Accident in an Adolescent Male

Our patient suffered a perineal straddle injury, resulting in right cavernosal artery pseudoaneurysm in combination with a cavernosal-urethral fistula. The urethra failed to heal after several weeks, and the patient presented with severe intermittent urethral bleeding. The pseudoaneurysm was successfully treated by coil embolization, with resolution of the bleeding. The patient recovered completely, with normal erectile and voiding function. This type of injury is very rare in the literature: traumatic cavernosal arterial pseudoaneurysm is known to cause high flow priapism, but in this case additional cavernosal-urethral fistula resulted in a severe urethraggia. This is the only case, to our knowledge, of delayed urethral bleeding from cavernosal artery pseudoaneursym in combination with a cavernosal-urethral fistula.

Unplanned Hospital Visits in the First 30 Days After Urethral Sling Procedures

OBJECTIVE

To evaluate unplanned hospital visits within 30 days of urethral sling placement in the form of emergency department visits, inpatient admissions, or repeat surgery.

METHODS

We accessed nonpublic data from the Office of Statewide Health Planning and Development in the state of California for the years 2005-2011. All female patients who underwent an ambulatory urethral sling procedure (Current Procedural Terminology 57288) without concomitant surgery (other than cystoscopy) were included. Any subsequent emergency department visit, inpatient admission, or sling revision operation within 30 days of the original surgery were then examined.

RESULTS

A total of 28,635 women were identified who underwent outpatient urethral sling placement as a sole procedure. Within 30 days, 1630 women (5.7%) had at least 1 unplanned hospital visit. This included 1327 emergency department visits (4.7%), 295 inpatient admissions (1.0%), and 79 sling revisions (0.28%). Urinary retention and Foley catheter problems were the most common emergency department visit diagnoses (18.7% of visits), followed by urinary tract infection (9.3% of visits).

CONCLUSION

One in 18 women will have an unplanned hospital visit within 30 days of urethral sling placement, the majority of which are emergency department visits (~81%). Our findings can be used to improve patient counseling and suggest areas that one might target to decrease unnecessary emergency department visits in the early postoperative period.

Life after colectomy for fulminant Clostridium difficile colitis: a 7-year follow up study

BACKGROUND

The long-term prognosis of patients undergoing colectomy for fulminant Clostridium difficile colitis has not been well studied. The authors present 7-year survival trends in such patients.

METHODS

Patients were identified through a pathologic database. Medical records were reviewed and follow-up phone calls made to determine relevant patient history, longevity, and quality of life.

RESULTS

The 61 patients identified had mean and median survival of 18.1 and 3.2 months, respectively, and 1-year, 2-year, 5-year, and 7-year mortality of 68.5%, 79.6%, 88.9%, and 90.7%, respectively. Previous C difficile infection, hypotension, requirement of vasopressors, mental status changes, elevated arterial lactate, decreased platelet counts, intubation, and longer duration on nonoperative therapy were associated with in-hospital mortality. There were no factors correlated with long-term survival.

CONCLUSIONS

Patients who require colectomy for fulminant C difficile colitis have a poor prognosis with poor long-term survival and significant morbidity. Although there are several factors associated with in-hospital mortality, there were no factors correlated with long-term survival.

Laparoscopic versus open inguinal hernia repair in octogenarians: a follow-up study

AIM

The elderly population is the fastest growing demographic in developed countries. It is thus imperative to assess common medical procedures in this age group. Inguinal hernia repair is a commonly carried out operation in the USA with two methods of repair existing - laparoscopic and open. Although the advantages of laparoscopic inguinal hernia repair in the general population have been shown, its role in the elderly has yet to be elucidated.

METHODS

A retrospective medical record review with prospective follow up of 115 patients aged over 80 years who underwent either open or laparoscopic inguinal hernia repair was carried out. Outcome measures included postoperative pain score, recovery time, chronic pain, wound infection, urinary retention, urinary tract infection, hematoma and recurrence. Patient satisfaction was measured with the Likert score.

RESULTS

Of the 115 repairs, 31 repairs were carried out laparoscopically and 84 open. Mean patient age was 83.3 years (range 80-95 years), with no difference in demographics or comorbidities between the two groups. Mean recovery time was significantly shorter in the laparoscopic group (7.5 vs 23.1 days, P = 0.02), as was the mean duration of pain in the laparoscopic group (1.4 vs 9.6 days, P = 0.04). There were no significant differences in other outcomes. There was a trend towards increased patient satisfaction in the laparoscopic group (P = 0.10).

CONCLUSION

In octogenarians, laparoscopic inguinal hernia repair confers a significantly shorter duration of pain and recovery time as compared with open inguinal hernia repair, with no increase in complications. For elderly patients, laparoscopy is a viable alternative to open repair.

Management and Outcomes of Colovesical Fistula Repair

This large retrospective study presents the largest colovesical fistula (CVF) series to date. We report on recurrence risk factors and patient satisfaction based on quality of life after CVF repair. Approval was obtained from The Mount Sinai School of Medicine Institutional Review Board, and a retrospective review was performed from 2003 to 2010 involving 72 consecutive patients who underwent a colovesical fistula repair. The CVF recurrence rate was 11 per cent. Ten percent of our patients who had a history of radiation therapy were at a significantly higher risk of developing a recurrence. Noted recurrence rates were significantly higher in advanced bladder repairs compared with simple repair ( P = 0.022). The modified (Gastrointestinal Quality of Life Index) surveys showed overall patient satisfaction score was 3.6, out of a maximum score of 4, regardless of the type of repair or any postoperative complications. Our study found the CVF recurrence rate to be 11 per cent. Patients at higher risk of recurrence include those needing advanced bladder repair, those with “complex” CVF, and those whose fistulas involve the urethra. Patient satisfaction was found to be more closely linked to the resolution of CVF symptoms, irrespective of the type of repair performed or development of postoperative complications.

Management and outcomes of colovesical fistula repair

This large retrospective study presents the largest colovesical fistula (CVF) series to date. We report on recurrence risk factors and patient satisfaction based on quality of life after CVF repair. Approval was obtained from The Mount Sinai School of Medicine Institutional Review Board, and a retrospective review was performed from 2003 to 2010 involving 72 consecutive patients who underwent a colovesical fistula repair. The CVF recurrence rate was 11 per cent. Ten percent of our patients who had a history of radiation therapy were at a significantly higher risk of developing a recurrence. Noted recurrence rates were significantly higher in advanced bladder repairs compared with simple repair (P = 0.022). The modified (Gastrointestinal Quality of Life Index) surveys showed overall patient satisfaction score was 3.6, out of a maximum score of 4, regardless of the type of repair or any postoperative complications. Our study found the CVF recurrence rate to be 11 per cent. Patients at higher risk of recurrence include those needing advanced bladder repair, those with "complex" CVF, and those whose fistulas involve the urethra. Patient satisfaction was found to be more closely linked to the resolution of CVF symptoms, irrespective of the type of repair performed or development of postoperative complications.