Failure After Laparoscopic Pyeloplasty: Prevention and Management

Background and Purpose: Because of the high success of laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction, strategies for managing failures are less well described. We report our experience with persistent or recurrent obstruction after LP. Patients and Methods: We reviewed 128 patients who were treated with LP at our institution from 1996 through 2008. Success was defined as objective resolution of obstruction by renal scintigraphy, Whitaker testing, or direct visualization. We extracted data by chart review regarding patient demographics, medical history, operative technique, and salvage treatments. We then assessed for association between patient characteristics and treatment failure. Results: Overall, 102 patients had sufficient follow-up, of which 84 (82%) were successes. Of 18 failures, median time to failure was 2.5 months (0.5-88-mos). Of 10 failures managed endoscopically, 7 were salvaged. One of two patients treated conservatively ultimately had resolution while six patients needed simple nephrectomy. Overall, 8 (44%) were salvageable with median follow-up of 19 months (4-58-mos). Patients with failure were more likely to have diabetes mellitus, longer length of stay, higher American Society of Anesthesiologists (ASA) score, a stent placed at the time of pyeloplasty, or ureteral stent malfunction (P30-kg/m2 (P2 were associated with failure (P<0.05) while periureteral fibrosis trended toward a significant association (P=0.061). Conclusion: Nearly half of failures after LP are salvageable, many with endoscopic management.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90445/1/end-2E2010-2E0647.pd

Understanding Potential Intraoperative Impediments for Learning Laparoscopic Nephrectomy

Purpose: We evaluated factors that impact the ability to learn hand-assisted laparoscopic donor nephrectomy (HALDN) to identify impediments to diffusion of this procedure. Methods: From February 2002 to June 2004, we collected data from our institutional database on 70 patients who underwent HALDN. Time for individual steps of the procedure (colon mobilization, kidney/ureter mobilization, renal vein tributary dissection, renal hilum dissection, removal of the kidney, and overall time) were recorded. The impact of patient factors on surgical times was assessed using a general linear model. The impact of individual operative steps on overall operative time was assessed using Pearson correlation. The influence of case experience and training level were evaluated graphically and in a multivariable model. Results: A total of 13 residents, 2 fellows, and 1 attending surgeon participated in procedures for 70 patients. Body mass index (P = 0.03) and male sex (P = 0.04) prolonged operative times. Colon mobilization and hilar dissection were most correlated with overall operative time. While experience improved operative times for several steps, level of training appeared more likely to influence the time for individual operative steps. Conclusions: Impediments to learning HALDN include patient factors, level of training, and particular surgical steps. Repeated exposure at increasing levels of training may improve diffusion of laparoscopic nephrectomy among urologists.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63194/1/end.2008.0439.pd

Early impact of Medicare accountable care organizations on cancer surgery outcomes

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/134271/1/cncr30111.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/134271/2/cncr30111_am.pd

Understanding the Use of Prostate Biopsy Among Men with Limited Life Expectancy in a Statewide Quality Improvement Collaborative

BACKGROUND: The potential harms of a prostate cancer (PCa) diagnosis may outweigh its benefits in elderly men. OBJECTIVE: To assess the use of prostate biopsy in men with limited life expectancy (LE) within the practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). DESIGN, SETTING, AND PARTICIPANTS: MUSIC is a consortium of 42 practices and nearly 85% of the urologists in Michigan. From July 2013 to October 2014, clinical data were collected prospectively for all men undergoing prostate biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We calculated comorbidity-adjusted LE in men aged ≥66 yr and identified men with(limited LE) undergoing a first biopsy. Our LE calculator was not designed for men agedyr; thus these men were excluded. Multivariable models estimated the proportion of all biopsies performed for men with limited LE in each MUSIC practice, adjusting for differences in patient characteristics. We also evaluated what treatments, if any, these patients received. RESULTS AND LIMITATIONS: Among 3035 men aged ≥66 yr undergoing initial prostate biopsy, 60% had none of the measured comorbidities. Overall, 547 men (18%) had limited LE. Compared with men with a longer LE, these men had significantly higher prostate-specific antigen levels and abnormal digital rectal examination findings. The adjusted proportion of biopsies performed for men with limited LE ranged from 3.8% to 39% across MUSIC practices (p \u3c 0.001). PCa was diagnosed in 69% of men with limited LE; among this group, 74% received any active treatment. Of these men, 46% had high-grade cancer (Gleason score 8-10). CONCLUSIONS: Among a large and diverse group of urology practices, nearly 20% of prostate biopsies are performed in men with limited LE. These data provide useful context for quality improvement efforts aimed at optimizing patient selection for prostate biopsy. PATIENT SUMMARY: In this report, nearly 2 of every 10 men undergoing prostate biopsy had a life expectancy (LE)biopsy

Understanding the relationship between the Centers for Medicare and Medicaid Services’ Hospital Compare star rating, surgical case volume, and short‐term outcomes after major cancer surgery

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138844/1/cncr30866.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138844/2/cncr30866_am.pd

Delays in diagnosis and bladder cancer mortality

BACKGROUND: Mortality from invasive bladder cancer is common, even with high-quality care. Thus, the best opportunities to improve outcomes may precede the diagnosis. Although screening currently is not recommended, better medical care of patients who are at risk (ie, those with hematuria) has the potential to improve outcomes. METHODS: The authors used the Surveillance, Epidemiology, and End Results-Medicare linked database for the years 1992 through 2002 to identify 29,740 patients who had hematuria in the year before a bladder cancer diagnosis and grouped them according to the interval between their first claim for hematuria and their bladder cancer diagnosis. Cox proportional hazards models were fitted to assess relations between these intervals and bladder cancer mortality, adjusting first for patient demographics and then for disease severity. Adjusted logistic models were used to estimate the patient's probability of receiving a major intervention. RESULTS: Patients (n = 2084) who had a delay of 9 months were more likely to die from bladder cancer compared with patients who were diagnosed within 3 months (adjusted hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.20-1.50). This risk was not markedly attenuated after adjusting for disease stage and tumor grade (adjusted HR, 1.29; 95% CI, 1.14-1.45). In fact, the effect was strongest among patients who had low-grade tumors (adjusted HR, 2.11; 95% CI, 1.69-2.64) and low-stage disease (ie, a tumor [T] classification of Ta or tumor in situ; adjusted HR, 2.02; 95% CI, 1.54-2.64). CONCLUSIONS: A delay in the diagnosis of bladder cancer increased the risk of death from disease independent of tumor grade and or disease stage. Understanding the mechanisms that underlie these delays may improve outcomes among patients with bladder cancer. Cancer 2010. © 2010 American Cancer Society.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78303/1/25310_ftp.pd

Evaluation of a needle disinfectant technique to reduce infection‐related hospitalisation after transrectal prostate biopsy

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142074/1/bju13982_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142074/2/bju13982.pd

Disparities in the use of ambulatory surgical centers: a cross sectional study

<p>Abstract</p> <p>Background</p> <p>Ambulatory surgical centers (ASCs) provide outpatient surgical services more efficiently than hospital outpatient departments, benefiting patients through lower co-payments and other expenses. We studied the influence of socioeconomic status and race on use of ASCs.</p> <p>Methods</p> <p>From the 2005 State Ambulatory Surgery Database for Florida, a cohort of discharges for urologic, ophthalmologic, gastrointestinal, and orthopedic procedures was created. Socioeconomic status was established at the zip code level. Logistic regression models were fit to assess associations between socioeconomic status and ASC use.</p> <p>Results</p> <p>Compared to the lowest group, patients of higher socioeconomic status were more likely to have procedures performed in ASCs (OR 1.07 CI 1.05, 1.09). Overall, the middle socioeconomic status group was the most likely group to use the ASC (OR 1.23, CI 1.21 to 1.25). For whites and blacks, higher status is associated with increased ASC use, but for Hispanics this relationship was reversed (OR 0.84 CI 0.78, 0.91).</p> <p>Conclusion</p> <p>Patients of lower socioeconomic status treated with outpatient surgery are significantly less likely to have their procedures in ASCs, suggesting that less resourced patients are encountering higher cost burdens for care. Thus, the most economically vulnerable group is unnecessarily subject to higher charges for surgery.</p

Geological and geochemical controls on mineralization and alteration, Screamer Carlin-type Gold Depo

Master of ScienceGeological SciencesUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/115713/1/39015051820861.pd