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Editorial Comment

Metcalf, Meredith R
PMID: 34284617
ISSN: 1527-3792
CID: 4952012

Volume-outcome relationships for kidney cancer may be driven by disparities and patient risk

Wainger, Julia J; Cheaib, Joseph G; Patel, Hiten D; Huang, Mitchell M; Biles, Michael J; Metcalf, Meredith R; Canner, Joseph K; Singla, Nirmish; Trock, Bruce J; Allaf, Mohamad E; Pierorazio, Phillip
PURPOSE:Provider and hospital factors influence healthcare quality, but data are lacking to assess their impact on renal cancer surgery. We aimed to assess factors related to surgeon and hospital volume and study their impact on 30-day outcomes after radical nephrectomy. MATERIALS AND METHODS:Renal surgery data were abstracted from Maryland's Health Service Cost Review Commission from 2000 to 2018. Patients ≤18 years old, without a diagnosis of renal cancer, and concurrently receiving another major surgery were excluded. Volume categories were derived from the mean annual cases distribution. Multivariable logistic and linear regression models assessed the association of volume on length of stay, intensive care days, cost, 30-day mortality, readmission, and complications. RESULTS:7,950 surgeries, completed by 573 surgeons at 48 hospitals, were included. Demographic, surgical, and admission characteristics differed between groups. Radical nephrectomies performed by low volume surgeons demonstrated increased post-operative complication frequency, mortality frequency, length of stay, and days spent in intensive care relative to other groups. However, after logistic regression adjusting for clinical risk and socioeconomic factors, only increased length of stay and ICU days remained associated with lower surgeon volume. Similarly, after adjusted logistic regression, hospital volume was not associated with the studied outcomes. CONCLUSIONS:Surgeons and hospitals differ in regards to patient demographic and clinical factors. Barriers exist regarding access to high-volume care, and thus some volume-outcome trends may be driven predominantly by disparities and case mix.
PMID: 34078583
ISSN: 1873-2496
CID: 4951992

Evidence-Based Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery

Koo, Kevin; Winoker, Jared S; Patel, Hiten; Faisal, Farzana; Gupta, Natasha; Metcalf, Meredith; Mettee, Lynda; Meyer, Alexa; Pavlovich, Christian; Pierorazio, Philip; Matlaga, Brian R
INTRODUCTION/BACKGROUND:Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus. METHODS:A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naïve adult patients after uncomplicated procedures. RESULTS:Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement. CONCLUSION/CONCLUSIONS:Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making prior to prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.
PMID: 34107778
ISSN: 1557-900x
CID: 4952002

Gender Differences in the Clinical Management of clinical T1a Renal Cell Carcinoma

Metcalf, Meredith R; Cheaib, Joseph G; Wainger, Julia; Peña, Vanessa N; Patel, Hiten D; Singla, Nirmish; Pierorazio, Phillip M
OBJECTIVE:To evaluate gender differences in the management of clinical T1a (cT1a) renal cell carcinoma (RCC) before and after release of the AUA guidelines for management in 2009, which prioritized nephron-sparing approaches. METHODS:Patients aged ≥66 years diagnosed with cT1a RCC from 2004 to 2013 in Surveillance, Epidemiology, and End Results-Medicare were analyzed. Multivariable mixed-effects logistic regression models were used to evaluate factors associated with radical nephrectomy (RN) for cT1a RCC before (2004 to 2009) and after (2010 to 2013) guidelines release. Predictors of pathologic T3 upstaging and high grade pathology in the postguidelines period were examined using multivariable logistic regression among patients who underwent RN or partial nephrectomy. RESULTS:Twelve thousand four hundred and two patients with cT1a RCC were identified, 42% of whom were women. Overall, the likelihood of RN decreased postguidelines (odds ratio [OR] = 0.44, P <.001), but women were at increased odds of undergoing RN both before and after guideline release (OR = 1.27, P <.001 and OR = 1.37, P <.001, respectively) upon multivariable mixed-effects logistic regression. Tumor size >2 cm was also associated with increased likelihood of RN before and after guidelines (OR = 2.61, P <.001 and OR = 2.51, P <.001, respectively). In the postguidelines period, women had significantly lower odds of pathologic upstaging (OR = 0.75, P = .024) and harboring high grade pathology (OR = 0.71, P <.001) compared to men. CONCLUSION/CONCLUSIONS:Gender differences persist in the management of cT1a RCC, with women having higher odds of undergoing RN, even after release of AUA guidelines and despite having lower odds of pathologic upstaging and high-grade disease.
PMID: 32890618
ISSN: 1527-9995
CID: 4951922

Outcomes of Active Surveillance for Young Patients with Small Renal Masses: Prospective Data from the DISSRM Registry

Metcalf, Meredith R; Cheaib, Joseph G; Biles, Michael J; Patel, Hiten D; Peña, Vanessa N; Chang, Peter; Wagner, Andrew A; McKiernan, James M; Pierorazio, Phillip M
PURPOSE/OBJECTIVE:A paradigm shift in the management of small renal masses has increased utilization of active surveillance. However, questions remain regarding safety and durability in younger patients. MATERIALS AND METHODS/METHODS:and Fisher's exact tests, and Kruskal-Wallis and Wilcoxon signed-rank tests. Survival outcomes were calculated using the Kaplan-Meier method and compared with the log-rank test. RESULTS:Of 224 patients with median followup of 4.9 years 30.4% chose surveillance. There were 20 (29.4%) surveillance progression events, including 4 elective crossovers, and 13 (19.1%) patients underwent delayed intervention. Among patients with initial tumor size ≤2 cm, 15.1% crossed over, compared to 33.3% with initial tumor size 2-4 cm. Overall survival was similar in primary intervention and surveillance at 7 years (94.0% vs 90.8%, log-rank p=0.2). Cancer-specific survival remained at 100% for both groups. There were no significant differences between primary and delayed intervention with respect to minimally invasive or nephron-sparing interventions. Recurrence-free survival at 5 years was 96.0% and 100% for primary and delayed intervention, respectively (log-rank p=0.6). CONCLUSIONS:Active surveillance is a safe initial strategy in younger patients and can avoid unnecessary intervention in a subset for whom it is durable. Crucially, no patient developed metastatic disease on surveillance or recurrence after delayed intervention. This study confirms active surveillance principles can effectively be applied to younger patients.
PMID: 33356478
ISSN: 1527-3792
CID: 4951972

Reply by Authors [Comment]

Metcalf, Meredith R; Cheaib, Joseph G; Biles, Michael J; Patel, Hiten D; Peña, Vanessa N; Chang, Peter; Wagner, Andrew A; McKiernan, James M; Pierorazio, Phillip M
PMID: 33635089
ISSN: 1527-3792
CID: 4951982

Testis-sparing Surgery: A Single Institution Experience

Egan, Jillian; Cheaib, Joseph G; Biles, Michael J; Huang, Mitchell M; Metcalf, Meredith; Matoso, Andres; Pierorazio, Phillip
OBJECTIVE:To demonstrate the safety and efficacy of testis-sparing surgery (TSS) in 2 specific circumstances: small, nonpalpable masses suspected to be benign and masses suspicious for germ cell tumor in a solitary or functionally solitary testicle or bilateral disease. METHODS:Our institutional review board-approved testicular cancer registry was reviewed for men who underwent inguinal exploration with intent for TSS (2013-2020). The attempted TSS and completed TSS groups were evaluated for differences using Student's t test for normally-distributed variables, chi-squared and Fisher's exact tests for proportions, and Wilcoxon rank-sum test for nonparametric variables. RESULTS:TSS was attempted in 28 patients and completed in 14. TSS was completed only if intraoperative frozen section demonstrated benign disease, except for 1 patient with stage I seminoma and solitary testicle. Sensitivity and specificity of frozen section analysis was 100% and 93%, respectively. There were no significant differences in demographics between attempted vs completed TSS cohorts. Median tumor size was significantly smaller in the completed TSS cohort (1.0 cm vs 1.7 cm, P = .03). In patients with unilateral masses without history of testis cancer, the testis was successfully spared in 9 of 22 cases (41%). In patients with bilateral disease or germ cell tumor in solitary testis, the testis was spared in 5 of 6 cases (83%). At a median follow up of 12.2 months, all patients were alive, and 27 of 28 had no evidence of disease (96%). CONCLUSION/CONCLUSIONS:TSS is safe and effective for small, benign masses and in the setting of bilateral disease or tumor in a solitary testis.
PMID: 33137349
ISSN: 1527-9995
CID: 4951952

Feasibility of a Weight Management Program Tailored for Overweight Men with Localized Prostate Cancer - A Pilot Study

Hamilton-Reeves, Jill M; Johnson, Chelsea N; Hand, Lauren K; Bechtel, Misty D; Robertson, Hilary L; Michel, Carrie; Metcalf, Meredith; Chalise, Prabhakar; Mahan, Nicholas J; Mirza, Moben; Lee, Eugene K; Sullivan, Debra K; Klemp, Jennifer R; Befort, Christie A; Parker, William P; Gibbs, Heather D; Demark-Wahnefried, Wendy; Thrasher, J Brantley
BACKGROUND/UNASSIGNED:Overweight men with prostate cancer are more likely to suffer from recurrence and death following prostatectomy compared with healthy weight men. This study tested the feasibility of delivering a comprehensive program to foster weight loss before and weight maintenance after surgery in overweight men with localized prostate cancer. METHODS/UNASSIGNED: = 5). Anthropometrics, biomarkers, diet quality, nutrition literacy, quality of life, and long-term follow-up were assessed in both groups. RESULTS/UNASSIGNED:The intervention led to 5.55 kg of weight loss including 3.88 kg of fat loss from baseline to surgery (mean = 8.3 weeks). The intervention significantly increased fiber, protein, fruit, nut, and vegetable intake; and decreased trans fats intake during weight loss. The intervention significantly reduced insulin, C-peptide, systolic blood pressure, leptin:adiponectin ratio, and visceral adiposity compared to the nonintervention. Post-surgically, weight loss was maintained. Changes in lipid profiles, nutrition literacy, and follow-up were not statistically significant in either group. CONCLUSION/UNASSIGNED:Significant weight loss (≥5%) is feasible with a coaching intervention in overweight men preparing for prostatectomy and is associated with favorable cardiometabolic effects. This study is registered under NCT02252484 (www.clinicaltrials.gov).
PMID: 33295204
ISSN: 1532-7914
CID: 4951962

Plastic exposure and urological malignancies - an emerging field

Patel, Sunil H; Metcalf, Meredith; Bivalacqua, Trinity J; Kates, Max
PMID: 33028980
ISSN: 1759-4820
CID: 4951942

Future strategies to enhance kidney preservation in upper urinary tract urothelial carcinoma

Metcalf, Meredith; Pierorazio, Phillip M
Though radical nephroureterectomy remains the gold standard treatment for high grade or invasive disease in upper tract urothelial cancer (UTUC), kidney-sparing surgery has become preferred for low risk disease, in order to minimize morbidity and preserve renal function. Many methods exist for endoscopic management, whether via an antegrade percutaneous or retrograde ureteroscopic approach, including electroresection, laser ablation, and fulguration. There has been an increase in use of adjuvant intracavitary therapy, predominantly using mitomycin and bacillus Calmette-Guerin (BCG), to reduce recurrence after primary endoscopic management for noninvasive tumors, although efficacy remains questionable. Intraluminal BCG has additionally been used for primary treatment of CIS in the upper tract, with around 50% success. Newer investigations include use of narrow band imaging or photodynamic diagnosis with ureteroscopy to improve visualization during diagnosis and treatment. Genomic characterization may improve selection for kidney-sparing surgery as well as identify actionable mutations for systemic therapy. The evolution in adjuvant management has seen strategies to increase the dwell time and the urothelial contact of intraluminal agents. Lastly, chemoablation using a hydrogel for sustained effect of mitomycin is under investigation with promising early results. Continued expansion of the armamentarium available and better identification and characterization of tumors ideal for organ-sparing treatment will further improve kidney preservation in UTUC.
PMCID:7475682
PMID: 32944547
ISSN: 2223-4691
CID: 4951932