Faculty Bibliography

PURPOSE: While robot-assisted radical prostatectomy (RARP) is associated with shortened convalescence and decreased blood loss over open prostatectomy, little objective data is available regarding postoperative pain/discomfort and use of analgesic medications after RARP. We sought to examine these parameters in a contemporary cohort. PATIENTS AND METHODS: From 2011 to 2013, patients undergoing RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while the patient recovered in the hospital. After discharge, the patients were asked to fill out a daily questionnaire regarding their pain parameters and self-report opiate usage. All questionnaires were based on the Wong-Baker FACES pain rating scale (0-10). Opiate dosages were converted to the approximate oral morphine sulfate equivalent dose (MSE). RESULTS: A total of 60 patients, mean age 61 years, were enrolled in the study, underwent RARP, and completed follow-up questionnaires. None had a history of chronic narcotic use. Intraoperative opiate use was 94.1 mg MSE. There were 73.3% who received immediate postoperative ketorolac. After RARP, the main source of pain/discomfort was abdominal/incisional, followed by urethral catheter-related, penile, and bladder spasm-related discomfort. Abdominal pain was generally moderate for most patients and decreased significantly after about 4 days. Penile and urethral catheter-related discomfort was mild throughout the study period. Opiate analgesic medication use quickly decreased as the subjective pain scores improved. CONCLUSIONS: After RARP, most patients experience mild/moderate abdominal discomfort, which improves steadily over several days. There is also a quick decline in the average opiate pain medication use that corresponds to the subjective improvement in pain symptoms. This information is useful for clinicians counseling patients on the pain associated with RARP and can serve as a reference to compare the convalescence associated with the other options for treatment of patients with localized prostate cancer.

PURPOSE: To validate the Spanish translation of the Overactive Bladder Symptom Score (OABSS) questionnaire. MATERIALS AND METHODS: The OABSS was translated into Spanish (OABSS-S) and back translated. The OABSS-S was self-administered to subjects, following internal IRB and ISPOR Good Practices guidelines. Spanish speaking patients >18 years of age were recruited from primary care clinics. Content validity was achieved by having the first 25 subjects complete the questionnaire in privacy; afterwards they were interviewed and the clarity of each question was discussed with the patient. All subjects recruited, including the first 25, were divided into two groups by the presence of OAB as determined by a previously validated intake question. Subjects completed the OABSS-S in privacy on two occasions within 10 days. Patients were excluded if their symptoms changed between the first and second administration of the questionnaire. Internal consistency was determined with Cronbach's alpha. Test-retest was determined by Spearman's rho. Discriminant validity was assessed between each group using one-way ANOVA and the Tukey post hoc test. RESULTS: One hundred and seventeen of 128 enrolled subjects completed this study (mean age 55; SD 18). Of 117, 74 (63%) were women 29 with OAB and 45 without OAB. There were 43 men (37%), 18 with OAB and 25 without OAB. A high level of consistency was observed among the seven items answered at visit 1 and 2, with a Cronbach's raw alpha statistic of 0.92. No differences in OABSS-S with age or gender were noted. However, subgroup analysis showed patients in the OAB group were significantly older and post-test analysis showed they had higher scores both for each individual question as well as overall symptom severity scores. Spearman's rank order correlation coefficients showed that there was significant difference between the seven items of the OABSS-S; a strong association (Spearman's rho) was also observed between the total seven-item score at visits 1 and 2 for the total score of all subjects r = 0.84, with O r = 0.81, and without O r = 0.83. Comparison of average total scores obtained for all patients at visits 1 and 2 was not significant (10.47 +/- 6.53 vs. 11.02 +/- 0.66). Discriminant validity testing revealed that there were significant differences in the responses between all diagnostic groups at visits 1 and 2: with OAB versus without OAB; total versus with OAB; total versus without OAB. CONCLUSION: The Spanish version of the OABSS is valid and reliable and will allow health care providers to easily and quickly assess a Spanish-speaking patient's symptoms.

OBJECTIVE: * o determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy. PATIENTS AND METHODS: * We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan(R) Medstat database, a national employer-based administrative database. * We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach. RESULTS: * Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day (P = 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, (P = 0.023). * These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P = 0.049), miscellaneous surgical complications (3.6 to 2.3%, P = 0.006) and intestinal injury (1.5 to 0.1%, P= 0.009). * Median length of stay for RRP decreased from 3.2 to 2.9 days, (P < 0.001), overall perioperative complications decreased from 18.1 to 14.6%, (P = 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P = 0.002) and heterologous blood transfusions. * Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P < 0.001), blood transfusions (1.5 vs 8.9%, P < 0.001) and anastomotic strictures (6.3 vs 12.8%, P < 0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P < 0.001) during the study period. CONCLUSION: * The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control.

STUDY TYPE: Prognosis (cohort). LEVEL OF EVIDENCE: 2b. What's known on the subject? and What does the study add? Prior population and single-centre studies have assessed incidence of positive surgical margins. The current study derived population-based positive surgical margin cut-offs in order to help identify underperforming surgeons who may benefit from further courses and/or self study to improve outcomes. OBJECTIVE: To characterize factors associated with positive surgical margins (PSMs) and derive population-based PSM cutoffs to evaluate surgeon performance in radical prostatectomy (RP). PATIENTS AND METHODS: SEER-Medicare data were used to identify 4247 men diagnosed with prostate cancer during 2004-2005 who underwent RP up to 2006. We performed logistic regression to assess the impact of tumour characteristics, surgeon volume and surgical approach on the likelihood of PSMs for pT2 and PT3a disease. Moreover, we derived 25th and 10th percentile cutoffs from binomial distribution equations. RESULTS: Overall, 19.4% of men experienced PSMs with a pT2 vs pT3a PSM rate of 14.9% vs 42% (P<0.001). Extrapolating from our population-based results, a surgeon incurring more than three PSMs in 10 cases of pT2 disease performed below the 25th percentile. There was a trend for fewer PSMs with minimally invasive vs open RP (17.4% vs 20.1%, P=0.086), and the PSM rate also decreased over the study period from 21.3% in 2004 to 16.6% in 2006 (P=0.028) with significant geographic variation (P<0.001). In adjusted analyses, temporal and geographic variation in PSM persisted, and men with high (odds ratio 3.68, 95% CI 2.82-4.81) and intermediate (odds ratio 2.52, 95% CI 2.03-3.13) vs low-risk disease were at greater odds to experience PSMs. Notably, neither surgical approach nor surgeon volume was significantly associated with PSMs. CONCLUSION: Our population-based PSM benchmarks allow identification of under-performing outliers who may seek courses or video self-study to improve outcomes. There was significant temporal and geographic variation in PSMs but neither surgeon volume nor surgical approach was associated with PSMs.

PURPOSE: Significant research has been dedicated to the management of vesicoureteral reflux (VUR). However, few studies have been published to evaluate the impact of this disease on quality of life. The aim of this study was a prospective examination of the health-related quality of life (HRQoL) in children with VUR who have either been treated medically (antibiotics or surveillance) or by ureteral reimplant (UR) using a validated patient satisfaction survey. MATERIALS AND METHODS: A prospective, longitudinal study was conducted using a validated HRQoL questionnaire, the Pediatric Quality of Life Inventory (PedsQL 4.0 Generic Core). 353 children or parents of children with VUR, age 2-18 years, completed the survey. Statistical analysis was performed with significance set at p-value