Introduction

We assessed surgeon knowledge of commonly used instruments and disposable items and described attitudes toward incorporating cost data into daily practice.

Methods

An electronic, e-mail based survey was distributed to faculty and trainees in the University of California San Francisco (UCSF) Department of Urology. The 26-question survey assessed opinions regarding general operating room supply cost information and specific costs of 10 supplies used for laparoscopic nephrectomy. A response was considered accurate when it fell within 50% of the actual cost.

Results

The response rate was 71% among faculty (13) and 90% among trainees (17). Overall 55% of faculty and 82% of trainees considered their knowledge of costs "fair" or "poor." The overall accuracy of cost estimation for 10 commonly used supply items was 27% (SD ± 45%), with no significant difference between trainees and faculty (p=0.70). Accuracy was not associated with self-reported cost knowledge (p=0.25) or number of laparoscopic nephrectomies performed (p=0.47). Of the faculty 33% and of the trainees 41% reported that having more knowledge of costs would motivate them to decrease their operating room supply costs, and 42% of faculty raised the idea of an incentive program. Overall 75% of study participants believe that there is "too little" or "not enough" emphasis placed on cost awareness.

Conclusions

Trainees and faculty generally have poor knowledge of operating room supply costs. In our academic setting we noted an interest among faculty and residents to make cost data more accessible. These data would provide an opportunity for surgeons to act as cost arbiters in the operating room.

A 29-year-old man presenting with a retroperitoneal mass was found to have a testis lesion consistent with mixed germ cell tumor and the RPLND specimen showed teratoma with an area of central nervous system-type primitive neuroectodermal tumor (PNET) not present in the testis. Whether such primitive tumor components represent a de novo tumor component or represent progression from existing neuroepithelial teratomatous elements is unclear. Given the high likelihood of residual tumor and possibility of malignant transformation, post-chemotherapy RPLND remains vital in treating patients with testis cancer. PNET is chemo-resistant and lesions should be resected, without clear evidence for adjuvant chemotherapy.

Introduction

Rising health care costs are leading to efforts to minimize costs while maintaining high quality care. Practice variation in the operating room that is not dictated by patient necessity or clinical guidelines presents an opportunity for cost containment. We identified variation in surgical supply costs among urological surgeons performing laparoscopic nephrectomy and evaluated whether this variation was associated with patient outcomes.

Methods

A total of 211 consecutive laparoscopic nephrectomies performed at an academic center between September 1, 2012 and December 31, 2015 were identified and surgical supply costs for each case were determined from the institutional negotiated rate. Patient and surgical factors relevant to case complexity, comorbidity and perioperative outcomes were obtained. Univariate and multivariable analysis of predictors of surgical supply costs and patient outcome as determined by length of stay was conducted.

Results

Median supply cost was $2,537, with individual medians ranging from $1,642 to $4,524, representing a significant variation among surgeons (p <0.01). On multivariable analysis, accounting for patient factors and case complexity, most surgeons remained significant predictors of surgical supply costs. Case supply cost was not a significant predictor of patient outcomes as measured by length of stay on univariate or multivariable analysis controlling for surgeon, patient factors and case complexity.

Conclusions

Significant variation in surgeons' surgical supply costs for laparoscopic nephrectomy exists and is driven by surgeons, and this does not correlate with length of stay. Targeting variation in surgical supply costs in this setting represents an opportunity for cost savings without adversely impacting patient outcomes.

Purpose

In many patients partial nephrectomy is the preferred alternative to radical nephrectomy for upper urinary tract cancers. We describe the use of laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation to expand the realm of minimally invasive, nephron sparing surgery to the most complex renal tumors.

Materials and methods

In our cohort undergoing renal surgery 2 patients had a solitary kidney with renal tumors not considered amenable to in situ partial nephrectomy. After transperitoneal laparoscopic nephrectomy ex vivo tumor excision and renorrhaphy were performed. The kidney was transplanted to the ipsilateral iliac vessels through the Gibson extraction incision.

Results

Indications for surgery were high grade urothelial carcinoma within a caliceal diverticulum and a central 5 cm renal cell carcinoma. Mean nephrectomy, cold ischemic and transplantation times were 4.5, 2 and 3.7 hours, respectively. No intraoperative or postoperative complications were noted. Hospitalization was 12 and 6 days, respectively. At 20 and 12 months of followup each patient remained off dialysis without evidence of recurrence.

Conclusions

Despite experience with conventional nephron sparing surgery some cases may be more appropriate for ex vivo excision and reconstruction. In these situations the minimally invasive approach provides a kidney suitable for renal autotransplantation, while simultaneously decreasing patient morbidity. This novel approach to complex renal tumors is feasible when one applies principles of laparoscopic donor nephrectomy and possesses experience with renal transplantation.

Background

Testicular sex cord stromal tumors (SCSTs) are managed similarly to germ cell tumors (GCTs); however, few studies have directly compared outcomes between these tumor types. Using the National Cancer Database (NCDB), we sought to compare overall and stage-specific all-cause mortality (ACM) between SCSTs versus GCTs.

Methods

NCDB was queried for patients diagnosed with SCSTs and GCTs between 2004 and 2013. Descriptive statistics were used to compare sociodemographic and clinical characteristics between groups. Univariable and multivariable Cox proportional hazards regression analyses were used to assess associations with ACM.

Results

We identified 42,192 patients diagnosed with testicular cancer between 2004 and 2013, with 280 having SCSTs and 41,912 patients having GCTs. Median age for SCSTs and GCTs was 45 (interquartile range [IQR] 34-59) and 34 (IQR 27-43), respectively (p < 0.001). Median follow-up was 39 and 52 months, respectively. Overall, patients with SCSTs had greater risk of ACM compared to those with GCTs (HR 1.69, 95% CI 1.14-2.50). Private insurance, greater education, and fewer comorbidities were associated with reduced risk of ACM (p < 0.05 for all). Among those with stage I disease, tumor type was not associated with ACM on multivariable analysis. Among those with stage II/III disease, patients with SCSTs had increased risk of ACM compared to patients with GCTs (HR 3.29, 95% CI 1.89-5.72).

Conclusions

Patients with advanced SCSTs had worse survival outcomes compared to those with advanced GCTs. These data suggest a need for further investigation to ascertain effective management recommendations for SCSTs.

Purpose

Re-examine association of fluoxetine and paroxetine with risk of testicular cancer noted in drug screening, with 4 years more follow-up and expanded study of these and other antidepressant drugs.

Methods

In the Kaiser Permanente Medical Care Program in Northern California, 906 men with testicular cancer diagnosed August 1996-December 2010 were compared with 38,253 matched controls with race/ethnicity recorded regarding receipt of antidepressant drugs at least 2 years before diagnosis or control index date. Analyses emphasized duration of use and histological subgroups.

Results

With control for race/ethnicity and use of other antidepressant drugs, odds ratios (OR) and 95 % confidence intervals (CI) for associations with testicular cancer were as follows: fluoxetine 1.22 (0.88-1.71), paroxetine 1.19 (0.78-1.83), and 1.21 (0.92-1.58) for all serotonin reuptake inhibitors. There was no statistically significant association with risk of all testicular cancers or their histological subtypes for any individual drug or for tricyclics or all antidepressants combined except for citalopram with all testicular cancers 2.55 (1.43-4.52) and those of mixed histology 4.36 (1.50-12.68) and nefazodone with embryonal cancers 9.79 (1.85-51.81). These could readily be chance findings in the context of the many analyses that were performed. Duration of use was not associated with risk of the drugs and drug groups with sufficient numbers of exposed cases for analysis.

Conclusions

We found little evidence to support a testicular carcinogenic effect of fluoxetine, paroxetine, or other antidepressant drugs, but a weakly positive association is not ruled out. The signals in prior screening may have been due to chance and/or uncontrolled confounding.