Citations

Abstract Purpose We compared perioperative morbidity after repeat transurethral resection (re-TURP) versus primary TURP, focusing on transfusion and broader bleeding-related complications relevant to counseling and risk stratification. Methods We analyzed the American College of Surgeons National Surgical Quality Improvement Program (2013–2023) to identify men undergoing primary TURP (Current Procedural Terminology [CPT] 52601) or re-TURP (CPT 52630). The primary outcome was 30-day red blood cell transfusion. Secondary outcomes included a prespecified postoperative hematuria endpoint based on ICD-10 codes. Multivariable logistic regression evaluated associations with bleeding endpoints and downstream complications. Results Among 83,539 TURP procedures, 76,983 (92.2%) were primary and 6,556 (7.8%) were repeat. Re-TURP patients were older, had higher ASA class, and more often underwent urgent surgery. Transfusion occurred in 1.9% after re-TURP versus 1.5% after primary TURP; hematuria-coded events occurred in 3.5% versus 1.3%, respectively. After adjustment, re-TURP was associated with postoperative hematuria (adjusted odds ratio [aOR] 2.42, 95% CI 2.03–2.88) but not with transfusion (aOR 1.09, 95% CI 0.87–1.36). Older age, urgent/emergent status, bleeding disorder, and lower hematocrit predicted both bleeding endpoints. Re-TURP was associated with slightly lower odds of readmission (aOR 0.87; 95% CI 0.76–0.99) and was not associated with return to the operating room. Transfusion strongly predicted return to the operating room (aOR 7.21) and readmission (aOR 2.05), whereas hematuria predicted return to the operating room only (aOR 1.50). Conclusions Compared with primary TURP, re-TURP was associated with more hematuria-coded events but not higher adjusted transfusion risk, suggesting a relative shift toward lower-severity bleeding morbidity.

Introduction: The Revised Cardiac Risk Index (RCRI) and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) are well-recognized tools to predict 30-day postoperative cardiac events in noncardiac surgeries. However, their predictive accuracy is yet to be assessed in minimally invasive transurethral prostate surgery. We compared the RCRI- and NSQIP-predicted postoperative cardiac outcomes with the actual incidence of cardiac events after transurethral prostate surgery. Methods: We conducted a retrospective review of patients who underwent transurethral prostate surgery between July and December of 2022. We assessed for postoperative cardiac events within 30 days, as defined by the seminal cardiac VISION study. The RCRI and NSQIP cardiac event predictions were calculated. Fisher’s exact test was used for analysis. Results: We included 185 patients with an average age of 73 ± 8.4 (standard deviation) years, 86 of whom (46%) had transurethral resection of the prostate, and 99 underwent Holmium Laser Enucleation of the Prostate (54%). Myocardial injury after noncardiac surgery surveillance was needed for 34 patients (18.4%) as per standard practice. No patient had any intraoperative cardiac events. One patient experienced a nonfatal postoperative cardiac event (asystole) within hours of surgery. The 30-day cardiac event prediction by the RCRI was 4.8% of the patient cohort ( n ≈ 9), significantly higher than the observed incidence of 0.5% ( p = 0.0198). NSQIP predicted that 0.54% of the patient cohort ( n = 1) will have a cardiac complication within 30 days, which is not significantly different from the observed cardiac event incidence ( p = 1). Conclusion: The RCRI significantly overestimated the 30-day cardiac risk after transurethral prostate surgery, whereas NSQIP predictions and the observed rate of cardiac events were similar. Utilizing more representative predictive tools helps improve risk stratification and will allow patients and surgeons to make better-informed decisions.

Introduction: Percutaneous nephrolithotomy (PCNL) has been a mainstay treatment for large stone burdens since the 1980s, historically offering improved stone-free rates over retrograde intrarenal surgery (RIRS). Gaining optimal access into the renal collecting system can be challenging, requiring advanced skills or interventional radiology assistance. The learning curve for fluoroscopic and ultrasonography access can be steep, with only a minority of PCNL access performed by urologists in the United States. This study compares robotic-assisted electromagnetic (EM) guidance to traditional fluoroscopy for obtaining percutaneous renal access between cohorts of novice and expert urologists. Methods: Ten novices and five expert urologists used robotic-assisted EM guidance to obtain access in a modified supine position compared with using fluoroscopy in a traditional prone position in human cadavers. Primary success was defined as papillary access. Performance metrics, including number of puncture attempts, time to access, radiation exposure, and participant confidence, were compared between novices and experts. Results: Robotic-assisted EM guidance improved success rates for both novices (100% vs 70%) and experts (93% vs 87%) compared with fluoroscopy. Novices showed greater accuracy using robotic assistance (97% vs 37%). The number of insertion attempts decreased with robotic guidance for both groups (novices: 3.42 ± 0.44 vs 1.47 ± 0.19; experts: 2.13 ± 0.36 vs 1.40 ± 0.24; p < 0.002). EM guidance ( p < 0.05) and experience ( p < 0.05) significantly reduced the time from needle insertion to access (novices: 12.86 ± 2.41 minutes vs 4.49 ± 0.96 minutes; experts: 4.90 ± 1.40 minutes vs 4.09 ± 1.12 minutes). Radiation exposure was notably lower with EM guidance (novices, 1.12 ± 0.17 mGy vs 4.86 ± 0.70 mGy; experts, 0.69 ± 0.12 mGy vs 4.11 ± 1.21 mGy; p < 0.001). Novices felt more confident (5[3–5] vs 2[1–4], p < 0.001) and at ease (5[3–5] vs 2.75[1–3], p < 0.001) with EM guidance. Conclusion: Robotic-assisted EM guidance improves percutaneous access success, reduces attempts and radiation exposure, and enhances novice confidence and accuracy. This technology could enable urologists to more effectively and safely perform PCNL, especially for less experienced practitioners.

Importance Trimodal therapy (TMT) is included as an alternative to radical cystectomy (RC) for definitive management of muscle-invasive bladder cancer (MIBC) in current clinical guidelines. Moreover, a 2023 retrospective analysis reported similar oncologic outcomes between these treatments among patients deemed fit for RC. Data regarding the comparative value of these treatments are lacking. Objective To evaluate the comparative cost-effectiveness of TMT and RC for treatment of MIBC. Design, Setting, and Participants This economic evaluation compared cost-effectiveness of treatments using a health transition state microsimulation model of patients with bladder cancer treated between 2005 and 2017 with 5- and 10-year horizons from a Medicare perspective. Model probabilities were informed by multicenter retrospective analyses published in 2023 comparing TMT with RC. The index patient was aged 71 years, with clinical stage T2-4aN0M0 MIBC, solitary tumor smaller than 7 cm, no or unilateral hydronephrosis, adequate bladder function, and lack of multifocal or extensive carcinoma in situ. Patients unfit for RC, radiation, or cisplatin-based chemotherapy were excluded. Exposures TMT and RC. Main Outcome and Measures Primary outcomes included effectiveness measured in quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICER) using a willingness-to-pay threshold of $100 000 per QALY. Sensitivity analyses were performed to assess the robustness of the model. Results For the index patient, at 5 years, the average cost was $30 525 higher for TMT than RC. Average QALYs were 3.87 and 3.94 for RC and TMT, respectively. As such, TMT was not cost-effective at 5-year (ICER, $464 291 per QALY) or 10-year (ICER, $308 638 per QALY) time horizons. On 1-way sensitivity analyses, TMT would become cost-effective if (1) TMT costs were less than $17 605; or (2) TMT resulted in an 11.6% improvement in metastasis-free survival relative to RC. Conclusions and Relevance In this economic evaluation study of TMT and RC for treatment of MIBC, TMT was associated with improved quality of life but was not cost-effective relative to RC at 5 and 10 years given higher treatment costs. These findings highlight the importance of developing policy initiatives that help reduce TMT costs and of providing patients with accurate expectations of long-term toxic effects to help guide preference-sensitive care.