Wang, Jeffrey K.

SAGE-Journals-Accessible-Video-Player 10.1089/vid.2014.0017.M1 sj-vid-1-vid-10.1089_vid.2014.0017

What's known on the subject? and What does the study add? Variations in the type of urinary diversion exist for patients undergoing radical cystectomy. Although its use has been increasing from 2001 to 2008, patients who are older, female, and primary insured by Medicaid are less likely to receive continent diversions. Furthermore, patients treated surgically at high‐volume and teaching hospitals are more likely to receive continent diversions. Objective To describe the contemporary trends in urinary diversion among patients undergoing radical cystectomy ( RC ) for bladder cancer; and elucidate whether socioeconomic disparities persist in the type of diversion performed in the USA from a population‐based cohort. Patients and Methods Using the Nationwide Inpatient Sample, we identified patients who underwent RC for bladder cancer between 2001 and 2008. Multivariable regression models were used to identify patient and hospital covariates associated with continent urinary diversion and enumerate predicted probabilities for statistically significant variables over time. Results Overall, 55 635 (92%) patients undergoing RC for bladder cancer received incontinent urinary diversion, while 4552 (8%) patients received continent diversion from 2001 to 2008. Receipt of continent urinary diversion increased from 6.6% in 2001–2002 to 9.4% in 2007–2008 ( P < 0.001 for trend). Patients who were older (odds ratio [ OR ] 0.93; P < 0.001), female ( OR 0.52; P < 0.001) and insured by Medicaid ( OR 0.54; P = 0.002) were less likely to receive continent urinary diversion. However, patients treated at teaching ( OR 2.14; P < 0.001) and high‐volume hospitals ( OR 2.39; P = 0.04) had higher odds of continent urinary diversion. Predicted probabilities of continent diversion remained lower for female patients, Medicaid insurance status, and non‐teaching and medium/low‐volume hospitals over time. Conclusions In this nationally representative sample of hospitals from 2001 to 2008, the use of continent diversion in RC gradually increased. Although variations in urinary diversion exist by hospital teaching status, case volume, patient gender and primary health insurance, increased attention in expanding the use of continent diversions may help reduce these disparities for patients undergoing RC for bladder cancer.

ObjectivesTo evaluate risk factors associated with iatrogenic splenectomy during nephrectomy and to assess outcomes among patients undergoing nephrectomy for renal tumors.MethodsOf 4323 patients who underwent nephrectomy at Mayo Clinic between 1992 and 2008, 33 (0.8%) had an iatrogenic/unplanned splenectomy. In a case–control study design, controls without splenectomy were matched 1:3 based on age, sex, surgical date, side of the renal tumor, surgical approach and surgeon. Perioperative features and survival were evaluated using conditional logistic and Cox regression.ResultsAmong the 33 iatrogenic splenectomy patients, the majority (94%) underwent radical, open and left‐sided nephrectomy. Primary tumor classification ≥T3 was the only clinicopathological risk factor significantly associated with splenectomy (odds ratio 3.4; P = 0.02). Compared with controls, patients with an iatrogenic splenectomy were more likely to have longer operative time (205 vs 171 min; P = 0.02), higher estimated blood loss (1.3 vs 0.3 L; P = 0.001), longer length of stay (median 7 vs 5 days; P = 0.03) and a higher likelihood for postoperative complications (odds ratio 5.3; P = 0.002). With a median of 9.8 years of follow up, splenectomy patients tended to have greater all‐cause mortality (hazard ratio 1.6; P = 0.07), although this difference approached statistical significance.ConclusionsIatrogenic splenectomy is a rare complication during nephrectomy and is associated with locally advanced tumors (≥pT3). It also carries prognostic significance for adverse perioperative outcomes and possibly diminished survival, although this warrants further study.

AbstractPurposeWe assessed risk factors for splenic injury during colectomy and associated outcomes for a 15‐year period at a single institution.MethodsAll adult general surgery patients who sustained a splenic injury during colectomy at our institution from 1992 to 2007 were retrospectively identified and matched 1:1 to controls without splenic injury. Putative risk factors were assessed using paired univariate analysis and conditional logistic regression. Differences in short‐ and long‐term mortality were assessed using the log‐rank test. Results are reported as a proportion, median, or odds ratio [OR (95% confidence intervals)].ResultsA total of 118 patients were included: 59 patients with splenic injury and 59 control patients. Statistically significant risk factors for splenic injury during colectomy found on univariate analysis included: splenic flexure mobilization, OR 21.00 (2.82–156.12); Charlson comorbidity index ≥5, OR 3.17 (1.26–7.93); ASA class ≥3, OR 5.33 (1.55–18.3); and nonelective surgery, OR 5.00 (1.1–22.82). On multivariate analysis, only splenic flexure mobilization was independently associated with increased risk of splenic injury (OR 18.4 (2.1–161); p = 0.0085). Splenic injured patients trended toward decrease survival both at 30 days (98 vs. 88%; p = 0.06) and at 5 years (58 vs. 55%), with a hazard ratio of 1.6 (1.0, 2.6; p = 0.05).ConclusionsSplenic flexure mobilization is the primary risk factor for splenic injury during colectomy, independent of other factors, such as higher ASA class, Charlson score, and nonelective surgery. Splenic injury during colectomy has an increased risk of death in both the short‐ and long‐term.