Publications by authors named "Robert Abouassaly"

134 Publications

Reply by Authors.

J Urol 2021 Feb 24:101097JU000000000000154903. Epub 2021 Feb 24.

Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000001549.03DOI Listing
February 2021

Contemporary management of advanced prostate cancer: an evolving landscape.

Clin Adv Hematol Oncol 2021 Feb;19(2):108-118

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.

Recent population-based studies suggest that the incidence of advanced and metastatic prostate cancer may be increasing. Concurrently with this apparent stage migration toward advanced disease, several major developments have occurred in the treatment paradigm for men with advanced prostate cancer. These include the US Food and Drug Administration approval of 8 novel agents over the last decade. In addition to novel pharmaceuticals, rapidly evolving diagnostic tools have emerged. This review provides a primer for clinicians who treat men with advanced prostate cancer, including medical oncologists, radiation oncologists, and urologists.
View Article and Find Full Text PDF

Download full-text PDF

Source
February 2021

Editorial Comment.

J Urol 2021 Jan 25:101097JU000000000000152301. Epub 2021 Jan 25.

Glickman Urological and Kidney Institute, Louis Stokes Cleveland VA Medical Center, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000001523.01DOI Listing
January 2021

New Baseline Renal Function after Radical or Partial Nephrectomy: A Simple and Accurate Predictive Model.

J Urol 2020 Dec 24:101097JU0000000000001549. Epub 2020 Dec 24.

Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Purpose: Preoperative estimation of new baseline glomerular filtration rate after partial nephrectomy or radical nephrectomy for renal cell carcinoma has important clinical implications. However, current predictive models are either complex or lack external validity. We aimed to develop and validate a simple equation to estimate postoperative new baseline glomerular filtration rate.

Materials And Methods: For development and internal validation of the equation, a cohort of 7,860 patients with renal cell carcinoma undergoing partial nephrectomy/radical nephrectomy (2005-2015) at the Veterans Affairs National Health System was analyzed. Based on preliminary analysis of 94,327 first-year postoperative glomerular filtration rate measurements, new baseline glomerular filtration rate was defined as the final glomerular filtration rate within 3 to 12 months after surgery Multivariable linear regression analyses were applied to develop the equation using two-thirds of the renal cell carcinoma Veterans Administration cohort. The simplest model with the highest coefficient of determination (R) was selected and tested. This model was then internally validated in the remaining third of the renal cell carcinoma Veterans Administration cohort. Correlation/bias/accuracy/precision of equation were examined. For external validation, a similar cohort of 3,012 patients with renal cell carcinoma from an outside tertiary care center (renal cell carcinoma-Cleveland Clinic) was independently analyzed.

Results: New baseline glomerular filtration rate (in ml/minute/1.73 m) can be estimated with the following simplified equation: New baseline glomerular filtration rate = 35 + preoperative glomerular filtration rate (× 0.65) - 18 (if radical nephrectomy) - age (× 0.25) + 3 (if tumor size >7 cm) - 2 (if diabetes). Correlation/bias/accuracy/precision were 0.82/0.00/83/-7.5-8.4 and 0.82/-0.52/82/-8.6-8.0 in the internal/external validation cohorts, respectively. Additionally, the area under the curve (95% Confidence Interval) to discriminate postoperative new baseline glomerular filtration rate ≥45 ml/minute/1.73 m from receiver operating characteristic analyses were 0.90 (0.88, 0.91) and 0.90 (0.89, 0.91) in the internal/external validation cohorts, respectively.

Conclusions: Our study provides a validated equation to accurately predict postoperative new baseline glomerular filtration rate in patients being considered for radical nephrectomy or partial nephrectomy that can be easily implemented in daily clinical practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000001549DOI Listing
December 2020

Race, Decisional Regret and Prostate Cancer Beliefs: Identifying Targets to Reduce Racial Disparities in Prostate Cancer.

J Urol 2021 02 23;205(2):426-433. Epub 2020 Nov 23.

Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Purpose: African American men are more likely to be diagnosed with, die of and experience decisional regret about their prostate cancer than nonAfrican American men. Although some clinical discrepancies may be attributed to genetic risk and/or access to care, explanations for racial discrepancies in decisional regret remain largely speculative. We aim to identify sources of prostate cancer decisional regret with a focus on racial disparities.

Materials And Methods: A cohort of 1,112 patients with localized prostate cancer treated at the Cleveland Clinic between 2010 and 2016 were matched by race, Gleason score, treatment (external beam radiation, brachytherapy, prostatectomy, active surveillance), prostate specific antigen at diagnosis, age at treatment and time since treatment. All patients received 4 surveys, including the Expanded Prostate Cancer Index Composite (EPIC) 26, the Decisional Regret Scale, our novel Prostate Cancer Beliefs Questionnaire and a modified EPIC demographics form. Descriptive and comparative statistics and multivariable logistic regression were used to compare survey outcomes by race and treatment method.

Results: Of 1,048 deliverable surveys 378 (36.07%) were returned. African American men had worse decisional regret than nonAfrican American men even after adjusting for relevant covariates (OR 2.46, p <0.0001). African American men also had higher Prostate Cancer Beliefs Questionnaire medical mistrust and masculinity scores, both of which predicted worse decisional regret independent of race (1.415 and 1.350, p=0.0001, respectively).

Conclusions: African American men suffer worse decisional regret than nonAfrican American men, which may be partially explained by higher medical mistrust and concerns about masculinity as captured by the Prostate Cancer Beliefs Questionnaire. This novel survey may facilitate identifying targets to reduce racial disparities in prostate cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000001385DOI Listing
February 2021

Reply by Authors.

J Urol 2021 02 23;205(2):433. Epub 2020 Nov 23.

Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000001385.02DOI Listing
February 2021

"Robotic fatigue?" - The impact of case order on positive surgical margins in robotic-assisted laparoscopic prostatectomy.

Urol Oncol 2020 Nov 4. Epub 2020 Nov 4.

Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH. Electronic address:

Purpose: Multiple robotic-assisted surgeries are often performed within a single operating day; however, the impact of this practice on patient outcomes has not been examined. We aim to determine whether outcomes for robotic-assisted laparoscopic prostatectomy (RALP) differed when performed sequentially.

Materials And Methods: A multi-institutional, retrospective cohort study was conducted involving a total of 8 academic centers between years 2015 and 2018. Participants were adult males undergoing RALP for localized prostate cancer on operative days in which 2 RALP cases were performed sequentially by the same resident-attending team. The primary outcome of the study was presence of positive surgical margin (PSM). Secondary outcomes were lymph node yield, operative time, and estimated blood loss. The primary analysis was a random effects meta-analysis model for PSM.

Results: Overall, 898 RALP cases (449 sequential pairs) were included in the study. There was no significant difference in PSM rate (27.2% vs. 30.3%, P= 0.338) between first and second case groups, respectively. Utilizing random effects meta-analysis, the second case cohort had no increased risk of PSM (OR 1.23, P= 0.40). Higher blood loss was noted in the second case cohort (186.7 ml vs. 221.7 ml, P = 0.002). Additionally, factors associated with PSM were increasing prostate specific antigen, higher percent tumor involvement, extraprostatic extension, and seminal vesicle invasion.

Conclusion: Case sequence was not associated with PSM, lymph node yield, or operative time for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.urolonc.2020.10.071DOI Listing
November 2020

Hospital-level Effects Contribute to Variations in Prostate Cancer Quality of Care.

Eur Urol Oncol 2020 Sep 13. Epub 2020 Sep 13.

Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre-University Health Network, Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada. Electronic address:

A paucity of real-world data exists highlighting whether variations in prostate cancer quality of care occur at a hospital level, independent of differences in case mix. To overcome this knowledge gap, we benchmarked hospital-level quality (n = 1245 hospitals) across a broad multidisciplinary panel of previously reported disease-specific, expert-defined quality indicators (QIs), adjusting for differences in patient case mix by indirect standardization. A composite measure of prostate cancer quality-the prostate cancer quality score (PC-QS)-was derived, and associations between PC-QS and hospital volume, academic status, and location as well as patient all-cause mortality were determined. After adjusting for the case mix, of the total of 1245 hospitals evaluated, 2-37% were identified as those performing significantly below the national average for a given QI. Hospitals with a higher PC-QS displayed larger patient volumes, were more commonly academic affiliated, and had lower overall mortality. Collectively, our data-driven benchmarking analysis reveals that widespread hospital-level variations exist in prostate cancer quality of care after adjusting for differences in case mix, with the PC-QS serving as a novel, validated, quality benchmarking tool. PATIENT SUMMARY: Our statistical benchmarking method shows that the quality of prostate cancer care varies between hospitals, after accounting for differences in patient characteristics. The prostate cancer quality score is a novel, validated, quality benchmarking tool.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euo.2020.08.010DOI Listing
September 2020

Unplanned Conversion from Minimally Invasive to Open Kidney Surgery: The Impact of Robotics.

J Endourol 2020 Sep 6;34(9):955-963. Epub 2020 Aug 6.

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Unplanned conversion from minimally invasive surgery (MIS) to open surgery is a significant challenge, although the frequency of conversion for robotic and laparoscopic kidney surgery is not well described. We aimed to compare rates of conversion for robotic versus laparoscopic kidney surgery. The National Cancer Database was used to identify patients who underwent robotic or laparoscopic partial nephrectomy (PN), radical nephrectomy (RN), or nephroureterectomy (NU) from 2010 to 2014. Multivariate logistic regression was used to identify factors associated with conversion to open. Length of stay and 30-day mortality rate were compared between groups using Kruskal-Wallis and Fisher's exact tests. Propensity score matching was performed to confirm study results. A total of 61,191 patients underwent MIS PN, RN, or NU. Conversion rates were lower for robotics than for laparoscopy (PN: 2.1% 6.4%; RN: 4.9% 6.0%; NU: 3.8% 9.2%;  < 0.001). Median length of stay was longer for patients who underwent conversion than for those who did not (PN: 4.0 2.0 days; RN: 4.0 3.0; NU: 5.0 4.0;  < 0.0001). Thirty-day mortality rate was higher for patients who underwent conversion (PN: 0.24% 1.42%; RN: 0.73% 2.71%; NU: 1.0% 3.0%,  < 0.001). Results were confirmed in propensity score-matched cohorts. Among patients undergoing minimally invasive kidney surgery, robotics is associated with a lower rate of unplanned open conversion than laparoscopy. This relative advantage has implications on length of stay and short-term mortality rate and should be considered when weighing the costs and benefits of robotic kidney surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/end.2020.0357DOI Listing
September 2020

Reply by Authors.

J Urol 2020 09 25;204(3):441. Epub 2020 Jun 25.

Glickman Urological and Kidney Institute-Cleveland Clinic Foundation, Cleveland, Ohio.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000001021.02DOI Listing
September 2020

Partial Nephrectomy for Patients with Severe Chronic Kidney Disease-Is It Worthwhile?

J Urol 2020 Sep 18;204(3):434-441. Epub 2020 Mar 18.

Glickman Urological and Kidney Institute-Cleveland Clinic Foundation, Cleveland, Ohio.

Purpose: Partial nephrectomy is prioritized over radical nephrectomy in patients with chronic kidney disease whenever feasible. However, we hypothesized that some patients with severe chronic kidney disease might rapidly progress to end stage renal disease, in which case the morbidity that can be associated with partial nephrectomy would not be justified.

Materials And Methods: A retrospective review of all 62 patients with stage IV chronic kidney disease undergoing partial nephrectomy at our institution (1999-2015) was performed. We analyzed preoperative/intraoperative factors and postoperative outcomes. Survival-analyses evaluated factors associated with time-to-progression to end stage renal disease the primary end point.

Results: Median age was 67 years, 71% of patients were male, and 84% Caucasian. Comorbidities included hypertension (94%), cardiovascular disease (53%) and diabetes (32%). Median preoperative estimated glomerular filtration rate was 23 ml/minute/1.73 m and 73% had an open approach. Benign pathology was found in 10 (16%) patients; only 23 (37%) and 7 (11%) patients had tumor grade 3/4 or pT3a disease, respectively. Unfavorable outcomes occurred in 15 patients (24%) defined as either 90-day mortality (3%), postoperative complication Clavien IIIb or greater (14%), or positive surgical margin (12%). Median time to progression to end stage renal disease was only 27 months (58 months for preoperative glomerular filtration rate greater than 25 ml/minute/1.73 m versus only 14 months when preoperative glomerular filtration rate was less than 20 ml/minute/1.73 m). On multivariable analysis African American race (HR 2.55 [1.10-5.95]), preoperative estimated glomerular filtration rate 20 to 25 ml/minute/1.73 m or less than 20 ml/minute/1.73 m (HR 2.59 [1.16-5.84] and 5.03 [2.03-12.4], respectively) and minimally invasive approach (HR 2.05 [1.01-4.19]) were independently associated with progression to end stage renal disease.

Conclusions: Our data suggest that some patients with stage IV chronic kidney disease undergoing partial nephrectomy have substantial comorbidities and nonaggressive pathology, and are at risk for unfavorable perioperative outcomes and rapid-progression to end stage renal disease. Renal mass biopsy should be strongly considered to improve patient-selection. Alternate strategies (active surveillance or radical nephrectomy) may be more appropriate, particularly when partial nephrectomy is high complexity or when the patient is African American, or preoperative glomerular filtration rate is less than 25 ml/minute/1.73 m.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000001021DOI Listing
September 2020

Compensatory Changes in Parenchymal Mass and Function after Radical Nephrectomy.

J Urol 2020 Jul 14;204(1):42-49. Epub 2020 Feb 14.

Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, Ohio.

Purpose: Loss of renal function remains a major limitation of radical nephrectomy. The extent of renal functional compensation by the preserved kidney after radical nephrectomy has not been adequately studied in this elderly population with comorbidities.

Materials And Methods: A total of 273 patients treated with radical nephrectomy without end stage renal disease with available preoperative nuclear renal scans were included in the analysis. Renal functional compensation was defined as percent change in estimated glomerular filtration rate of the preserved kidney after radical nephrectomy. Estimated glomerular filtration rate was calculated by the Chronic Kidney Disease-Epidemiology Collaboration formula up to 5 years postoperatively. Preoperative/postoperative parenchymal volumes of the preserved kidney were measured from cross-sectional imaging. Multiple regression was used to identify predictive factors for renal functional compensation.

Results: Median age was 67 years and 67% of the patients were male. Overall 70% had hypertension, 26% diabetes and 37% preexisting chronic kidney disease. Locally advanced (T3a or greater) tumors were found in 53% of cases. Renal functional compensation was observed at 2 weeks (median 10%) and increased during the first 3 months (median 26%) after radical nephrectomy. Functional stability was then observed to 5 years. Renal parenchymal volume increased a median of 10% at 3 to 12 months but in addition, the functional efficiency per unit of parenchymal volume also increased 8% (estimated glomerular filtration rate units/cm of parenchyma was 0.236 postoperatively vs 0.208 preoperatively, p=0.004). Age (-0.85, p <0.01), global preoperative estimated glomerular filtration rate (-0.28, p <0.01) and split renal function of the removed kidney (0.61, p <0.01) were independent predictors of renal functional compensation.

Conclusions: Percent renal functional compensation after radical nephrectomy is greater in younger patients, when preoperative estimated glomerular filtration rate is lower and when the removed kidney has more robust function. Increases in measurable parenchymal mass and functional efficiency contribute substantially to renal functional compensation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000000797DOI Listing
July 2020

The Association of Urologic Oncology Fellowship Training and Diagnostic Yield of Prostate Biopsy.

Urology 2020 03 27;137:115-120. Epub 2019 Nov 27.

Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, OH.

Objective: To determine the relationship between urologic oncology fellowship training (UOFT) and diagnostic yield of prostate biopsy.

Methods: Retrospective review was conducted of patients who underwent prostate biopsy across the Cleveland Clinic between 2000 and 2018. Biopsies done by urologists with and without UOFT were detailed via descriptive statistics and appropriate (chi-square, Student t, Wilcoxon rank-sum) tests. Multivariate logistic regression was used to examine the association between UOFT and positive prostate biopsy, adjusting for relevant covariates.

Results: A total of 11,241 biopsies by 129 urologists had complete information available for review. Sixteen urologists (12.4%) had UOFT; 113 either completed a different fellowship or no fellowship. Those with UOFT were more likely to use MRI-guided biopsy (7.80% vs 3.05%, P <.0001), more likely to get a positive biopsy (41.25% vs 32.72%, P <.0001), and more likely to obtain an adequate number (by ≥12) of cores (90.25% vs 74.53%, P <.0001). UOFT remained a significant predictor of positivity when adjusting for patient age and race, PSA, 5-alpha-reductase-inhibitor use, year of biopsy, years in practice, and type of biopsy (MRI or transrectal ultrasound guided). UOFT also predicted higher-risk biopsy (Gleason sum ≥7), adjusting for the same variables, though this association lost significance when adjusting for adequacy of biopsy. The learning curve to achieve a higher percentage of positive biopsies was steeper for nonurologic oncology fellowship trained than for UOFT urologists.

Conclusion: UOFT is associated with higher diagnostic yield on prostate biopsy, higher uptake of MRI-guided biopsy, and less steep learning curve. This may be due to patient selection, technique, or, as we demonstrate here, adherence to guidelines.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.urology.2019.11.018DOI Listing
March 2020

Postoperative Emergency Department Visits After Urinary Stone Surgery: Variation Based on Surgical Modality.

J Endourol 2020 01 18;34(1):93-98. Epub 2019 Dec 18.

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.

Urinary stone disease is responsible for more than 1 million emergency department (ED) visits annually. There is increasing regulatory and cost pressure to reduce unplanned episodes of care, particularly after elective surgery. However, the frequency of ED visits in the early postoperative period after different modalities of stone surgery is not well characterized. We aimed at describing rates of postoperative ED visits after percutaneous nephrolithotomy (PCNL), ureteroscopy (URS), and extracorporeal shockwave lithotripsy (SWL). The Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) state databases for Florida (2010-2012), Iowa (2010-2012), California (2010-2011), and New York (2006-2012) were used to identify patients undergoing PCNL, URS, or SWL. The HCUP State Emergency Department Database was used to identify postoperative ED visits in the first 30 days after surgery. Rates of postoperative ED visits were compared across surgery types with chi-square and multivariate logistic regression. A total of 321,899 patients undergoing stone surgery during the study period were identified, including 151,006 (46.9%) URS, 128,040 (39.8%) SWL, and 42,853 (13.3%) PCNL. PCNL had the highest rate of 30-day postop ED visits (13.2%), followed by URS (10.6%) and SWL (7.5%;  < 0.0001). On multivariate logistic regression adjusting for baseline clinical and sociodemographic characteristics, both PCNL (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.56-1.69) and URS (OR 1.33, 95% CI 1.30-1.37) were independently associated with increased risk of postop ED visit when compared with SWL. Among kidney stone surgeries, PCNL has the highest rate of 30-day postoperative ED visits, whereas SWL has the lowest. Postoperative ED visits are an important outcome for both patients and surgeons, and observed differences across surgical modalities should be incorporated into the preoperative shared decision-making process.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/end.2019.0399DOI Listing
January 2020

Impact of using 29 MHz high-resolution micro-ultrasound in real-time targeting of transrectal prostate biopsies: initial experience.

World J Urol 2020 May 15;38(5):1201-1206. Epub 2019 Jul 15.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.

Purpose: This report presents our early experience at Cleveland Clinic replacing conventional ultrasound with a novel 29 MHz high-resolution micro-ultrasound system for both systematic sampling and real-time targeting of suspicious regions during prostate biopsy. The added value of micro-ultrasound and MRI over systematic biopsy is presented.

Methods: Sixty-seven consecutive subjects (January-August 2018) from our prospective database who underwent prostate biopsy using the micro-ultrasound system were included. 19/67 had prostate MRI imaging available. MRI targets were sampled using the UroNav fusion system. Patients had a median PSA of 5.37 ng/mL (IQR 4.13-8.74).

Results: 38/67 (56.7%) subjects were positive for prostate cancer. In six of these cases, systematic biopsy was negative with only micro-ultrasound targeted samples detecting cancer. In two other cases, patients were upgraded from Grade Group 1 to Grade Groups 4 and 2 based on micro-ultrasound targets. Micro-ultrasound targets detected cancer in two subjects where MRI was negative (Grade Groups 3 and 2). MRI targets alone did not change the overall diagnosis of any subjects. Switching biopsy guidance to real-time micro-ultrasound increased detection rate on prostate biopsy from 44.8% (30/67) to 56.7% (38/67), a relative increase of 26.7%.

Conclusion: High-resolution micro-ultrasound identified clinically significant cancer that would have, otherwise, been missed by both MRI fusion and systematic biopsy and was useful in both biopsy naïve and repeat negative patients. Early results from this small, single-center cohort are promising, particularly given the ease with which micro-ultrasound can replace the conventional ultrasound in standard prostate biopsy procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00345-019-02863-yDOI Listing
May 2020

Ureteral Stent Placement During Shockwave Lithotripsy: Characterizing Guideline Discordant Practice.

Urology 2019 Nov 21;133:67-71. Epub 2019 Jun 21.

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH.

Objective: To describe utilization patterns of ureteral stent placement during extracorporeal shockwave lithotripsy (ESWL).

Methods: The Healthcare Cost and Utilization Project State Inpatient and Ambulatory Surgery Databases for Florida (2010-2012), Iowa (2010-2012), California (2010-2011), and New York (2006-2012) were used to identify patients undergoing ESWL with or without concomitant ureteral stent placement. Multivariate logistic regression was used to identify factors associated with ureteral stent placement. Postoperative ER visits and reoperation were compared between groups with multivariate logistic regression.

Results: A total of 128,040 patients undergoing ESWL during the study period were identified. Concomitant ureteral stent placement during ESWL was performed in 20,800 (16.2%) cases. Stent placement was more common among older patients (odds ratio [OR] 1.003 per year, 95% confidence interval 1.002-1.004) and those with greater comorbidity burden (OR 1.10, 1.09-1.11), but also among those with higher income (OR 1.13, 1.08-1.19) and private insurance (OR 1.05, 1.01-1.10). Patients undergoing concomitant ureteral stent placement had higher rates of 30-day postoperative ER visits (8.9% vs 7.3%, P<.0001) and 90-day reoperation (13.4% vs 8.2%, P<.0001) compared to patients undergoing ESWL alone.

Conclusion: A significant portion of patients treated with ESWL undergo concomitant ureteral stent placement, despite clinical guidelines over the last 2 decades discouraging this practice. Use of ureteral stent during ESWL appears driven by both clinical and nonclinical factors. Ureteral stent placement confers no perceivable advantage in postoperative ER visits or reoperation after ESWL based on administrative data from the Healthcare Cost and Utilization Project.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.urology.2019.06.015DOI Listing
November 2019

Is there a benefit to additional neuroaxial anesthesia in open nephrectomy? A prospective NSQIP propensity score analysis.

Int Urol Nephrol 2019 Sep 20;51(9):1481-1489. Epub 2019 Jun 20.

Urology Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.

Introduction: Neuroaxial (i.e., spinal, regional, epidural) anesthesia has been shown to be associated with reduced readmission rate, decreased hospital stay, and decreased overall complication rate in orthopedic and gynecologic surgery. Our aim was to identify differences in intra- and postoperative complications, length of stay and readmission rates in open nephrectomy patients managed with neuroaxial anesthesia.

Materials And Methods: Utilizing National Surgical Quality Inpatient Program (NSQIP) database, we identified patients who have undergone an open nephrectomy between 2014 and 2017. Patients were further subdivided based on anesthesia modality. We used the propensity score-matching (PSM) method to adjust for baseline differences among patients who received general anesthesia alone and those with additional neuroaxial anesthesia. Using step-wise multivariable logistic regression, we identified preoperative and intraoperative predictors associated with 30-day procedure-related readmission, complications, and postoperative length of stay.

Results: Out of 3,633 patients identified, 2346 patients met our inclusion and exclusion criteria. There was no difference in baseline characteristics after propensity score matching between general and additional neuroaxial anesthesia. Postoperative outcomes including: procedure-related readmission, rate of reoperation, operative time, all complications were similar between the groups. Adjuvant neuroaxial anesthesia group did experience a prolonged postoperative hospital stay that was statistically significant as compared to patients with general anesthesia alone [5.3 (3.5) days vs 4.8 (2.9) days, p = 0.007]. Compared to GA alone after multivariable logistic regression, neuroaxial anesthesia was not statistically significant for readmission (p = 0.909), any complication (p = 0.505), but did showed increased odds ratio of prolonged postoperative stay [aOR 1.107, 95% CI 1.042-1.176, p = 0.001] after adjusting for multiple factors.

Conclusion: Using 2014-2017 NSQIP database, we were able to demonstrate no additional reduction in complication or readmission rate in patients with neuroaxial anesthesia as compared to general anesthesia alone. Furthermore, patients who did receive neuroaxial anesthesia experienced a longer postoperative course.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11255-019-02208-zDOI Listing
September 2019

Active Surveillance for Localized Small Renal Masses: Current Perspectives.

Eur Urol Oncol 2018 08 28;1(3):188-189. Epub 2018 Jun 28.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euo.2018.05.012DOI Listing
August 2018

Recommendations of Active Surveillance for Intermediate-risk Prostate Cancer: Results from a National Survey of Radiation Oncologists and Urologists.

Eur Urol Oncol 2019 03 31;2(2):189-195. Epub 2018 Aug 31.

Cancer Outcomes and Public Policy Effectiveness Research Center, Yale University, New Haven, CT, USA; Department of Medicine, Yale University, New Haven, CT, USA.

Background: While active surveillance (AS) for intermediate-risk prostate cancer (PCa) remains controversial, perceptions of AS and treatment recommendations among PCa specialists are largely unknown. Thus, we performed a national survey of radiation oncologists (ROs) and urologists (UROs) to elicit attitudes and AS recommendations for intermediate-risk PCa.

Objective: To determine whether AS for PCa is becoming readily accepted by PCa specialists in the USA.

Design, Setting, And Participants: From January to July 2017, we conducted a national survey of 915 ROs and 940 UROs on perceptions of AS and its use among patients with intermediate-risk PCa.

Outcome Measurements And Statistical Analysis: Perceived effectiveness and comfort with AS and recommendation of AS from case presentations represented the primary outcomes. Pearson chi-square and multivariable logistic regression analyses were used to identify physician characteristics associated with primary outcomes.

Results And Limitations: Overall, the response rate was 37.3% (n=692) and was similar for ROs and UROs (35.7% vs 38.7%; p=0.18). For intermediate-risk PCa, both UROs and ROs expressed limited favorable views that AS is effective (39.8% vs 33.0%; p=0.06) and felt comfortable recommending it (37.6% vs 25.9%; p=0.001). From clinical scenarios, both specialties infrequently recommended AS for a healthy patient diagnosed with intermediate-risk PCa. For a healthy 55-yr-old patient with PSA of 8ng/ml and Gleason 3+4 PCa, few ROs and UROs recommended AS (2.8% vs 4.3%; adjusted odds ratio [AOR] 0.42; p=0.12). AS was more likely to be recommended equally by ROs and UROs for a healthy 75-yr-old with the same clinicopathologic characteristics (29.0% vs 35.4%; AOR 0.68; p=0.09). Limitations include a modest response rate for our survey.

Conclusions: Our national survey revealed that many ROs and UROs do not believe that AS is effective or feel comfortable recommending it or selecting it as an option for younger patients with intermediate-risk PCa.

Patient Summary: We performed a national survey of radiation oncologists and urologists to assess attitudes regarding active surveillance (AS) and its use among patients with intermediate-risk prostate cancer. Our study demonstrates that radiation oncologists and urologists are not yet comfortable with recommending AS and rarely endorse its use for younger patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euo.2018.08.004DOI Listing
March 2019

Hospital Quality Metrics for Radical Cystectomy: Disease Specific and Correlated to Mortality Outcomes.

J Urol 2019 09 8;202(3):490-497. Epub 2019 Aug 8.

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.

Purpose: Measuring quality is a high priority for health care systems globally. Despite the high perioperative morbidity, mortality, expenditures and performance variation of radical cystectomy there is a paucity of validated bladder cancer quality metrics. We aimed to create a hospital quality scoring system for radical cystectomy which is disease specific and associated with patient centered outcomes.

Materials And Methods: We used the National Cancer Database to identify hospitals where radical cystectomy was performed from 2004 to 2014. Mixed effects models were constructed to assess variation in hospital performance across 7 quality indicators. Indirect standardization was used to case mix adjust hospital performance. We assessed associations between quality indicators as well as the novel BC-QS (Bladder Cancer Quality Score) composite hospital quality metric with 30-day, 90-day and overall mortality using logistic and Cox regression, respectively.

Results: At 1,200 facilities radical cystectomy was performed in a total of 48,341 patients from 2004 to 2014. Mixed effects models demonstrated significant between hospital variation across all quality indicators after case mix adjustment. The composite BC-QS metric was composed of the hospital positive margin rate, the lymph node dissection rate and the neoadjuvant chemotherapy rate. Better BC-QS performance was associated with lower 30-day and 90-day mortality (adjusted OR 0.78, 95% CI 0.64-0.96, and OR 0.84, 95% CI 0.72-0.97, respectively) and overall mortality (HR 0.86, 95% CI 0.81-0.92). Hospitals with a higher BC-QS had higher volume and more were affiliated with an academic institution than hospitals with a lower BC-QS (p <0.0001).

Conclusions: The BC-QS captures variations in the hospital performance of radical cystectomy and it shows an association of higher quality with lower patient mortality. Our validation of this quality metric provides support for its potential use by policy makers and payers in efforts to measure hospital quality for high cost surgeries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000000282DOI Listing
September 2019

Vascularized Parenchymal Mass Preserved with Partial Nephrectomy: Functional Impact and Predictive Factors.

Eur Urol Oncol 2019 02 14;2(1):97-103. Epub 2018 Jul 14.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Percentage parenchymal mass preserved (PPMP) is a key determinant of functional outcomes after partial nephrectomy (PN); however, predictors of PPMP have not been defined.

Objective: To provide a comprehensive analysis of the functional impact of and potential predictive factors for PPMP.

Design, Setting, And Participants: We analyzed data for 464 patients managed with PN at our center with necessary studies to determine vascularized parenchymal mass and function preserved within the operated kidney. PPMP was measured from computed tomography scans <2 mo before and 3-12 mo after PN.

Intervention: PN.

Outcome Measurements/statistical Analysis: Recovery from ischemia was defined as percentage ipsilateral glomerular filtration rate (GFR) preserved normalized by PPMP. We used Pearson correlation to evaluate the relationships between GFR preserved and PPMP. Multivariable logistic regression was used to assess predictors of PPMP.

Result And Limitations: Ninety-six patients (21%) had a solitary kidney. The median tumor size and RENAL score were 3.5cm and 8, respectively. Cold/warm ischemia were utilized in 183/281 patients for which the median ischemia time were 28/20min. The median preoperative and postoperative vascularized parenchymal mass in the operated kidney were 194 and 157cm, respectively, resulting in median PPMP of 84%. GFR preservation correlated strongly with PPMP (r=0.64; p<0.001). Recovery from ischemia was suboptimal (<80%) in 71 patients (15%), while suboptimal PPMP (<80%) was a more common adverse event, occurring in 160 patients (34%; p<0.001). Multivariable analysis demonstrated that greater tumor size and complexity were associated with lower PPMP (p≤0.04), while solitary kidney and hypothermia were associated with higher PPMP (p<0.001). Longer ischemia time was also associated with lower PPMP (p=0.003), probably reflecting the complexity of the surgery. Limitations include the retrospective design.

Conclusion: PPMP correlates strongly with functional outcomes after PN, and lower PPMP is the most common and important source of functional decline after PN. Larger tumors, greater tumor complexity, and prolonged ischemia time were associated with lower PPMP, while PPMP tended to be greater for solitary kidneys, confirming that PPMP is a modifiable factor.

Patient Summary: Kidney function after partial nephrectomy primarily depends on the amount of vascularized kidney preserved by the procedure. Lower recovery of function is seen when operating on larger tumors in unfavorable locations, but preservation of the parenchymal mass can be improved when truly necessary, such as when operating on a tumor in a solitary kidney.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euo.2018.06.009DOI Listing
February 2019

A National Survey of Radiation Oncologists and Urologists on Perceived Attitudes and Recommendations of Active Surveillance for Low-Risk Prostate Cancer.

Clin Genitourin Cancer 2019 06 7;17(3):e472-e481. Epub 2019 Feb 7.

Cancer Outcomes and Public Policy Effectiveness Research (COPPER) Center, Yale University, New Haven, CT; Department of Medicine, Yale University, New Haven, CT.

Background: Clinical factors and barriers affecting adoption of active surveillance (AS) for low-risk prostate cancer (PCa) remain poorly understood. We performed a national survey of radiation oncologists (RO) and urologists (URO) about the perceptions and recommendations of AS for low-risk PCa.

Materials And Methods: In 2017, we surveyed 915 RO and 940 URO about AS for low-risk PCa in the United States. Survey items queried respondents about their attitudes toward AS and recommendations of AS for low-risk PCa. Pearson chi-square and multivariable logistic regression identified clinical and physician factors related toward AS for low-risk PCa.

Results: Overall, the response rate was 37.3% (n = 691) and was similar for RO and URO (35.7% vs. 38.7%; P = .18). RO were less likely to consider AS effective for low-risk PCa (86.5% vs. 92.0%; P = .04) and more likely to rate higher patient anxiety on AS (49.5% vs. 29.5%; P < .001) than URO. Recommendations of AS varied modestly on the basis of age, prostate-specific antigen (PSA), and number of cores positive for Gleason 3 + 3 PCa. For a 55-year-old man with PSA 8 with 6 cores of Gleason 6 PCa, both RO and URO infrequently recommended AS (4.4% vs. 5.2%; adjusted odds ratio = 0.6; P = .28). For a 75-year-old patient with PSA 4 with 2 cores of Gleason 6 PCa, URO and RO most often recommended AS (89.6% vs. 83.4%; adjusted odds ratio = 0.5; P = .07).

Conclusion: RO and URO consider AS to be effective in the clinical management of low-risk PCa, but this varies by clinical and physician factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clgc.2019.01.008DOI Listing
June 2019

Author Reply.

Urology 2019 02;124:126

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.urology.2018.07.057DOI Listing
February 2019

Editorial Comment.

J Urol 2019 02;201(2):283

Department of Urology, Cleveland Clinic, Cleveland, Ohio.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/01.JU.0000552994.68650.8bDOI Listing
February 2019

Quality of Health Information on the Internet for Prostate Cancer.

Adv Urol 2018 4;2018:6705152. Epub 2018 Dec 4.

Department of Urology, Austin Hospital, VIC, Australia.

Introduction: To compare (1) the quality of prostate cancer health information on the Internet, (2) the difference in quality between websites appearing earlier or later in the search, and (3) the sources of sponsorship for each of these websites.

Materials And Methods: The top 150 listed websites on the Google search engine for each of the 11 search terms related to prostate cancer were analysed. Quality was assessed on whether the website conforms to the principles of the Health On the Net Foundation. Each of these websites was then reviewed to determine the main source of sponsorship. Statistical analysis was performed to determine if the proportion of HON accreditation varied among the different cohorts of listed websites and among the 11 search terms used.

Results: In total, 1650 websites were analysed. Among these, 10.5% websites were HON-accredited. The proportion of HON-accredited websites for individual search terms ranged from 3.3% to 19.3%. In comparison with the search term of "Prostate cancer," four search terms had statistically significant odds ratio of the rate of HON accreditation. Websites 51-150 were statistically less likely to have HON accreditation than websites 1-50. The top three website sponsors were journal/universities (28.8%), commercial (28.1%), and physician/surgeon (26.9%).

Conclusions: The lack of validated and unbiased websites for prostate cancer is concerning especially with increasing use of the Internet for health information. Websites sponsored or managed by the government and national departments were most likely to provide impartial health information for prostate cancer. We need to help our patients identify valid and unbiased online health resources.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2018/6705152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6305048PMC
December 2018

Variability in Partial Nephrectomy Outcomes: Does Your Surgeon Matter?

Eur Urol 2019 04 2;75(4):628-634. Epub 2018 Nov 2.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Understanding physician-level discrepancies is increasingly a target of US healthcare reform for the delivery of quality-focused patient care.

Objective: To estimate the relative contributions of patient and surgeon characteristics to the variability in key outcomes after partial nephrectomy (PN).

Design, Setting, And Participants: Retrospective review of 1461 patients undergoing PN performed by 19 surgeons between 2011 and 2016 at a tertiary care referral center.

Intervention: PN for a renal mass.

Outcomes Measurements And Statistical Analysis: Hierarchical linear and logistic regression models were built to determine the percentage variability contributed by fixed patient and surgeon factors on peri- and postoperative outcomes. Residual between- and within-surgeon variability was calculated while adjusting for fixed factors.

Results And Limitations: On null hierarchical models, there was significant between-surgeon variability in operative time, estimated blood loss (EBL), ischemia time, excisional volume loss, length of stay, positive margins, Clavien complications, and 30-d readmission rate (all p<0.001), but not chronic kidney disease upstaging (p=0.47) or percentage preservation of glomerular filtration rate (p=0.49). Patient factors explained 82% of the variability in excisional volume loss and 0-32% of the variability in the remainder of outcomes. Quantifiable surgeon factors explained modest amounts (10-40%) of variability in intraoperative outcomes, and noteworthy amounts of variability (90-100%) in margin rates and patient morbidity outcomes. Immeasurable surgeon factors explained the residual variability in operative time (27%), EBL (6%), and ischemia time (31%).

Conclusions: There is significant between-surgeon variability in outcomes after PN, even after adjusting for patient characteristics. While renal functional outcomes are consistent across surgeons, measured and unmeasured surgeon factors account for 18-100% of variability of the remaining peri- and postoperative variables. With the increasing utilization of value-based medicine, this has important implications for the goal of optimizing patient care.

Patient Summary: We reviewed our institutional database on partial nephrectomy performed for renal cancer. We found significant variability between surgeons for key outcomes after the intervention, even after adjusting for patient characteristics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eururo.2018.10.046DOI Listing
April 2019

The Association of Robot-assisted Versus Pure Laparoscopic Radical Nephrectomy with Perioperative Outcomes and Hospital Costs.

Eur Urol Focus 2020 03 22;6(2):305-312. Epub 2018 Oct 22.

Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Cancer Outcomes Public Policy and Effectiveness Research Center (COPPER), Yale University, New Haven, CT, USA.

Background: Although robot assistance can facilitate the advantages of minimally invasive surgery, it is unclear whether it offers benefits in settings in which laparoscopic surgery has been established as the standard of care.

Objective: To examine the comparative effectiveness of robot-assisted laparoscopic radical nephrectomy (RALRN) and laparoscopic radical nephrectomy (LRN) using a nationwide data set.

Design, Setting, And Participants: 8316 adults who underwent RALRN or LRN for non-urothelial renal cancer from the Nationwide Inpatient Sample from 2010 to 2013.

Intervention: RALRN and LRN.

Outcome Measurements And Statistical Analysis: The associations of surgical approach with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression.

Results And Limitations: Over the study period, utilization of RALRN increased from 46% to 69%. Compared to LRN, RALRN was associated with lower rates of intraoperative (0.9% vs 1.8%; p<0.001) and postoperative complications (20.4% vs 27.2%; p<0.001), but there were no differences in perioperative blood transfusion (5.6% vs 6.2%; p=0.27) and prolonged hospitalization (7.2% vs 7.1%; p=0.81). RALRN was also significantly associated with higher total hospital costs (median $16 207 vs $15 037; p<0.001). In multivariable analyses, RALRN remained independently associated with a lower risk of intraoperative (odds ratio [OR] 0.50; p=0.001) and postoperative complications (OR 0.72; p<0.001) but not perioperative blood transfusion (OR 1.10; p=0.34), and with a higher risk of prolonged hospitalization (OR 1.29; p=0.007) and higher mean total hospital costs (+$1468; p<0.001). There was no effect modification by hospital volume.

Conclusions: Although RALRN was independently associated with a reduction in perioperative complications compared to LRN, it was associated with prolonged hospitalization and higher total hospital costs. These relationships must be interpreted in light of potential differences in case mix.

Patient Summary: Although robot-assisted laparoscopic radical nephrectomy was independently associated with a reduction in perioperative complications compared to laparoscopic radical nephrectomy, it was associated with prolonged hospitalization and higher total hospital costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euf.2018.10.004DOI Listing
March 2020

Can We Predict Functional Outcomes after Partial Nephrectomy?

J Urol 2019 04;201(4):693-701

Glickman Urological and Kidney Institute, Cleveland Clinic , Cleveland , Ohio.

Purpose: The percent of preserved parenchymal mass is the primary determinant of functional outcomes after partial nephrectomy. Accurate methods to predict the percent of preserved parenchymal mass based on preoperative imaging could facilitate patient counseling.

Materials And Methods: We evaluated the records of 428 patients who had undergone partial nephrectomy and the studies necessary to assess preserved ipsilateral parenchymal mass and function. Preoperative and postoperative ipsilateral parenchymal volumes were measured from contrast enhanced computerized tomography less than 2 months before and 3 to 12 months after partial nephrectomy and the actual percent of preserved parenchymal mass was determined. The ipsilateral percent of preserved parenchymal mass and the final global glomerular filtration rate were estimated based on preoperative imaging using subjective estimation, quantitative estimation, or estimation derived from the contact surface area or the R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior and location relative to polar lines) score.

Results: Median tumor diameter was 3.5 cm, median contact surface area was 24 cm and the median R.E.N.A.L. score was 8. The median actual ipsilateral percent of preserved parenchymal mass was 84% and the preserved percent of the global glomerular filtration rate was 89%. The median estimated ipsilateral percent of preserved parenchymal mass was 85%, 87%, 88% and 83% based on subjective estimation, quantitative estimation, contact surface area and the R.E.N.A.L. score, respectively. Correlations between the actual and the estimated percent of preserved parenchymal mass were relatively weak in all instances (all r ≤0.46). Prediction of the final global glomerular filtration rate was strong for all 4 methods (all r = 0.91). However, a similarly strong correlation was obtained when presuming that 89% of the preoperative global glomerular filtration rate would be saved in each case (r = 0.91). On multivariable analyses a solitary kidney, the preoperative glomerular filtration rate and various estimates of the percent of preserved parenchymal mass were significantly associated with the final global glomerular filtration rate. However, the preoperative glomerular filtration rate proved to be the strongest predictor. It had more than a tenfold impact compared to the estimated percent of preserved parenchymal mass or a solitary kidney.

Conclusions: Currently available methods to estimate the percent of preserved parenchymal mass have important limitations. The final global glomerular filtration rate, which is the most important functional outcome, could be predicted fairly accurately by all tested methods. However, none of them were better than simply presuming that 89% of function would be saved due to strong anchoring to the preoperative glomerular filtration rate.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.juro.2018.09.055DOI Listing
April 2019

Utilization of Bacillus Calmette-Guerin for Nonmuscle Invasive Bladder Cancer in an Era of Bacillus Calmette-Guerin Supply Shortages.

Urology 2019 02 13;124:120-126. Epub 2018 Sep 13.

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH; Louis Stokes Cleveland VA Medical Center, Cleveland, OH.

Objectives: To study trends in Bacillus Calmette-Guerin (BCG) utilization for nonmuscle invasive bladder cancer (NMIBC) before and during national BCG shortages.

Methods: The National Cancer Database was used to identify patients with localized NMIBC. Multivariate logistic regression was used to assess factors associated with BCG use. Temporal trends in BCG use were studied using segmented regression analysis.

Results: We identified 238,279 patients with NMIBC from 2004 to 2015. Overall, 33,660 (14.1%) patients with NMIBC received intravesical BCG during the study period. Segmented regression revealed a slower rate of rise of BCG utilization following major supply interruptions in 2011 and 2012 (2004-2012: +0.62% increase per year [P < .0001]; 2013-2015: +0.29% increase per year [P = .084]). This trend was most pronounced in Ta-low grade patients and least pronounced in T1-high grade patients.

Conclusions: BCG utilization for NMIBC increased significantly over the study period, possibly representing increased adoption of national guidelines for BCG in NMIBC. In the years following interruptions in BCG supply, BCG use appears to have been rationed based on clinical risk, with the steepest declines in BCG use occurring in the lowest risk patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.urology.2018.07.055DOI Listing
February 2019

Diagnostic Accuracy of a Rapid Biparametric MRI Protocol for Detection of Histologically Proven Prostate Cancer.

Urology 2018 Dec 7;122:133-138. Epub 2018 Sep 7.

Department of Radiology, Case Western Reserve University, Cleveland, OH; Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH; Department of Urology, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH; Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH. Electronic address:

Objective: To evaluate the performance of a rapid, low cost, noncontrast MRI examination as a secondary screening tool in detection of clinically significant prostate cancer.

Methods: In this prospective single institution study, 129 patients with elevated prostate-specific antigen levels or abnormal digital rectal examination findings underwent MRI with an abbreviated biparamatric MRI protocol consisting of high-resolution axial T2- and diffusion-weighted images. Index lesions were classified according to modified Prostate Imaging - Reporting and Data System (mPI-RADS) version 2.0. All patients underwent standard transrectal ultrasound-guided biopsy after MRI with the urologist being blinded to MRI results. Subsequently, all patients with suspicious lesions (mPI-RADS 3, 4, or 5) underwent cognitively guided targeted biopsy after discussion of MRI results with the urologist. Sensitivity and negative predictive value for identification of clinically significant prostate cancer (Gleason score 3+4 and above) were determined.

Results: Rapid biparametric MRI discovered 176 lesions identified in 129 patients. Rapid MRI detected clinically significant cancers with a sensitivity of 95.1% with a negative predictive value of 95.1% and positive predictive value of 53.2%, leading to a change in management in 10.8% of the patients. False negative rate of biparametric (bp) MRI was 4.7%.

Conclusion: We found that a bp-MRI examination can detect clinically significant lesions and changed patient management in 10.8% of the patients. A rapid MRI protocol can be used as a useful secondary screening tool in men presenting with suspicion of prostate cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.urology.2018.08.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6295224PMC
December 2018