Partial Nephrectomy Drives the Association Between High-volume Centers and Decreased Mortality: A Surveillance, Epidemiology, and End Results-Medicare Analysis.

Objective: To better understand the association between high-volume surgical kidney cancer centers and decreased mortality. To identify quality metrics that mediate this association.

Methods: We designed a cohort of 14,044 patients who were diagnosed with kidney cancer between 2004 and 2013 and underwent a partial or radical nephrectomy using SEER-Medicare data.

Resident Duty Hour Compliance and Sleep after Transitioning to a Night Float System: A Prospective Observational Study in an Academic Urology Program.

Introduction: Our urology residency program transitioned to a night float system, where dedicated residents cover nights and are off duty during the day. Junior residents previously covered 5 hospitals every 5 to 7 nights and worked the following day (home call). This prospective observational study compared the 2 systems before and after the transition.

Large reduction in opioid prescribing by a multipronged behavioral intervention after major urologic surgery.

Background: Surgeons play a pivotal role in combating the opioid crisis that currently grips the United States. Changing surgeon behavior is difficult, and the degree to which behavioral science can steer surgeons toward decreased opioid prescribing is unclear.

Methods: This was a single-institution, single-arm, pre- and postintervention study examining the prescribing of opioids by urologists for adult patients undergoing prostatectomy or nephrectomy.

Statewide Price Variation for Generic Benign Prostatic Hyperplasia Medications.

Objective: To examine the geographic and pharmacy-type variation in costs for generic benign prostatic hyperplasia (BPH) medications in order to improve drug price transparency and reduce health disparities. Medical therapy for BPH can be expensive, having significant implications for uninsured and underinsured patients.

Methods: We generated a 20% random sample of all pharmacies in Pennsylvania and queried each for the uninsured cash price of a 30-day prescription of tamsulosin 0.

Life-threatening gross hematuria: case report of renal artery aneurysm.

Renal artery aneurysms can present with gross hematuria and are potentially life-threatening in cases of rupture. We report a case of a young male with no prior genitourinary history who presents to an emergency department with sudden onset gross hematuria, clot retention, and right-sided flank pain. On evaluation, he was found to have a renal artery aneurysm bleeding into his collecting system and underwent renal artery embolization and rapid resolution of his hematuria.

Decrease in Urologic Discharge Opioid Prescribing after Mandatory Query of Statewide Prescription Drug Monitoring Program.

Objective: To examine the effectiveness of the introduction of the Pennsylvania Prescription Drug Monitoring Program (PDMP) on discharge postoperative opioid prescriptions in patients undergoing major urologic procedures within a large single tertiary care hospital. Opioids have historically been prescribed to control postoperative pain, but with growing concern regarding opioid overdose, misuse, and diversion, measures have been introduced to curb opioid prescribing. Numerous states have introduced PDMP programs as a method to search patients' prior opioid prescriptions.

Comparison of Neoadjuvant and Adjuvant Chemotherapy in Muscle-invasive Bladder Cancer.

Background: We use observational methods to compare impact of perioperative chemotherapy timing (ie, neoadjuvant and adjuvant) on overall survival (OS) in muscle-invasive bladder cancer because there is no head-to-head randomized trial, and patient factors may influence decision-making.

Patients And Methods: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients receiving cystectomy for muscle-invasive bladder cancer diagnosed between 2004 and 2013. Patients were classified as receiving neoadjuvant or adjuvant chemotherapy.

The Safety and Short-term Outcomes of Leukocyte Depleted Autologous Transfusions During Radical Cystectomy.

Objective: To examine long- and short-term outcomes using cell salvage with a commercially available leukocyte depletion filter following radical cystectomy in an oncologic population.

Materials And Methods: One hundred and fifty-seven patients, 87 of whom received a cell salvage transfusion, were retrospectively identified from chart review. Ninety-day outcomes as well as long-term mortality and cancer recurrence data were collected.

Implications of Cystectomy Travel Distance for Hospital Readmission and Survival.

Background: Regionalization of complex surgical care results in increasing need for patients to travel for complex oncologic procedures such as cystectomy in bladder cancer. We examined the association between travel distance to a cystectomy center, readmission, and survival.

Patients And Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified bladder cancer patients undergoing radical cystectomy during 2004-2011.

The development and comparative effectiveness of a patient-centered prostate biopsy report: a prospective, randomized study.

Purpose: The prostate biopsy pathology report represents a critical document used for decision-making in patients diagnosed with prostate cancer, yet the content exceeds the health literacy of most patients. We sought to create and compare the effectiveness of a patient-centered prostate biopsy report compared with standard reports.

Materials And Methods: Using a modified Delphi approach, prostate cancer experts identified critical components of a prostate biopsy report.

Evaluation of the Risks and Benefits of Computed Tomography Urography for Assessment of Gross Hematuria.

Objective: To model the risk of radiation-induced malignancy from computed tomography urography (CTU) in evaluation of gross hematuria and contrast this with the benefits of urinary tract cancer detection when compared to renal ultrasound.

Methods: A PUBMED-based literature search was performed to identify model inputs. Estimates of radiation-induced malignancy rates were obtained from the Biological Effects of Ionizing Radiation VII report with dose extrapolation using the linear no-threshold model.

Trends and appropriateness of perioperative chemotherapy for muscle-invasive bladder cancer.

Introduction: Contemporary guidelines recommend cystectomy with neoadjuvant or adjuvant cisplatin-based chemotherapy given with curative intent for patients with resectable muscle-invasive bladder cancer (MIBC). However, rates and appropriateness of perioperative chemotherapy utilization remain unclear. We therefore sought to characterize use of perioperative chemotherapy in older radical cystectomy MIBC patients and examine factors associated with use.

Multiparametric Magnetic Resonance Imaging Is Associated with Increased Medicare Spending in Prostate Cancer Active Surveillance.

Background: Multiparametric magnetic resonance imaging (mpMRI) may improve prostate cancer risk stratification and decrease the need for repeat biopsies in men on prostate cancer active surveillance (AS). However, the impact of mpMRI on AS-related healthcare spending has not been established.

Objective: To characterize the impact of mpMRI on AS-related Medicare expenditures.

Increasing Utilization of Multiparametric Magnetic Resonance Imaging in Prostate Cancer Active Surveillance.

Objective: To characterize the use of multiparametric magnetic resonance imaging (mpMRI) in male Medicare beneficiaries electing active surveillance for prostate cancer. mpMRI has emerged as a tool that may improve risk-stratification and decrease repeated biopsies in men electing active surveillance. However, the extent to which mpMRI has been implemented in active surveillance has not been established.

Palliative care use amongst patients with bladder cancer.

Objectives: To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

Patients And Methods: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients diagnosed with muscle-invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist.

Extreme Price Variation for Generic Benign Prostatic Hyperplasia Medications.

Objective: To characterize geographic variability of generic benign prostatic hyperplasia (BPH) medications in order to improve drug price transparency and improve patient access to affordable medication sources. This is of interest because BPH is one of the most common chronic diseases in men and contributes to individual healthcare cost. Medical therapy is the main treatment modality for BPH, burdening patients with lifelong medication expenses which may impact adherence and subsequent outcomes.

Manufacturing and the Market: Rationalizing the Shortage of Bacillus Calmette-Guérin.

Bacillus Calmette-Guérin (BCG) is used as first-line intravesical therapy following tumor resection of non-muscle-invasive bladder cancer. Primary producers of BCG announced shortages within the last decade, leading to a worldwide shortage. We review the literature examining the BCG shortage and propose solutions to cope with this problem.

The United States opioid epidemic: a review of the surgeon's contribution to it and health policy initiatives.

Opioid abuse and addiction is causing widespread devastation in communities across the USA and resulting in significant strain on our healthcare system. There is increasing evidence that prescribers are at least partly responsible for the opioid crisis because of overprescribing, a practice that developed from changes in policy and reimbursement structures. Surgeons, specifically, have been subject to scrutiny as 'adequate treatment' of post-surgical pain is poorly defined and data suggest that many patients receive much larger opioid prescriptions than needed.

Effect of multimodal analgesia with paravertebral blocks on biochemical recurrence in men undergoing open radical prostatectomy.

Background: Recent studies suggest that anesthetic technique during radical prostatectomy for prostate cancer may affect recurrence or progression. This association has previously been investigated in series that employ epidural analgesia. The objective of this study is to determine the association between the use of a multimodal analgesic approach incorporating paravertebral blocks and risk of biochemical recurrence following open radical prostatectomy.

Risk of Radiation from Computerized Tomography Urography in the Evaluation of Asymptomatic Microscopic Hematuria.

Purpose: The AUA (American Urological Association) guidelines for asymptomatic microscopic hematuria recommend that patients undergo computerized tomography urography, which is associated with high doses of ionizing radiation. To our knowledge the associated risk of secondary malignancy and mortality remains unknown. We modeled the risk of malignancy and associated mortality due to ionizing radiation from computerized tomography urography relative to the additional diagnostic benefit offered over renal ultrasound.

Disparities in Access and Regionalization of Care in Testicular Cancer.

Introduction: Timely mobilization of specialized resources are needed to achieve optimal outcomes in testicular cancer. We used the National Cancer Database to investigate the hospital and demographic features driving disparity.

Patients And Methods: We identified adult men with testicular tumors diagnosed from 2004 to 2013.

Comparative Effectiveness of Initial Surgery vs Initial Systemic Therapy for Metastatic Kidney Cancer in the Targeted Therapy Era: Analysis of a Population-based Cohort.

Objective: To use econometric methods to assess comparative overall survival of patients with metastatic renal cell carcinoma (mRCC) managed with initial cytoreductive nephrectomy (CN) vs initial systemic therapy. Randomized data demonstrate improved survival for CN preceding cytokine-based therapy in mRCC. This benefit may be attenuated in the contemporary mRCC era given more effective systemic therapies.

Urinary Catheter Management for Nonurologists: A Resident Driven Educational Initiative.

Introduction: Prevention of catheter associated urinary tract infection relies on timely catheter removal and care of indwelling catheters. Educational and quality improvement initiatives to prevent catheter associated urinary tract infection should address the basics of urinary catheter placement and management. Internal medicine residents are an appropriate target for these efforts and they may lack formal training in these issues.