Publications

INTRODUCTION: The perioperative morbidity of radical cystectomy (RC) is a critical factor for optimal decision-making in older adults with bladder cancer (BC). However, existing literature is dated and does not focus on older adults. We aimed to examine the real-world, perioperative morbidity of RC among older adults with BC.

MATERIALS AND METHODS: We identified 6041 patients aged 66-89 years diagnosed with TanyNanycM0 urothelial bladder cancer from 2000 to 2017 who underwent RC in SEER-Medicare. Rates of perioperative morbidity and healthy days at home (HDAH) were examined using Medicare claims. The associations between baseline characteristics and each outcome were evaluated using logistic regression and negative binomial regression.

RESULTS: The perioperative morbidity of RC is substantial, with 3859 (64 %) patients experiencing a complication during hospitalization or one requiring care utilization post-discharge. A total of 1764 (29 %) patients required ER evaluation within 90 days of surgery, and 2637 (44 %) were readmitted to the hospital. The median number of HDAH was 78 (interquartile range 66-82). Adjusted multivariable analyses demonstrated that a higher Charlson Comorbidity Index (CCI) and higher census tract poverty level were associated with increased risk of 90-day inpatient readmission, while older age, Black race, higher CCI, and lower annual hospital RC volume were associated with increased risk of 90-day complications.

DISCUSSION: The real-world perioperative morbidity of RC in older adults is substantial and even greater than reported in prior institutional studies, with 44 % of patients requiring hospital-based care within 90 days of surgery. These observations inform clinical counseling of older adults with bladder cancer.

OBJECTIVE: Frailty is increasingly recognized as an important component of geriatric assessment in older adults and an important predictor of clinical outcomes. Bladder cancer (BC) is a potentially lethal disease, and treatments like radical cystectomy (RC) are associated with high rates of morbidity. We examined the associations of baseline frailty with perioperative outcomes and survival in a population-based cohort of older adults undergoing RC.

MATERIALS AND METHODS: We identified older adults aged 66 to 89 years with Tany Nany cM0 urothelial carcinoma of the bladder who underwent RC from 2000 to 2017 in SEER-Medicare. Baseline frailty was assessed using the claims-based frailty index (CFI), a validated deficit accumulation frailty measure, within the 12-months preceding surgery. The associations of CFI with perioperative outcomes and survival were evaluated using multivariable regression models.

RESULTS: A total of 6,041 patients were included in the study cohort, including 2,640 (44%) who were robust (CFI <0.15), 2,980 (49%) who were prefrail (CFI 0.15-<0.25), and 421 (7%) who were mildly to severely frail (CFI ≥0.25). Increasing CFI was associated with statistically significantly higher rates of prolonged hospitalization, 90-day emergency department utilization, 90-day complications, and 90-day hospital readmission, and fewer healthy days at home (HDAH). CFI remained independently associated with an increased risk of perioperative outcomes and worse mortality in multivariable regression models.

CONCLUSIONS: In a national, contemporary cohort of older adults with BC undergoing RC, increasing frailty was independently associated with a higher risk of perioperative morbidity, fewer HDAH, and worse mortality. The CFI provides an objective assessment to improve decision-making in older adults with bladder cancer.

OBJECTIVE: To review speaking valve (SV) use at a tertiary academic medical center and determine whether a multidisciplinary team implementation of SV protocols increased SV use and decreased time to SV trials.

METHODS: Retrospective case series of patients who underwent a tracheostomy between 2017 and 2023 before and after the dissemination of new protocols from a new multidisciplinary tracheostomy care initiative in 2019. The calendar days between meeting SV eligibility criteria and initial trial of SV were compared. Eligibility criteria for SV was defined as any patient ≥48 hours posttracheotomy who can breathe unassisted, off mechanical ventilation, tolerate a deflated cuff, and participate in an evaluation. Interrupted time series analysis using segmented negative binomial regression assessed the change in time to SV placement before and after protocol implementation.

RESULTS: A total of 421 patients were identified. After new protocols were disseminated, eligible patients with a SV trial increased from 75% to 95% with an increase in percentage of patients who tolerated the SV on their first attempt from 60% to 75%. Interrupted time series analysis demonstrated protocol implementation was associated with an overall 80% decrease in time to SV placement.

DISCUSSION: Continued barriers to SV implementation such as elevated tracheal pressures due to large tracheostomy sizes, or inappropriately early consultations with patients unable to participate in SV exam, may be amenable to further institution-level quality improvement initiatives.

IMPLICATIONS FOR PRACTICE: A multidisciplinary initiative's dissemination of protocols with algorithms for SLP consultation and SV use can help standardize post-operative tracheostomy care.

BACKGROUND: The utilization of kidneys donated after circulatory death (DCD) is an important strategy to address the ongoing shortage of organs suitable for transplantation in the United States. However, the nonuse rate of DCD kidneys remains high compared with kidneys donated after brain death (DBD) because of concerns regarding the injury incurred during donor warm ischemia time (DWIT). Therefore, we investigated the impact of DWIT on the risk of death-censored graft failure after DCD kidney transplantation (KT).

METHODS: Retrospective analysis was conducted on DCD KTs using the Standard Transplant Analysis and Research data set. The association of DWIT with death-censored graft failure was evaluated using multivariable Cox proportional hazard regression, with reference to DCD KTs with Kidney Donor Risk Index (KDRI) of ≤0.78 and the median DWIT of 26 min.

RESULTS: A total of 28 032 DCD kidney-alone transplants between January 2010 and December 2021 were studied. When stratified by KDRI, increasing DWIT was associated with a clinically significant increased risk for death-censored graft failure only in the subset of kidneys with KDRI >1.14 but not in those with KDRI >0.78-≤0.94 and >0.94-≤1.14, compared with the reference group.

CONCLUSIONS: We suggest that clinicians should not decline kidneys on the basis of DWIT in favor of potential offers of DBD or other DCD kidneys with shorter DWIT, provided that their KDRI scores are within an acceptable limit. Our study highlights opportunities for more efficient usage of DCD kidneys and improving the shortage of transplantable organs.

There are 18 million living military veterans in the United States, yet this population has not been the focus of educational campaigns to increase donation awareness and willingness to donate organs. This study examined whether willingness to donate organs varies by veteran-inclusive and vascularized composite allograft (VCA)-inclusive messaging. A total of 549 US veterans nondonors were randomized to four education groups: (1) general donation messaging, no veterans or VCA, (2) veteran-inclusive donation messaging, no VCA, (3) veteran- and VCA-inclusive donation messaging, or (4) no donation messaging (Control). Willingness to donate traditional and VCA organs was assessed pre-intervention, post-intervention, and at 3-weeks. Generalized Estimating Equations (GEE) models showed significant group X time interaction effects for traditional (Wald χ2 = 91.3, p < 0.001) and VCA (Wald χ2 = 36.3, p < 0.001) donation willingness. For traditional donation willingness, improvements were higher in veteran-inclusive messaging groups than the Control group (p < 0.01). There was no difference between veteran-inclusive and non-veteran groups, nor between VCA-inclusive and non-VCA video groups. For VCA donation willingness, significant increases were observed in the veteran-inclusive plus VCA messaging group compared to messaging without veterans or VCA and Control groups (p < 0.03). At follow-up, the education groups had more veterans who registered as donors, compared to the Control group (p = 0.02). Veteran-inclusive donation messaging may not be necessary to increase willingness to donate traditional organs, although it offers some advantages for increasing VCA donation willingness.

Background: Distinguishing between organ-confined disease and extraprostatic extension (EPE) is crucial for the treatment of patients with prostate cancer. EPE is associated with an increased risk of biochemical recurrence, positive surgical margins, and metastatic disease. An MRI-based EPE scoring system was developed by Mehralivand in 2019; however, it has not been adopted in the Urology community. The purpose of this study is to evaluate the association of MRI-based EPE scoring with the pathologic EPE (pEPE) after radical prostatectomy. Methods: We conducted a retrospective review on a prospectively collected database of male patients who underwent a prostate MRI with EPE scoring by a trained genitourinary radiologist and subsequent robotic radical prostatectomy at our institution from September 2020 to December 2022. The associations between MRI EPE (mEPE) score and the presence of EPE on surgical pathology (pEPE) were examined using multivariable logistic regression. Results: A total of 194 patients met inclusion criteria with a median age of 63 years and prostate specific antigen (PSA) 7 ng/mL. Among those with mEPE score 3, 96% had pEPE. Those patients with an mEPE score ≥2 had an increased risk of pEPE compared with those with mEPE score 0 (odds ratio 3.79; 95% confidence interval 1.28-11.3) Furthermore, those with an mEPE score 3 were significantly more likely to have pEPE compared with those with mEPE score 0, 1 and 2 independently. Conclusion: MRI EPE is a straightforward tool that strongly correlates with the presence of pEPE. If validated prospectively, this scoring system could assist in counseling patients regarding nerve-sparing approach.

BACKGROUND: Tracheobronchoplasty (TBP) is a definitive anatomic intervention for patients with severe symptomatic expiratory central airway collapse. Although stent evaluations have been described for surgical workup, current literature does not address if improvement during stent evaluation is sustained after TBP. We compared health-related quality of life (HRQOL) and functional status responses after airway stenting to those post-TBP.

METHODS: A retrospective review was performed in patients with severe expiratory central airway collapse who underwent stent evaluation followed by TBP from January 2004 to December 2019. Baseline, poststent, 3- and 12-month postoperative HRQOL scores, and functional status were analyzed with statistical tests as appropriate.

RESULTS: One hundred twenty patients underwent a stent evaluation and TBP. Baseline and stent evaluation measurements were compared with statistically and clinically significant differences in the Cough Quality-of-life Questionnaire (CQLQ) (55 vs. 68, P <0.01), Modified Medical Research Council (mMRC) 0 to 2 (90% vs. 47%, P <0.01), 6-minute walk test (6MWT) (1301 ft vs. 1138 ft, P <0.01). Improvements in the HRQOL and functional status were maintained from stent evaluation to 3 months postoperatively [CQLQ 55 vs. 54, P =0.63; mMRC 0 to 2 (87% vs. 84%), P =0.39; 6MWT 1350 ft vs. 1314 ft, P =0.33], and 12 months postoperatively [CQLQ 54 vs. 54, P =0.91; mMRC 0 to 2 (95% vs. 86%), P =0.74; 6MWT 1409 ft vs. 1328 ft, P =0.13]. The magnitude of change between the data was not significantly different between the stent evaluation, 3-, and 12 months postoperative. Predicted forced expiratory volume in 1-second measurements at baseline, after stent placement, 3 months, and 12 months post-TBP were 74%, 79%, 73%, and 73%, respectively, and not clinically significant.

CONCLUSIONS: Improvement after stent evaluation and the magnitude of improvement may be predictive of postoperative outcomes up to 1 year after surgery.

PURPOSE: Transrectal prostate biopsy is a common ambulatory procedure that can result in pain and anxiety for some men. Low-dose, adjustable nitrous oxide is increasingly being used to improve experience of care for patients undergoing painful procedures. This study seeks to evaluate the efficacy and safety of low-dose (<45%) nitrous oxide, which has not been previously established for transrectal prostate biopsies.

MATERIALS AND METHODS: A single-institution, prospective, double-blind, randomized, controlled trial was conducted on patients undergoing transrectal prostate biopsies. Patients were randomized to receive either self-adjusted nitrous oxide or oxygen, in addition to routine periprostatic bupivacaine block. Nitrous oxide at levels between 20% and 45% were adjusted to patients' desired effect. Patients completed a visual analog scale for anxiety, State Trait Anxiety Inventory, and a visual analog scale for pain immediately before and after biopsy. The blinded operating urologist evaluated ease of procedure. Periprocedural vitals and complications were assessed. Patients were allowed to drive home independently.

RESULTS: A total of 133 patients received either nitrous oxide (66) or oxygen (67). There was no statistically significant difference in the primary anxiety end point of State Trait Anxiety Inventory or the visual analog scale for anxiety scores between the nitrous oxide and oxygen groups. However, patients in the nitrous oxide group reported significantly lower visual analog scale for pain scores compared to the oxygen group (P = .026). The operating urologists' rating of tolerance of the procedure was better in the nitrous oxide group (P = .03). There were no differences in biopsy performance time. Complications were similarly low between the 2 groups.

CONCLUSIONS: Patient-adjusted nitrous oxide at levels of 20% to 45% is a safe adjunct during transrectal prostate biopsy. Although there was not an observed difference in the primary end point of anxiety, nitrous oxide was associated with lower patient-reported pain scores.

BACKGROUND: Contemporary prostate cancer (PCa) screening uses first-line prostate-specific antigen (PSA) testing, possibly followed by multiparametric magnetic resonance imaging (mpMRI) for men with elevated PSA levels. First-line biparametric MRI (bpMRI) screening has been proposed as an alternative.

OBJECTIVE: To evaluate the comparative effectiveness and cost-effectiveness of first-line bpMRI versus PSA-based screening.

DESIGN: Decision analysis using a microsimulation model.

DATA SOURCES: Surveillance, Epidemiology, and End Results database; randomized trials.

TARGET POPULATION: U.S. men aged 55 years with no prior screening or PCa diagnosis.

TIME HORIZON: Lifetime.

PERSPECTIVE: U.S. health care system.

INTERVENTION: Biennial screening to age 69 years using first-line PSA testing (test-positive threshold, 4 µg/L) with or without second-line mpMRI or first-line bpMRI (test-positive threshold, PI-RADS [Prostate Imaging Reporting and Data System] 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography.

OUTCOME MEASURES: Screening tests, biopsies, diagnoses, overdiagnoses, treatments, PCa deaths, quality-adjusted and unadjusted life-years saved, and costs.

RESULTS OF BASE-CASE ANALYSIS: For 1000 men, first-line bpMRI versus first-line PSA testing prevented 2 to 3 PCa deaths and added 10 to 30 life-years (4 to 11 days per person) but increased the number of biopsies by 1506 to 4174 and the number of overdiagnoses by 38 to 124 depending on the biopsy imaging scheme. At conventional cost-effectiveness thresholds, first-line PSA testing with mpMRI followed by either biopsy approach for PI-RADS 4 to 5 produced the greatest net monetary benefits.

RESULTS OF SENSITIVITY ANALYSIS: First-line PSA testing remained more cost-effective even if bpMRI was free, all men with low-risk PCa underwent surveillance, or screening was quadrennial.

LIMITATION: Performance of first-line bpMRI was based on second-line mpMRI data.

CONCLUSION: Decision analysis suggests that comparative effectiveness and cost-effectiveness of PCa screening are driven by false-positive results and overdiagnoses, favoring first-line PSA testing with mpMRI over first-line bpMRI.

PRIMARY FUNDING SOURCE: National Cancer Institute.

OBJECTIVES: Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on "fast-track" cardiac surgery outcomes.

DESIGN: A retrospective cohort study.

SETTING: At a university hospital.

PARTICIPANTS: Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016.

INTERVENTIONS: An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016.

MEASUREMENTS AND MAIN RESULTS: The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p = 0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p = 0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p = 0.57) or readmission (OR 1.22, p = 0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant.

CONCLUSIONS: The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.