Laird Harrison

About half of postoperative visits to emergency rooms following urologic surgery could be prevented, but simply improving patient education may not significantly reduce the number of these visits, researchers say.

“What we may think is common sense would have prevented a lot of emergency department visits,” Hari Sawkar, MD, chief urology resident at the University of Southern California (USC) in Los Angeles told 

. He presented the research at the AUA annual meeting in San Francisco.

Few studies describe emergency department visits following urologic surgery, he said. Most of these are after stone surgery, and study designs vary substantially, with researchers reporting rates of emergency department visits from 7% to 15%.

How artificial intelligence may reshape urologic practice

To characterize emergency department utilization and readmissions, the authors used data from the USC Los Angeles County + USC Medical Center. Located in East Los Angeles, the 600-bed facility has 40,000 discharges and handles 150,000 emergency department visits per year. The patient population is ethnically and linguistically diverse, with many economically disadvantaged.

Dr. Sawkar and his colleagues identified cases of patients returning to the emergency room within 90 days of urologic surgery. They reviewed medical records to determine clinical causes and whether the emergency room visits were preventable. They then designed interventions in an attempt to reduce the number of preventable emergency department visits.

At baseline (July to September 2015), the medical center did 53 urologic procedures per month, of which 20.8% resulted in emergency department visits, with 50.9% of those visits deemed preventable. The mean number of days from surgery to an emergency department visit was 13.9.

The most common reason for an emergency room visit, accounting for 25.8% of the visits, was a question about a wound. Another 16.4% stemmed from a non-wound infection, and 16.1% were for surgical site pain. Drain and catheter issues accounted for another 15.8%, and hematuria for 13.3%.

Based on their analysis of these causes, the authors found two common problems leading to a preventable emergency department visit. First, the patients couldn’t get access to urology providers to ask questions. Second, they had unclear expectations about recovery from the surgery.

To see if they could address these problems, the authors devised handouts specific to the most common urologic procedures and provided them to patients in English and Spanish. Patients received preoperative calls from nurse practitioners and postoperative calls by operating residents.

The handouts include a description of the procedure. They tell patients how to prepare-for example, by avoiding medications that can increase bleeding. They explain what to expect after surgery, such as pain and hematuria with transurethral resection of a bladder tumor (TURBT).

What 2019 MIPS changes mean for your practice

The handouts also list symptoms that justify a trip to the emergency room or a 911 call. In the case of TURBT, symptoms listed are: severe pain, uncontrolled vomiting, high fevers, significant bleeding, chest pain, shortness of breath, severe headache, or loss of consciousness.

In the 24 months after introducing the handouts, the authors recorded 1,333 urologic procedures leading to 204 emergency department visits (15.3%), of which 99 (48.53%) were preventable, and 51 readmissions (3.83%). The mean time from the operating room to the emergency department was 12.6 days.

The most common reasons for the emergency department visits after the introduction of the handouts were pain and clogged, leaking, or dislodged Foley catheter, drain, or percutaneous nephrostomy tubes. Both of these accounted for 18%. Another 11% each were for infectious complications and hematuria.

The change in the rate of preventable emergency department visits was not statistically significant, said Dr. Sawkar, who worked on the research with Jeffrey Loh-Doyle, MD, and colleagues. “Even though our intervention didn’t work, we can try new things,” Dr. Sawkar said.

Since collecting these statistics, the medical center has launched a website with procedure-specific information, a comprehensive urology phone tree to reduce the number of calls fielded by front-line staff, and opportunities for patients to contact residents on call after the clinic is closed. The authors have not yet determined the results of these new efforts.

Articles

Study: Many post-op ER visits preventable

Convective radiofrequency water vapor thermal therapy (Rezum) can modestly improve symptoms of BPH, according to Daniel Mollengarden, MD.

The new technology offers a minimally invasive alternative treatment that usually satisfies patients, said Dr. Mollengarden, MD, a fourth-year resident at University of Texas Southwestern Medical Center, working with Claus G. Roehrborn, MD, and colleagues.

Dr. Mollengarden presented a "real-life" retrospective review of a case series of 129 patients treated with convective radiofrequency water vapor using the Rezum device at the AUA annual meeting in San Francisco.

The procedure takes only 2 to 5 minutes to perform, said Dr. Mollengarden.

"This is a fairly novel technology. The big advantages are that it can be easily performed in the office, it can be used on any shape of prostate, and it preserves ejaculatory function,” he told 

All the patients were treated by the same surgeon using local anesthesia. Twenty-five were part of the Rezum II trial. Median lobes were treated if present. The patients had a mean age of 67.4 years, prostate volume of 52.6 cc (ranging up to 86 cc), PSA of 2.45 ng/mL, maximum flow rate (Qmax) of 10.5 mL/sec, and post-void residual test of 106 mL.

Mean International Prostate Symptom Score (IPSS) was 18.3. Thirteen patients (10.4%) had an IPSS less than 8, 56 (44.8%) had an IPSS between 8 and 19, and 56 had an IPSS greater than 19. Ninety-seven patients (75.2%) were taking medication for BPH.

Mean IPSS dropped to 11.2 at 15-45 days after the procedure, then 8.5 from 46-90 days, and 6.9 at 90-180 days. Qmax increased to 13.2 mL/sec, then 16.3 mL/sec, and then 16.8 mL/sec over these time periods.

Ninety percent of the patients were no longer using BPH medication at the last follow-up. The average prostate shrunk by 17.9% using transrectal ultrasonography and 14.0% by PSA.

The improvements were independent of starting IPSS, treatment of a median lobe, and prostate size.

Dr. Mollengarden and his colleagues administered a scripted patient questionnaire over the phone to gauge the patients' satisfaction. Fifty-nine percent of the patients said they were very satisfied with the procedure, 18% satisfied, 10% neutral, 7% dissatisfied, and 6% very dissatisfied. Forty-eight percent were very satisfied with the results, 25% were satisfied, 13% neutral, 4% dissatisfied, and 10% very dissatisfied. Eighty-six percent of patients would recommend the procedure to a friend.

The most common adverse event was a urinary tract infection, with 17.1% affected. A UTI was defined as 50,000 colony-forming units with symptoms. That was followed by urinary retention, which affected 14.0, and was transient in all cases. Cystoscopic evaluation of lower urinary tract symptoms was required in 7.8%. Events requiring anesthesia occurred in six patients.

TURP duration linked with complication rate

The authors are now starting to study glands larger than 80 grams.

"Currently, larger glands require more aggressive therapy. If we had a transurethral therapy that was effective for a large gland, that would be a nice part of the repertoire,” Dr. Mollengarden said.

Dr. Roehrborn was a paid investigator in a RezÅ«m randomized clinical trial. Dr. Roehrborn is an investigator and meeting participant/lecturer for PROCEPT BioRobotics; a consultant/adviser, investigator, and meeting participant/lecturer for NeoTract, Inc.; and an investigator and consultant/adviser for NxThera, Inc. He has several other disclosures related to pharmaceutical companies.

Water vapor thermal Tx modestly improves BPH symptoms

-Transurethral resection of the prostate (TURP) is safest when performed in under 60 minutes and should not be performed for longer than 120 minutes, researchers say.

The study supports the conventional wisdom about the procedure, said Christopher B. Riedinger, MD, a fourth-year resident who works with attending surgeon Norm Smith, MD, at the University of Chicago.

“We mostly confirmed what we thought,” Dr. Riedinger said. He presented the research at the AUA annual meeting in San Francisco.

Around the world, 1.2 million men undergo surgery for BPH or lower urinary tract symptoms per year, with TURP the most common procedure, said Dr. Riedinger.

Complication rates are improving with advances in instrumentation and perioperative care, yet a “dogma” persists that the procedure should be done in under an hour, he said. To see whether this tradition is supported by actual complication rates, Dr. Riedinger and his colleagues analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2006 to 2016 for patients undergoing TURP, as defined by CPT codes 52601 and 52630.

They excluded patients whose cases were classified as an emergency, who were diagnosed with preoperative sepsis, or who underwent a concurrent procedure. That left them with 31,813 TURPs.

They separated these patients into five groups based on operative time: 0 to 30 minutes (8,163 patients), 30.1 to 60 minutes (12,932 patients), 60.1 to 90 minutes (6,790 patients), 90.1 to 120 minutes (2,517 patients), and greater than 120 minutes (1,411 patients).

They found an overall complication rate of 9.00%, which increased with longer surgical duration 

The odds ratio of having any complication was 1.1 in the 30.1- to 60-minute group, 1.3 in the 60.1- to 90-minute group, 1.6 in the 90.1- to 120-minute group, and 2.1 in the >120-minute group.

Patients whose American Society of Anesthesiologists classification was at least 4 were more likely to have fast procedures.

General anesthesia was used in 62.4% of the procedures in the 0- to 30-minute group. Another 33.8% had spinal anesthesia and 3.8% had some other type of anesthesia. The proportion getting general anesthesia increased with the duration of the procedure, reaching 79.8% in the group whose TURP took more than 2 hours.

<.001) also increased with the operative time in a linear fashion.

The risk of deep vein thrombus or pulmonary embolism was highest in the group whose surgery took longer than 2 hours, and was lowest in the groups whose surgery took 30.1 to 90 minutes 

The risk of sepsis or septic shock remained relatively constant, below 1%, for all the duration groups except the group whose TURP took longer than 2 hours, whose risk was 1.8%. Controlling for age, comorbidities, American Society of Anesthesiologists class, race, year of surgery, and type of anesthesia administered did not affect this association.

The risk of transfusion remained significantly increased across all groups, while each of the above complications remained significantly increased for surgeries lasting longer than 120 minutes.

Procedure safest when performed in <60 minutes.

Tissue-eliminating procedures outperform tissue-necrosing procedures for reducing the need for medication in patients with benign prostatic enlargement (BPE), researchers say.

"There's less advantage to heating the tissue," Bradley Gill, MD, chief urology resident at Cleveland Clinic, told 

Dr. Gill, working with Daniel Shoskes, MD, and colleagues, presented the findings at the AUA annual meeting in San Francisco.

Medical treatments for BPE don't always work, may be expensive, and cause adverse effects, he said. But few studies have examined the effectiveness of surgery in reducing the need for medication.

Dr. Gill and his colleagues hypothesized that tissue-eliminating procedures would beat tissue-necrosing procedures at allowing patients to avoid urologic medication.

To see if they were right, they analyzed records of BPE procedures from 2001 to 2016 at Cleveland Clinic. The researchers included 2,549 patients who underwent photovaporization, 2,304 who underwent transurethral resection, 165 who underwent either microwave therapy or needle ablation, and 132 who underwent simple prostatectomy.

They defined a medication as discontinued if it was used before surgery but not from 3 months afterward. A medication was defined as resumed if the patient started using it again after discontinuing it. And a medication was defined as initiated if it was used from 3 months after but not before surgery.

Grouped by procedure, the patients' demographics were similar, but there were some statistically significant differences. The most significant was that only 37% of those undergoing microwave or needle ablation (which the authors lumped together in analyses) were using 5-alpha-reductase inhibitors at baseline, compared to 44.4% of those undergoing photovaporization, 51.8% of those undergoing transurethral resection, and 53.8% of those undergoing simple prostatectomy 

There were differences in baseline alpha-blocker use as well; this class of drugs was used by 68.2% of the simple prostatectomy group, 79.6% of the transurethral resection group, 79.7% of the photovaporization group, and 83.6% of the microwave/needle ablation group.

In addition, only 15.8% of the simple prostatectomy group had coronary artery disease, compared to 18.8% of the microwave/needle ablation group, 25.7% of the transurethral resection group, and 25.9% of the photovaporization group.

There were less significant differences in baseline anticholinergic drug use, history of smoking, age at surgery, and baseline beta-3 agonist use. Differences in alcohol abuse and type 2 diabetes were not statistically significant.

Simple prostatectomy patients stop 5-ARIs

Three months after the procedures, the authors found that 98.6% of simple prostatectomy patients were able to discontinue use of 5-alpha-reductase inhibitors, compared to 91.5% of photovaporization patients, 89.4% of transurethral resection patients, and 80.3% of microwave or needle ablation patients. The differences were statistically significant 

<.01). Differences in initiation of these drugs were not significant.

Similarly, 95.6% of the simple prostatectomy patients, 90.2% of the photovaporization patients, 89.1% of the transurethral resection patients, and 78.3% of the microwave or needle ablation patients stopped using alpha-blockers 

<.01). Differences in initiation were not statistically significant.

Anticholinergics were the only class of drugs for which there was a statistically significant difference in initiation: 8.33% of simple prostatectomy patients started taking them after surgery, compared to 7.89% of photovaporization patients, 5.74% of transurethral resection patients, and 4.76% of microwave or needle ablation patients 

=.041). The differences in discontinuation were not statistically significant for this class of drugs.

Urethral lift efficacious in men with large median lobe

The differences in initiation and discontinuation was not significant for beta-3 agonists.

After 12 months, similar patterns persisted, with statistical significance increasing and some patients beginning to initiate new medications.

The class of drugs initiated the most was alpha-blockers; 51.6% of patients undergoing microwave or needle ablation started on these drugs. No patients started taking these drugs after undergoing simple prostatectomy. But 22.1% of photovaporization patients and 12.8% of transurethral resection patients initiated treatment with these drugs.

Overall, the microwave and needle ablation patients were the most likely to initiate medication after surgery, followed by the photovaporization patients, then the transurethral resection patients. The simple prostatectomy patients were the least likely to start drugs after surgery.

Each of the tissue-eliminating procedures has some advantages, said Dr. Gill.

"We're in a good spot. We have a lot of different options,” he said.

Tissue-eliminating procedures outperform tissue-necrosing procedures for reducing the need for medication in patients with benign prostatic enlargement, researchers say.

Author | Laird Harrison

Articles

Study: Many post-op ER visits preventable

Water vapor thermal Tx modestly improves BPH symptoms

TURP duration linked with complication rate

Which BPH procedures best reduce need for meds?