Benjamin I. Chung

All Publications

• Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015. JAMA Jeong, I. G., Khandwala, Y. S., Kim, J. H., Han, D. H., Li, S., Wang, Y., Chang, S. L., Chung, B. I. 2017; 318 (16): 1561?68

  Abstract

  Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown.To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy.This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes.Robotic-assisted vs laparoscopic radical nephrectomy.The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost.Among 23?753 patients included in the study (mean age, 61.4 years; men, 13?792 [58.1%]), 18?573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19?530 vs $16?851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498).Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

  View details for PubMedID 29067427

• Extracting Patient-Centered Outcomes from Clinical Notes in Electronic Health Records: Assessment of Urinary Incontinence After Radical Prostatectomy. EGEMS (Washington, DC) Gori, D., Banerjee, I., Chung, B. I., Ferrari, M., Rucci, P., Blayney, D. W., Brooks, J. D., Hernandez-Boussard, T. 2019; 7 (1): 43

  Abstract

  Objective: To assess documentation of urinary incontinence (UI) in prostatectomy patients using unstructured clinical notes from Electronic Health Records (EHRs).Methods: We developed a weakly-supervised natural language processing tool to extract assessments, as recorded in unstructured text notes, of UI before and after radical prostatectomy in a single academic practice across multiple clinicians. Validation was carried out using a subset of patients who completed EPIC-26 surveys before and after surgery. The prevalence of UI as assessed by EHR and EPIC-26 was compared using repeated-measures ANOVA. The agreement of reported UI between EHR and EPIC-26 was evaluated using Cohen's Kappa coefficient.Results: A total of 4870 patients and 716 surveys were included. Preoperative prevalence of UI was 12.7 percent. Postoperative prevalence was 71.8 percent at 3 months, 50.2 percent at 6 months and 34.4 and 41.8 at 12 and 24 months, respectively. Similar rates were recorded by physicians in the EHR, particularly for early follow-up. For all time points, the agreement between EPIC-26 and the EHR was moderate (all p < 0.001) and ranged from 86.7 percent agreement at baseline (Kappa = 0.48) to 76.4 percent agreement at 24 months postoperative (Kappa = 0.047).Conclusions: We have developed a tool to assess documentation of UI after prostatectomy using EHR clinical notes. Our results suggest such a tool can facilitate unbiased measurement of important PCOs using real-word data, which are routinely recorded in EHR unstructured clinician notes. Integrating PCO information into clinical decision support can help guide shared treatment decisions and promote patient-valued care.

  View details for DOI 10.5334/egems.297

  View details for PubMedID 31497615

• Examining the relationship between complications and perioperative mortality following radical cystectomy: a population-based analysis BJU INTERNATIONAL Mossanen, M., Krasnow, R. E., Zlatev, D. V., Tan, W., Preston, M. A., Trinh, Q., Kibel, A. S., Sonpavde, G., Schrag, D., Chung, B. I., Chang, S. L. 2019; 124 (1): 40?46

  View details for DOI 10.1111/bju.14636

  View details for Web of Science ID 000471830900010

• Letter to the Editor RE: Srougi et al., Septic Shock Following Surgical Decompression of Obstructing Ureteral Stones: A Prospective Analysis (From: Srougi V, Moscardi PR, Marchini GS, et al. J Endourol 2017;32:446-450; DOI: 10.1089/end.2017.0896) JOURNAL OF ENDOUROLOGY Yoo, K., Min, G., Lee, H., Chung, B. 2019

  View details for DOI 10.1089/end.2019.0128

  View details for Web of Science ID 000475257300001

• Hospital Charges for Urologic Surgery Episodes of Care Are Rising Despite Declining Costs MAYO CLINIC PROCEEDINGS McClintock, T. R., Wang, Y., Shah, M. A., Mossanen, M., Chung, B. I., Chang, S. L. 2019; 94 (6): 995?1002

  View details for DOI 10.1016/j.mayocp.2019.02.008

  View details for Web of Science ID 000470060400015

• Re: Timu J. Murtola, Hemo Syvala, Teemu Tolonen, et al. Atorvastatin Versus Placebo for Prostate Cancer Before Radical Prostatectomy-A Randomized, Double-blind, Placebo-controlled Clinical Trial. Eur Urol 2018;74:697-701 EUROPEAN UROLOGY Kim, J., Chung, B. I. 2019; 75 (6): E164?E165

  View details for DOI 10.1016/j.eururo.2019.01.042

  View details for Web of Science ID 000467916500006

• Change of Trends in the Treatment Modality for Pediatric Nephrolithiasis: Retrospective Analysis of a US-Based Insurance Claims Database JOURNAL OF ENDOUROLOGY Park, H., Kim, J., Min, G., Choi, W., Li, S., Chung, K., Chung, B. I. 2019: 1?5

  View details for DOI 10.1089/end.2019.0154

  View details for Web of Science ID 000469289300001

• Point Shear Wave Elastography Using Machine Learning to Differentiate Renal Cell Carcinoma and Angiomyolipoma. Ultrasound in medicine & biology Sagreiya, H., Akhbardeh, A., Li, D., Sigrist, R., Chung, B. I., Sonn, G. A., Tian, L., Rubin, D. L., Willmann, J. K. 2019

  Abstract

  The question of whether ultrasound point shear wave elastography can differentiate renal cell carcinoma (RCC) from angiomyolipoma (AML) is controversial. This study prospectively enrolled 51 patients with 52 renal tumors (42 RCCs, 10 AMLs). We obtained 10 measurements of shear wave velocity (SWV) in the renal tumor, cortex and medulla. Median SWV was first used to classify RCC versus AML. Next, the prediction accuracy of 4 machine learning algorithms-logistic regression, naive Bayes, quadratic discriminant analysis and support vector machines (SVMs)-was evaluated, using statistical inputs from the tumor, cortex and combined statistical inputs from tumor, cortex and medulla. After leave-one-out cross validation, models were evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Tumor median SWV performed poorly (AUC?=?0.62; p?=?0.23). Except logistic regression, all machine learning algorithms reached statistical significance using combined statistical inputs (AUC?=?0.78-0.98; p < 7.1?*?10-3). SVMs demonstrated 94% accuracy (AUC?=?0.98; p?=?3.13?*?10-6) and clearly outperformed median SWV in differentiating RCC from AML (p?=?2.8?*?10-4).

  View details for DOI 10.1016/j.ultrasmedbio.2019.04.009

  View details for PubMedID 31133445

• Bisphosphonate use and risk of renal cell carcinoma: A population-based case-control study BASIC & CLINICAL PHARMACOLOGY & TOXICOLOGY Chung, B. I., Hellfritzsch, M., Ulrichsen, S. P., Sorensen, H. T., Ehrenstein, V. 2019; 124 (5): 642?46

  View details for DOI 10.1111/bcpt.13180

  View details for Web of Science ID 000465187300015

• Changing Trends in the Treatment of Nephrolithiasis in the Real World JOURNAL OF ENDOUROLOGY Chung, K., Kim, J., Min, G., Park, H., Li, S., Del Giudice, F., Han, D., Chung, B. I. 2019; 33 (3): 248?53

  View details for DOI 10.1089/end.2018.0667

  View details for Web of Science ID 000462452100011

• How Have Hospital Pricing Practices for Surgical Episodes of Care Responded to Affordable CareAct-Related Medicaid Expansion? Urology McClintock, T. R., Wang, Y., Shah, M. A., Chung, B. I., Chang, S. L. 2019; 125: 79?85

  Abstract

  OBJECTIVE: To determine how Medicaid expansion under the Affordable Care Act of 2010 (ACA) has affected hospital pricing practices for surgical episodes of care.METHODS: Given that safety net hospitals would be more vulnerable to decreasing reimbursement due to an increase in proportion of Medicaid patients, we utilized the Premier Healthcare Database to compare institutional charge-to-cost ratio (CCR) in safety net hospitals vs nonsafety net hospitals for 8 index urologic surgery procedures during the period from 2012 to 2015. The effect of Medicaid expansion on CCR was assessed through difference-in-differences analysis.RESULTS: CCR among safety net hospitals increased from 4.06 to 4.30 following ACA-related Medicaid expansion. This did not significantly differ from the change among nonsafety net hospitals, which was from 4.00 to 4.38 (P?=?.086). The census division with the highest degree of Medicaid expansion experienced a smaller increase in CCR among safety net hospitals relative to nonsafety net (P < .0001). CCR increased by a greater degree in safety net hospitals compared to nonsafety net in the census division where Medicaid expansion was the least prevalent (P < .0001).CONCLUSION: Safety net hospitals have not preferentially increased CCR in response to ACA-related Medicaid expansion. Census divisions where safety net hospitals did increase CCR more than their nonsafety net counterparts do not correspond to those where Medicaid expansion was most prevalent. This could indicate that, despite being more vulnerable to an increased proportion of more poorly reimbursing Medicaid patients, safety net hospitals have not reacted by increasing charges to private payers.

  View details for PubMedID 30803723

• Postoperative vacuum therapy following AMS LGX 700 inflatable penile prosthesis placement: penile dimension outcomes and overall satisfaction. International journal of impotence research Antonini, G., De Berardinis, E., Busetto, G. M., Del Giudice, F., Chung, B. I., Conti, S. L., Ferro, M., Musi, G., Fragas, R., De Cobelli, O., Sperduti, I., Gross, M. S., Perito, P. E. 2019

  Abstract

  Penile shortening after inflatable penile prosthesis for erectile dysfunction is a common postoperative patient complaint and can reduce overall satisfaction with the procedure. In this prospective study we report our results regarding penile dimensions and patient satisfaction outcomes after 1 year of follow-up from AMSLGX700 penile prosthesis implant with 6 months of vacuum erectile device therapy. Seventy-four selected patients with medically refractory erectile dysfunction underwent AMS LGX 700 IPP placement. Postoperatively, patients were assigned vacuum device therapy for 5min twice daily. Follow-up continued for 1 year after surgery. Dimensional and functional results were assessed. Baseline median preoperative stretched penile length and girth were 14cm (range 10-17) and 9cm (range 7-12), respectively. At the end of the study penile median dimensional outcomes were 17cm (range 13-23) for length and 11cm (range 10-13) for girth while a median number of 24 pumps (range 18-29) to fully inflate the device was seen. Baseline median International Index of Erectile Function (IIEF-5) score was 9 (range 5-11), at 6 months 20 (range 18-26) and at 1 year was 25 (range 20-27) (p<0.0001). Median Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score at the end of the follow-up was 74 (range 66-78). Our postoperative rehabilitation program is feasible and should be recommended after prothesis surgery in order to increase overall satisfaction with the procedure. Penile postoperative dimensional outcomes were statistically significant improved and complications were negligible.

  View details for PubMedID 30745567

• Re: Timu J. Murtola, Hemo Syvala, Teemu Tolonen, et al. Atorvastatin Versus Placebo for Prostate Cancer Before Radical Prostatectomy-A Randomized, Double-blind, Placebo-controlled Clinical Trial. Eur Urol 2018;74:697-701. European urology Kim, J. H., Chung, B. I. 2019

  View details for PubMedID 30738708

• Changing trends in the treatment of nephrolithiasis in the real world. Journal of endourology Chung, K. J., Kim, J. H., Min, G. E., Park, H. K., Li, S., Del Giudice, F., Han, D. H., Chung, B. I. 2019

  Abstract

  INTRODUCTION: Changes in the surgical treatment of nephrolithiasis, owing to recent technical advances and innovations, have made treatments more effective and less invasive. In this retrospective observational cohort study, we identified the changing trends in the treatment of nephrolithiasis.METHODS: We included patients with newly diagnosed nephrolithiasis who received any treatment in the United States, including extracorporeal shock wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and open surgery, from January 2007 to December 2014. Demographic factors, such as age, sex, region, surgical treatment type, and cost data, were analyzed.RESULTS: The median age of the patients at treatment was 52 years, and the ratio of men and women was similar. There were definite changes in the trends of all treatment modalities (p<0.01). Both the number and percentage tended to increase for RIRS, whereas for SWL, the number increased but the percentage showed a steady decrease. In PCNL, both number and percentage increased to a minor degree. The overall cost of nephrolithiasis treatments during the study period nearly doubled (from $30,998,726 to $57,310,956). The number of treatments and average cost per treatment increased annually for each treatment modality. RIRS was the least expensive; the other procedures in the decreasing order of their mean costs were as follows: SWL, PCNL, and open surgery.CONCLUSIONS: There was a gradual but constant change in treatment trends of nephrolithiasis, with an increasing trend for RIRS and a decreasing trend for SWL. Although PCNL has relatively invasive characteristics, it is still in steady demand.

  View details for PubMedID 30628473

• Risk of Depression after 5 Alpha Reductase Inhibitor Medication: Meta-Analysis. The world journal of men's health Kim, J. H., Shim, S. R., Khandwala, Y., Del Giudice, F., Sorensen, S., Chung, B. I. 2019

  Abstract

  Although five-alpha reductase inhibitor (5-ARI) is one of standard treatment for benign prostatic hyperplasia (BPH) or alopecia, potential complications after 5-ARI have been issues recently. This study aimed to investigate the risk of depression after taking 5-ARI and to quantify the risk using meta-analysis.A total of 209,940 patients including 207,798 in 5-ARI treatment groups and 110,118 in control groups from five studies were included for final analysis. Inclusion criteria for finial analysis incudes clinical outcomes regarding depression risk in BPH or alopecia patients. Overall hazard ratio (HR) and odds ratio (OR) for depression were analyzed. Moderator analysis and sensitivity analysis were performed to determine whether HR or OR could be affected by any variables, including number of patients, age, study type, and control type.The pooled overall HRs for the 5-ARI medication was 1.23 (95% confidence interval [CI], 0.99-1.54) in a random effects model. The pooled overall ORs for the 5-ARI medication was 1.19 (95% CI, 0.95-1.49) in random effects model. The sub-group analysis showed that non-cohort studies had higher values of HR and OR than cohort studies. Moderator analysis using meta-regression showed that there were no variables that affect the significant difference in HR and OR outcomes. However, in sensitivity analysis, HR was significantly increased by age (p=0.040).Overall risk of depression after 5-ARI was significantly not high, however its clinical importance needs validation by further studies. These quantitative results could provide useful information for both clinicians and patients.

  View details for DOI 10.5534/wjmh.190046

  View details for PubMedID 31190484

• Change of trends in the treatment modality for pediatric nephrolithiasis: Retrospective analysis of a US-based insurance claims database. Journal of endourology Park, H. K., Kim, J. H., Min, G. E., Choi, W. S., Li, S., Chung, K. J., Chung, B. I. 2019

  Abstract

  The objective of this study was to show the prevalence and investigate treatment trends of pediatric nephrolithiasis based on a large population of US insurance individual's data.This research involved a retrospective observational cohort study. Administrative claims data were extracted from the IBM® MarketScan Research Database. We included all newly diagnosed patients with nephrolithiasis, aged less than 18 years old at the time of diagnosis from January 1, 2007 to December 31, 2014. The patient cohort with nephrolithiasis was selected using the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) code for nephrolithiasis. Each treatment method was searched by Current Procedural Terminology (CPT) code.A total of 28,014 patients were diagnosed with nephrolithiasis in our cohort. Of nephrolithiasis patients, 701 (2.5%) patients were treated by surgical methods. The mean age of patients at the time of treatment was 13 years old. Shockwave lithotripsy (SWL) was the most used treatment modality during the period. SWL was performed in 66% of patients. The case number of SWL did not tend to change according to year, while Retrograde intrarenal surgery (RIRS) tended to increase from 15% to 31%. Percutaneous nephrolithotripsy (PCNL) decreased from 13% to fewer than 10 cases. The number of open surgeries was very small and did not show any tendency.During the study period, SWL is stable. RIRS has become more popular in treating renal stones while PCNL has decreased. These results suggest that the RIRS has become more popular than PCNL in treating large renal stones.

  View details for PubMedID 31016995

• Re: Srougi, et al., Septic Shock Following Surgical Decompression of Obstructing Ureteral Stones: A Prospective Analysis. Journal of endourology Yoo, K. H., Min, G. E., Lee, H. L., Chung, B. I. 2019

  Abstract

  N/A.

  View details for PubMedID 31094235

• Hospital Charges for Urologic Surgery Episodes of Care Are Rising Despite Declining Costs. Mayo Clinic proceedings McClintock, T. R., Wang, Y., Shah, M. A., Mossanen, M., Chung, B. I., Chang, S. L. 2019

  Abstract

  To investigate the temporal relationship of hospital charges relative to recorded costs for surgical episodes of care.This retrospective cohort study selected individuals who underwent any of 8 index urologic surgical procedures at 392 unique institutions from January 1, 2005, through December 31, 2015. For each surgical encounter, cost and charge data reported by hospitals were extracted and adjusted to 2016 US dollars. Trend analysis and multivariable logistic regression modeling were used to assess outcomes. The primary outcome was trend in median charge and cost. Secondary outcomes consisted of hospital characteristics associated with membership in the highest quartile of institutional charge-to-cost ratio.Cohort-level median cost per encounter trended down from $6824 in 2005 to $5586 in 2015 (P for trend<.001), and charges increased from $20,210 to $25,773 during the same period (P for trend<.001). Hospitals in the highest quartile of institutional charge-to-cost ratio were more likely to be safety net, nonteaching, urban, lower surgical volume, smaller, and located outside the Midwest (P<.001 for each characteristic).The pricing trends shown herein could indicate some success in cost-containment for surgical episodes of care, although higher hospital charges may be increasingly used to bolster reimbursement from third-party payers and to compensate for escalating costs in other areas.

  View details for PubMedID 31079963

• Association of Prevalence of Benign Pathologic Findings After Partial Nephrectomy With Preoperative Imaging Patterns in the United States From 2007 to 2014. JAMA surgery Kim, J. H., Li, S., Khandwala, Y., Chung, K. J., Park, H. K., Chung, B. I. 2018

  Abstract

  Importance: Although the intent of nephron-sparing surgery is to eradicate malignant tumors found on preoperative imaging, benign masses often cannot be differentiated from malignant tumors. However, in the past there have been discrepancies in the reported percentages of benign masses removed by partial nephrectomy (PNx).Objective: To investigate the annual trend of prevalence of benign pathologic findings after PNx and to investigate what potential factors are associated with this prevalence.Design, Setting, and Participants: A total of 18?060 patients who underwent PNx between 2007 and 2014 were selected from Truven Health MarketScan Research Databases. We selected those patients who underwent PNx as an inpatient from 2007 and set the surgery date as the index date. Overall, a total of 21?445 patients with International Classification of Diseases, Ninth Revision, Clinical Modification code of 55.4 were identified from 2007 to 2015.Main Outcomes and Measures: The annual trend of benign pathologic findings was described as an actual number and as a proportion. Univariate and multiple analyses were performed to investigate factors predictive of a benign final pathologic diagnosis, including type of preoperative imaging modality or performance of a renal mass biopsy.Results: Among the 18?060 patients, mean (SD) age was 57 (12) years, and there were 10637 (58.9%) men and 7423 (41.1%) women. The overall prevalence of benign pathologic findings was 30.9% and the annual trends demonstrated a prevalence of over 30% for nearly every year of the study period. On univariate analysis, the performance of magnetic resonance imaging (MRI) and renal mass biopsy was associated with benign pathologic findings (P=.02 and P<.001, respectively). On multivariable analysis, female sex (odds ratio [OR], 0.62; 95% CI, 0.58-0.66; P<.001), older age (>65 years) (OR, 0.99; 95% CI, 0.99-0.99; P<.001), and computed tomography (CT) only preoperative imaging (OR, 1.16; 95% CI, 1.05-1.28; P=.004) were associated with benign pathologic findings after PNx.Conclusions and Relevance: We found that the overall prevalence of benign pathologic findings after PNx was higher than the literature suggests, with consistent year-over-year rates exceeding 30%. Female sex, older age (>65 years), and CT only preoperative imaging were predictive of a benign tumor. Further elucidation concerning covariates associated with a benign diagnosis should be the focus of future investigations to identify a cohort of patients who could potentially avoid unnecessary surgical intervention.

  View details for PubMedID 30516801

• Costs variations for percutaneous nephrolithotomy in the US from 2003-2015: A contemporary analysis of an all-payer discharge database CUAJ-CANADIAN UROLOGICAL ASSOCIATION JOURNAL Leow, J. J., Valiquette, A., Chung, B. I., Chang, S. L., Quoc-Dien Trinh, Korets, R., Bhojani, N. 2018; 12 (12): 407?14

  Abstract

  We sought to evaluate population-based costs variations and predictors of outlier costs for percutaneous nephrolithotomy (PCNL) in the U.S.Using the Premier Healthcare Database, we identified all patients diagnosed with kidney/ureter calculus who underwent PCNL from 2003-2015. We evaluated 90-day direct hospital costs, defining high- and low-cost surgery as those >90th and <10th percentile, respectively. We constructed a multilevel, hierarchical regression model and calculated the pseudo-R2 of each variable, which translates to the percentage variability contributed by that variable on 90-day direct hospital costs.A total of 114 581 patients underwent PCNL during the 12-year study period. Mean cost in the low-cost group was $5787 (95% confidence interval [CI] 5716-5856) vs. $38 590(95% CI 37 357-39 923) in the high-cost group. Cost variations were substantially impacted by patient (63.7%) and surgical (18.5%) characteristics and less so by hospital characteristics (3.9%). Significant predictors of high costs included more comorbidities (?2 vs. 0: odds ratio [OR] 1.81; p=0.01) and hospital region (Northeast vs. Midwest: OR 2.04; p=0.03). Predictors of low cost were hospital bed size of 300-499 beds (OR 1.35; p<0.01) and urban hospitals (OR 2.77; p=0.01). Factors less likely to be associated with low-cost PCNL were more comorbidities (Charlson Comorbidity Index [CCI] ?2: OR 0.69; p<0.0001), larger hospitals (OR 0.61; p=0.01), and teaching hospitals (OR 0.33; p<0.0001).Our contemporary analysis demonstrates that patient and surgical characteristics had a significant effect on costs associated with PCNL. Poor comorbidity status contributed to high costs, highlighting the importance of patient selection.

  View details for PubMedID 29940133

  View details for PubMedCentralID PMC6261720

• Examining the relationship between complications and perioperative mortality following radical cystectomy: A population-based analysis. BJU international Mossanen, M., Krasnow, R. E., Zlatev, D. V., Tan, W. S., Preston, M. A., Trinh, Q., Kibel, A. S., Sonpavde, G., Schrag, D., Chung, B. I., Chang, S. L. 2018

  Abstract

  OBJECTIVE: To examine the incidence of perioperative complications after RC and assess their impact on 90-day postoperative mortality during the index stay and upon readmission.MATERIAL AND METHODS: A total of 57,553 bladder cancer patients (unweighted cohort: 9,137 patients) treated with RC at 360 hospitals in the United States between 2005 to 2013 within the Premier Healthcare Database were used for analysis. Ninety-day perioperative mortality was the primary outcomes. Multivariable regression was used to predict the probability of mortality; models were adjusted for patient, hospital, and surgical characteristics.RESULTS: An increase in the number of complications resulted in an increasing predicted probability of mortality with a precipitous increase if patients had ?4 complications compared to one complication during hospitalization following RC (index stay) (1.0% to 9.7%, p<0.001) and during readmission (2.0% to 13.1%, p<0.001). A readmission complication nearly doubled the predicted probability of postoperative mortality as compared to an initial complication (3.9% vs. 7.4%, p <0.001). During the initial hospitalization cardiac (OR=3.1, 95% CI 1.9-5.1), pulmonary (OR=4.8, 95% CI 2.8-8.4), and renal (OR=3.6, 95% CI 2-6.7) related complications had the most significant impact on the odds of mortality across categories examined.CONCLUSIONS: The number and nature of complications have a distinct impact on mortality after RC. As complications increase, there is an associated increase in perioperative mortality. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30499636

• Bisphosphonate use and risk of renal cell carcinoma: a population-based case-control study. Basic & clinical pharmacology & toxicology Chung, B. I., Hellfritzsch, M., Ulrichsen, S. P., Sorensen, H. T., Ehrenstein, V. 2018

  Abstract

  The purpose of this study was to evaluate the association between the use of bisphosphonates and the risk of developing renal cell carcinoma (RCC). We conducted a case-control study in Denmark, using data linked from population-based health and administrative registries. We identified all cases of RCC from 1996 to 2013 and sampled population controls in a 10:1 ratio from the underlying population free of RCC, while matching on sex, birth year and calendar time. Bisphosphonate use before RCC diagnosis, excluding the year leading up to the diagnosis, was measured using outpatient prescription dispensations. We used conditional logistic regression to compute crude and adjusted odds ratios (ORs) comparing ever vs. never bisphosphonate use in doses indicated for treatment of osteoporosis, overall and stratified by sex, with the OR estimating the incidence rate ratio. We also examined the effects by cumulative dose and specific agent. There were 2748 RCC cases and 27,480 controls. The adjusted ORs for ever vs. never bisphosphonate use were 1.07 (95% confidence interval: 0.94-1.22) overall; 1.15 (1.00-1.32) for women; and 0.78 (0.54-1.12) for men. Smoking could not be directly controlled for in the analysis. We found a weak association between use of oral bisphosphonates and risk of renal cell carcinoma in females. The observed association could be due to confounding by cigarette smoking, and future studies are required to assess this association further. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30472809

• Crowd Sourced Assessment of Ureteroscopy with Laser Lithotripsy video feed does not correlate with Trainee Experience. Journal of endourology Conti, S. L., Brubaker, W., Chung, B. I., Sofer, M., Hsi, R. S., Shinghal, R., Elliott, C. S., Caruso, T., Leppert, J. T. 2018

  Abstract

  OBJECTIVES: We sought to validate the use of crowd sourced surgical video evaluation in the evaluation of flexible ureteroscopic laser lithotripsy videos using a modified global assessment scale previously validated for ureteroscopic skills.METHODS: We collected video feeds from 30 intra-renal ureteroscopic laser lithotripsy cases where residents post graduate year(PGY) 2 through 6 handled the ureteroscope. The video feeds were annotated to represent the overall performance and to contain the parts of the procedure being scored. The videos were submitted to a commercially available surgical video evaluation platform. We used a validated ureteroscopic laser lithotripsy global assessment tool that was modified to account for the fact that this scoring system looked at the video feed only. Videos were evaluated by crowd workers recruited using Amazon's Mechanical Turk as well as 5 Endourology trained experts. Mean scores were calculated and intraclass correlation coefficients(ICCs) were computed for the expert domain and total scores. The ICCs were estimated using a linear mixed-effects model. Spearman rank correlation coefficients were calculated as a measure of the strength of the relationships between the crowd mean and the expert average scores.RESULTS: 30 videos were reviewed 2,488 times by 487 crowd workers and five expert endourologists. ICCs between expert raters were all below accepted levels of correlation(0.30) with the overall score having an ICC of .000. Overall the crowd scores did not correlate with expert scores except for the stone retrieval domain (0.60 p = 0.015). Crowd sourced scores had a negative correlation with PGY level(-0.44 p=0.019).CONCLUSIONS: Given the poor agreement between experts and poor correlation between expert and crowd scores when evaluating video feeds of ureteroscopic laser lithotripsy, assessment of skills using intraoperative video feeds may not be reliable. This is further supported by the inverse correlation between crowd scores and PGY level.

  View details for PubMedID 30450963

• Contemporary trends in the utilisation of radical prostatectomy BJU INTERNATIONAL McClintock, T. R., Wang, Y., Cole, A. P., Chung, B. I., Kibel, A. S., Chang, S. L., Quoc-Dien Trinh 2018; 122 (5): 726?28

  View details for PubMedID 29797448

• Undertreatment of High-Risk Localized Prostate Cancer in the California Latino Population. Journal of the National Comprehensive Cancer Network : JNCCN Lichtensztajn, D. Y., Leppert, J. T., Brooks, J. D., Shah, S. A., Sieh, W., Chung, B. I., Gomez, S. L., Cheng, I. 2018; 16 (11): 1353?60

  Abstract

  Background: The NCCN Clinical Practice Guidelines in Oncology recommend definitive therapy for all men with high-risk localized prostate cancer (PCa) who have a life expectancy >5 years or who are symptomatic. However, the application of these guidelines may vary among ethnic groups. We compared receipt of guideline-concordant treatment between Latino and non-Latino white men in California. Methods: California Cancer Registry data were used to identify 2,421 Latino and 8,636 non-Latino white men diagnosed with high-risk localized PCa from 2010 through 2014. The association of clinical and sociodemographic factors with definitive treatment was examined using logistic regression, overall and by ethnicity. Results: Latinos were less likely than non-Latino whites to receive definitive treatment before (odds ratio [OR], 0.79; 95% CI, 0.71-0.88) and after adjusting for age and tumor characteristics (OR, 0.84; 95% CI, 0.75-0.95). Additional adjustment for sociodemographic factors eliminated the disparity. However, the association with treatment differed by ethnicity for several factors. Latino men with no health insurance were considerably less likely to receive definitive treatment relative to insured Latino men (OR, 0.34; 95% CI, 0.23-0.49), an association that was more pronounced than among non-Latino whites (OR, 0.63; 95% CI, 0.47-0.83). Intermediate-versus high-grade disease was associated with lower odds of definitive treatment in Latinos (OR, 0.75; 95% CI, 0.59-0.97) but not non-Latino whites. Younger age and care at NCI-designated Cancer Centers were significantly associated with receipt of definitive treatment in non-Latino whites but not in Latinos. Conclusions: California Latino men diagnosed with localized high-risk PCa are at increased risk for undertreatment. The observed treatment disparity is largely explained by sociodemographic factors, suggesting it may be ameliorated through targeted outreach, such as that aimed at younger and underinsured Latino men.

  View details for PubMedID 30442735

• Trends in penile prosthesis implantation and analysis of predictive factors for removal. World journal of urology Li, K., Brandes, E. R., Chang, S. L., Leow, J. J., Chung, B. I., Wang, Y., Eswara, J. R. 2018

  Abstract

  PURPOSE: This study aims to analyze patient demographics, hospital characteristics, and clinical risk factors which predict penile prosthesis removal. We also examine costs of penile prosthesis removal and trends in inflatable versus non-inflatable penile prostheses implantation in the USA from 2003 to 2015.METHODS: Cross-sectional analysis from Premier Perspective Database was completed using data from 2003 to 2015. We compared the relative proportion of inflatable versus non-inflatable penile prostheses implanted. We separated the prosthesis removal group based on indication for removal-Group 1 (infection), Group 2 (mechanical complication), and Group 3 (all explants). All groups were compared to a control group of patients with penile implants who were never subsequently explanted. Multivariate analysis was performed to analyze patient and hospital factors which predicted removal. Cost comparison was performed between the explant groups.RESULTS: There were 5085 penile prostheses implanted with a stable relative proportion of inflatable versus non-inflatable prosthesis over the 13-year study period. There were 3317 explantations. Patient factors associated with prosthesis removal were non-black race, Charlson Comorbidity Index, diabetes, and HIV status. Hospital factors associated with removal included non-teaching status, hospital region, year of removal, and annual surgeon volume. Median hospitalization costs of all explantations were $10,878. Explantations due to infection cost $11,252 versus $8602 for mechanical complications.CONCLUSIONS: This large population-based study demonstrates a stable trend in inflatable versus non-inflatable prosthesis implantation. We also identify patient and hospital factors that predict penile prosthesis removal which has clinical utility for patient risk stratification and counseling.

  View details for DOI 10.1007/s00345-018-2491-4

  View details for PubMedID 30251052

• Inflatable Penile Prosthesis Placement, Scratch Technique and Postoperative Vacuum Therapy as a Combined Approach to Definitive Treatment of Peyronie's Disease JOURNAL OF UROLOGY Antonini, G., De Berardinis, E., Del Giudice, F., Busetto, G., Lauretti, S., Fragas, R., Chung, B. I., Conti, S. L., Giannarelli, D., Sperduti, I., Gross, M. S., Perito, P. E. 2018; 200 (3): 642?47

  Abstract

  Peyronie's disease is a devastating condition resulting in penile malformation, erectile dysfunction, pain and emotional distress. In this prospective, 2 institution study we evaluated a multimodal surgical and mechanical combined approach to the definitive treatment of Peyronie's disease and concomitant erectile dysfunction.A total of 145 select patients underwent endocavernous disruption of Peyronie's disease plaques via the scratch technique, followed by inflatable penile prosthesis insertion. Postoperatively patients were assigned to vacuum device therapy for 3 minutes twice daily to continue penile curvature correction. Followup continued for 1 year after surgery. Anatomical and functional results were assessed.Patients with plaques in the proximal third, middle third and subcoronal areas of the penis had a mean ± SD postoperative residual curvature of 21.5 ± 4.5, 17.3 ± 4.8 and 14.1 ± 3.1 degrees, respectively. After 24 weeks of vacuum therapy the mean penile curvature deviation decreased to 8.7 ± 2.5, 9.1 ± 2.9 and 7.7 ± 0.9 degrees, respectively. The mean IIEF-5 (International Index of Erectile Function) score was 9.8 ± 2.3 preoperatively, 18.9 ± 3.1 at 6 months (p <0.001) and 24.1 ± 3.6 at 1 year (p <0.001). The mean EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) score at the end of followup was 64.6 ± 11.8. Operative and postoperative complications were minimal.Our novel combination of intraoperative and postoperative therapies in the treatment of patients with Peyronie's disease and an inflatable penile prosthesis was safe and efficacious with excellent functional outcomes. Penile curvature corrections were statistically significant and complications were negligible.

  View details for PubMedID 29678456

• Charge-to-Cost Ratio Varies among Common Urological Surgery Procedures UROLOGY PRACTICE McClintock, T. R., Mossanen, M., Shah, M. A., Wang, Y., Chung, B. I., Chang, S. L. 2018; 5 (5): 349?50

  View details for DOI 10.1016/j.urpr.2018.03.002

  View details for Web of Science ID 000444509300011

• Comparative Effectiveness of Transurethral Resection Techniques in the Inpatient Setting for Benign Prostatic Hyperplasia UROLOGY PRACTICE Meyer, C. P., Friedlander, D. F., Wang, Y., Hollis, M., Lipsitz, S. R., Eswara, J., Kathrins, M., Bhojani, N., Chughtai, B., Sun, M., Chung, B. I., Chang, S. L., Quoc-Dien Trinh 2018; 5 (5): 377?82

  View details for DOI 10.1016/j.urpr.2017.08.006

  View details for Web of Science ID 000444509300020

• National trends of preoperative imaging modalities before partial nephrectomy for renal masses in the U.S. from 2007-2015. Canadian Urological Association journal = Journal de l'Association des urologues du Canada Kim, J. H., Li, S., Khandwala, Y., Giudice, F. D., Chung, K. J., Park, H. K., Chung, B. I. 2018

  Abstract

  INTRODUCTION: Although the performance of partial nephrectomies (PNx) for renal masses has increased rapidly over the years, only a few studies investigated the frequency and patterns of preoperative imaging modalities. The aim of this study was to investigate the frequency and patterns in preoperative imaging modalities before PNx.METHODS: A total of 21 445 patients who underwent PNx between 2007 and 2015 were selected from a national representative population in the MarketScan database and included in this study. The annual incidence and proportion of PNx, as well as the use of each preoperative imaging modality were analyzed.RESULTS: Both annual crude number and frequency rate of PNx decreased or became static since 2012. Computed tomography (CT) shows the greatest proportion of the crude number and percentage; despite a slight decrease in percentage, it is still >80%. Among the combinations, CT alone and CT combined with ultrasonography showed the highest performance rate during the complete observational period. The proportion of all other combinations, which include other complex combinations except CT alone, CT plus ultrasonography, CT plus magnetic resonance imaging (MRI), and CT plus MRI plus ultrasonography, was 13.95% in 2007, but increased to 19.04% in 2014.CONCLUSIONS: CT still plays a major role in preoperative imaging for renal masses, whereby CT alone and CT combined with ultrasonography account for a major proportion of the preoperative imaging patterns. The use of other imaging combinations, as well as renal biopsies, shows an increasing trend. Additional studies are needed to investigate whether this trend in preoperative imaging is related to the frequency rate of PNx.

  View details for PubMedID 30169151

• Has the robot caught up? National trends in utilization, perioperative outcomes, and cost for open, laparoscopic, and robotic pediatric pyeloplasty in the United States from 2003 to 2015 JOURNAL OF PEDIATRIC UROLOGY Varda, B. K., Wang, Y., Chung, B., Lee, R. S., Kurtz, M. P., Nelson, C. P., Chang, S. L. 2018; 14 (4): 336.e1?336.e8

  Abstract

  Since 2010, there have been few new data comparing perioperative outcomes and cost between open (OP) and robotic pyeloplasty (RP). In a post-adoption era, the value of RP may be converging with that of OP.To 1) characterize national trends in pyeloplasty utilization through 2015, 2) compare adjusted outcomes and median costs between OP and RP, and 3) determine the primary cost drivers for each procedure.We performed a retrospective cohort study using the Premier database, which provides a nationally representative sample of U.S. hospitalizations between 2003 and 2015. ICD9 codes and itemized billing were used to abstract our cohorts. Trends in utilization and cost were calculated and then stratified by age. We used propensity scores to weight our cohorts and then applied regression models to measure differences in the probability of prolonged operative time (pOT), prolonged length of stay (pLOS), complications, and cost.During the study period 11,899 pyeloplasties were performed: 75% open, 10% laparoscopic, and 15% robotic. The total number of pyeloplasty cases decreased by 7% annually; OP decreased by a rate of 10% while RP grew by 29% annually. In 2015, RP accounted for 40% of cases. The largest growth in RPs was among children and adolescents. The average annual rate of change in cost for RP and OP was near stagnant: -0.5% for open and -0.2% for robotic. The summary table provides results from our regression analyses. RP conferred an increased likelihood of pOT, but a reduced likelihood of pLOS. The odds of complications were equivalent. RP was associated with a significantly higher median cost, but the absolute difference per case was $1060.Despite advantages in room and board costs for RP, we found that the cost of equipment and OR time continue to make it more expensive. Although the absolute difference may be nominal, we likely underestimate the true cost because we did not capture amortization, hidden or down-stream costs. In addition, we did not measure patient satisfaction and pain control, which may provide the non-monetary data needed for comparative value.Despite an overall decline in pyeloplasties, RP utilization continues to increase. There has been little change in cost over time, and RP remains more expensive because of equipment and OR costs. The robotic approach confers a reduced likelihood of pLOS, but an increased likelihood of pOT. Complication rates are low and similar in each cohort.

  View details for DOI 10.1016/j.jpurol.2017.12.010

  View details for Web of Science ID 000449186800023

  View details for PubMedID 29530407

  View details for PubMedCentralID PMC6105565

• The Research Implications of PSA Registry Errors: Data from the Veterans Health Administration. The Journal of urology Guo, D. P., Thomas, I., Mittakanti, H. R., Shelton, J. B., Makarov, D. V., Skolarus, T. A., Cooperberg, M. R., Sonn, G. A., Chung, B. I., Brooks, J. D., Leppert, J. T. 2018

  Abstract

  INTRODUCTION: We sought to characterize the effects of PSA registry errors on clinical research by comparing cohorts based on cancer registry PSA values with those based directly on results in the electronic health record.METHODS: We defined example cohorts of men with prostate cancer using data from the Veterans Health Administration: those with a PSA values less than 4.0 ng/mL, 4.0 to 10.0 ng/mL, 10.0 to 20.0 ng/mL, and 20.0 to 98.0 ng/mL. We compared the composition of each cohort and overall patient survival when using PSA values from either the VA Central Cancer Registry versus the gold standard electronic health record laboratory file results.RESULTS: There was limited agreement between cohorts defined using either the cancer registry PSA values versus the laboratory file of the electronic health record. The least agreement was seen in patients with PSA values < 4.0 ng/mL (58%) and greatest among patients with PSA values between 4.0 and 10.0 ng/mL (89%). In each cohort, patients assigned to a cohort based only on the cancer registry PSA value had significantly different overall survival when compared with patients assigned based on both the registry and laboratory file PSA values.CONCLUSIONS: Cohorts based exclusively on cancer registry PSA values may have high rates of misclassification that can introduce concerning differences in key characteristics and result in measurable differences in clinical outcomes.

  View details for PubMedID 29630980

• Re: The Risks and Benefits of Cavernous Neurovascular Bundle Sparing during Radical Prostatectomy: A Systematic Review and Meta-Analysis JOURNAL OF UROLOGY Kim, J., Chung, B. I. 2018; 199 (4): 1070?71

  View details for PubMedID 29305837

• Robotic-Assisted vs Laparoscopic Radical Nephrectomy Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Jeong, I., Khandwala, Y. S., Chung, B. I. 2018; 319 (11): 1166

  View details for PubMedID 29558551

• Exploring Patterns of Mitomycin C Use in Community Practice Urology UROLOGY PRACTICE Mossanen, M., Ingham, M. D., Leow, J. J., Tinay, I., Wang, Y., Krasnow, R. E., Preston, M. A., Bellmunt, J., Chung, B. I., Rosenberg, J. E., Chang, S. L. 2018; 5 (1): 7?13

  View details for DOI 10.1016/j.urpr.2017.02.002

  View details for Web of Science ID 000437130800002

• Efficacy and safety of 5 alpha-reductase inhibitor monotherapy in patients with benign prostatic hyperplasia: A meta-analysis. PloS one Kim, J. H., Baek, M. J., Sun, H. Y., Lee, B., Li, S., Khandwala, Y., Del Giudice, F., Chung, B. I. 2018; 13 (10): e0203479

  Abstract

  BACKGROUND: Although combination therapy with 5 alpha-reductase inhibitor (5ARI) and alpha-blocker is one of the standard interventions in symptomatic benign prostatic hyperplasia (BPH), 5ARI monotherapy is seldom the focus of attention. Adverse events associated with 5ARI include depression and suicidal attempts in addition to persistent erectile dysfunction. The aim of this study is to update our knowledge of clinical efficacy and incidence of adverse events associated with 5ARI treatment in symptomatic BPH.METHODS AND FINDINGS: A meta-analysis of randomized controlled clinical trials (RCTs) from 1966 until March, 2017 was performed using database from PubMed, Cochrane Collaboration and Embase. A total of 23395 patients were included in this study and the inclusion criteria were: RCTs with 5ARI and placebo in symptomatic BPH patients. Parameters included prostate specific antigen (PSA), prostate volume (PV), International Prostate Symptom Score (IPPS), post-void residual urine (PVR), voiding symptoms of IPSS (voiding IPSS), maximum urinary flow rate (Qmax), and adverse events (AEs). A meta-analysis with meta-regression was performed for each effect size and adverse events, sensitivity analysis, cumulative analysis along with the analysis of ratio of means (ROM) in the placebo group. A total of 42 studies were included in this study for review, and a total of 37 studies were included in the meta-analysis, including a total of 23395 patients (treatment group: 11392, placebo group: 12003). The effect size of all variables except PVR showed a significant improvement following 5ARI treatment compared with placebo. However, the effect size of differences showed declining trend in PV, IPSS and Qmax according to recent years of publication. In ROM analysis, PV showed no significant increase in the placebo group, with a ROM of 1.00 (95% CI, 0.88, 1.14). The 5ARI treatment resulted in a significantly higher incidence of decreased libido (OR = 1.7; 95% CI, 1.36, 2.13), ejaculatory disorder (OR = 2.94; 95% CI, 2.15, 4.03), gynecomastia (OR = 2.32; 95% CI, 1.41, 3.83), and impotence (OR = 1.74; 95% CI, 1.32, 2.29). Our study has the following limitations: included studies were heterogeneous and direct comparison of efficacy between alpha blocker and 5ARI was not performed. Adverse events including depression or suicidal attempt could not be analyzed in this meta-analysis setting.CONCLUSIONS: Although there was a significant clinical benefit of 5ARI monotherapy compared with placebo, the effective size was small. Moreover, the risk of adverse events including sexually related complications were high. Additional head-to-head studies are needed to re-evaluate the clinical efficacy of 5ARI compared with alpha-adrenergic receptor blockers.

  View details for PubMedID 30281615

• Performance of multiparametric MRI appears better when measured in patients who undergo radical prostatectomy. Research and reports in urology Wang, N. N., Fan, R. E., Leppert, J. T., Ghanouni, P., Kunder, C. A., Brooks, J. D., Chung, B. I., Sonn, G. A. 2018; 10: 233?35

  Abstract

  Utilization of pre-biopsy multiparametric MRI (mpMRI) is increasing. To optimize the usefulness of mpMRI, physicians should accurately quote patients a numerical risk of cancer based on their MRI. The Prostate Imaging Reporting and Data System (PIRADS) standardizes interpretation of mpMRI; however, reported rates of clinically significant prostate cancer (CSC) stratified by PIRADS score vary widely. While some publications use radical prostatectomy (RP) specimens as gold standard, others use biopsy. We hypothesized that much of the variation in CSC stems from differences in cancer prevalence in RP cohorts (100% prevalence) vs biopsy cohorts. To quantify the impact of this selection bias on cancer yield according to PIRADS score, we analyzed data from 614 men with 854 lesions who underwent targeted biopsy from 2014 to 2018. Of these, 125 men underwent RP. We compared the PIRADS detection rates of CSC (Gleason ?7) on targeted biopsy between the biopsy-only and RP cohorts. For all PIRADS scores, CSC yield was much greater in patients who underwent RP. For example, CSC was found in 30% of PIRADS 3 lesions in men who underwent RP vs 7.6% in men who underwent biopsy. Our results show that mpMRI performance appears to be better in men who undergo RP compared with those who only receive biopsy. Physicians should understand the effect of this selection bias and its magnitude when discussing mpMRI results with patients considering biopsy, and take great caution in quoting CSC yields from publications using RP as gold standard.

  View details for PubMedID 30538970

• Performance of multiparametric MRI appears better when measured in patients who undergo radical prostatectomy RESEARCH AND REPORTS IN UROLOGY Wang, N. N., Fan, R. E., Leppert, J. T., Ghanouni, P., Kunder, C. A., Brooks, J. D., Chung, B., Sonn, G. A. 2018; 10: 233?35

  View details for DOI 10.2147/RRU.S178064

  View details for Web of Science ID 000451113100001

• Re: Sungmin Woo, Chong Hyun Suh, Sang Youn Kim, Jeong Yeon Cho, Seung Hyup Kim. Diagnostic Performance of Magnetic Resonance Imaging for the Detection of Bone Metastasis in Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2017.03.042 EUROPEAN UROLOGY Kim, J., Lee, B., Chung, B. I. 2017; 72 (6): E164?E165

  View details for PubMedID 28689900

• Comparative rates of upstaging and upgrading in Caucasian and Korean prostate cancer patients eligible for active surveillance PLOS ONE Jeon, H., Yoo, J., Jeong, B., Seo, S., Jeon, S., Choi, H., Lee, H., Ferrari, M., Brooks, J. D., Chung, B. I. 2017; 12 (11)

  View details for DOI 10.1371/journal.pone.0186026

  View details for Web of Science ID 000415121200003

• Prophylactic Antibiotics and Postoperative Complications of Radical Cystectomy: A Population Based Analysis in the United States JOURNAL OF UROLOGY Krasnow, R. E., Mossanen, M., Koo, S., Kubiak, D. W., Preston, M. A., Chung, B. I., Kibel, A. S., Chang, S. L. 2017; 198 (2): 297?304

  Abstract

  Infectious, wound and soft tissue events contribute to the morbidity of radical cystectomy but the association between these events and antibiotic prophylaxis is not clear. We sought to describe the contemporary use of antibiotic prophylaxis in radical cystectomy and adherence to published guidelines, and identify regimens with the lowest rates of infectious events.We identified the intraoperative antibiotic prophylaxis regimen in a population based, retrospective cohort study of patients who underwent radical cystectomy across the United States between 2003 and 2013. Multivariable regression was done to evaluate 90-day infectious events and length of stay.In a weighted cohort of 52,349 patients there were 579 unique antibiotic prophylaxis regimens. Cefazolin was the most commonly used antibiotic (16% of cases). The overall infectious event rate was 25%. Only 15% of patients received antibiotic prophylaxis based on guidelines. Of guideline based antibiotic prophylaxis ampicillin/sulbactam had the lowest odds of infectious events (OR 0.34, p <0.001). In 2.7% of patients a penicillin based regimen with a ?-lactamase inhibitor was associated with a prominent reduction in the odds of infectious events (OR 0.45, p = 0.001) and decreased length of stay (-1.3 days, p = 0.016).Antibiotic prophylaxis practices are highly heterogeneous in radical cystectomy. There is a lack of adherence to published guidelines. We observed decreased infectious event rates and shorter length of stay with regimens that included broad coverage of common skin, genitourinary and gastrointestinal flora. The ideal antibiotic regimen requires further study to optimize perioperative outcomes.

  View details for PubMedID 28267603

• Re: Jim C. Hu, David M. Nanus, Art Sedrakyan. Increase in Prostate Cancer Metastases at Radical Prostatectomy in the United States. Eur Urol 2017; 71: 147-9 EUROPEAN UROLOGY Kim, J., Khandwala, Y. S., Chung, B. I. 2017; 72 (2): E41?E42

  View details for PubMedID 28365161

• Bisphosphonate Use and Risk of Renal Cell Carcinoma: A Population Based Case-Control Study Hellfritzsch, M., Chung, B. I., Ulrichsen, S. P., Sorensen, H. T., Ehrenstein, V. WILEY. 2017: 548?49

  View details for Web of Science ID 000437104300506

• Distal Corporal Anchoring Stitch: A Technique to Address Distal Corporal Crossovers and Impending Lateral Extrusions of a Penile Prosthesis. journal of sexual medicine Antonini, G., Busetto, G. M., Del Giudice, F., Ferro, M., Chung, B. I., Conti, S. L., Suarez Sarmiento, A., Pacchiarotti, A., De Berardinis, E., Perito, P. E. 2017; 14 (6): 767-773

  Abstract

  Unidentified distal crossovers, delayed distal crossovers, and impending lateral extrusion are complications of penile prosthesis implant insertion but are not as common as prosthesis infection or mechanical failure.To evaluate results of a surgical technique, the distal corporal anchoring stitch, that addresses fixation of the penile prosthesis in patients with these complications.A lateral sub-coronal incision is used on the side where the crossover or laterally extruding cylinder should be positioned. Dissection is carried through the Buck fascia, followed by a transverse incision of the tunica albuginea, where the distal aspect of the affected cylinder is delivered. A 4-0 PDS suture is threaded through the distal cylinder ring of the implant. A new, properly positioned intracorporal channel is created and the suture is passed through the distal end of the channel. Once the suture is through the glans and the cylinder is in the correct position, a small cruciate incision is made on the glans at the location of the anchor stitch. The suture is tied with the knot buried in the glans tissue.Fifty-three patients underwent treatment of their distal penile implant crossover with a distal corporoplasty using this method and their anatomic and functional outcomes and overall satisfaction were evaluated.This technique ensured that the cylinder remained in the newly created, appropriately positioned channel. No patients developed infections, wound-healing defect, glandular hypoesthesia, anesthesia, or altered sensation or pain in the glans related to the suture and only two reported recurrence of a lateral herniation that did not require further treatment.Distal fixation of the penile prosthesis is a useful surgical adjunct to treating patients with prosthetic lateral extrusions or crossovers that can be applied in almost all cases.Considering these rare complications, our experience is based on a relatively large number of patients and showed a low incidence of complications and a high satisfaction rate. The main limitation of this study is the retrospective nature of the data and the series included patients from two high-volume surgeons that might not be generalizable to all practices.The distal corporal anchoring stitch is safe and effective in securing distal fixation of the extruding inflatable penile prosthesis. Antonini G, Busetto GM, Del Giudice F, et al. Distal Corporal Anchoring Stitch: A Technique to Address Distal Corporal Crossovers and Impending Lateral Extrusions of a Penile Prosthesis. J Sex Med 2017;14:767-773.

  View details for DOI 10.1016/j.jsxm.2017.04.669

  View details for PubMedID 28583338

• Contemporary Trends In Utilization And Perioperative Outcomes Of Percutaneous Nephrolithotomy In The United States From 2003 To 2014. Journal of endourology Leow, J. J., Meyer, C. P., Wang, Y., Chang, S., Chung, B. I., Trinh, Q., Korets, R., Bhojani, N. 2017

  Abstract

  To investigate contemporary trends and perioperative outcomes of PCNL using a population-based cohort.Using the Premier Healthcare Database, we identified 225,321 patients diagnosed with kidney/ureter calculus who underwent PCNL at 447 different hospitals across the United States from 2003 to 2014. Outcomes included 90-day postoperative complications (as classified by the Clavien-Dindo system), prolonged hospital length of stay, operating room time, blood transfusions and direct hospital costs. Temporal trends were quantified by estimated annual percent change (EAPC) using least squares linear regression analysis. Multivariable logistic regression was performed to identify predictors of outcomes.PCNL utilization rates initially increased from 6.7% (2003) to 8.9% (2008) (EAPC +5.60%, p=0.02), before plateauing at 9.0% (2008-2011), then declining to 7.2% in 2014 (EAPC -4.37%, p=0.02). Overall (Clavien?1) and major complication (Clavien?3) rates rose significantly (EAPC: +12.2% and +16.4% respectively, both p<0.001). Overall/major complication and blood transfusion rates were 23.1%/4.8% and 3.3% respectively. Median operating room time and 90-day costs were 221 mins (IQR 4) and $12734 (IQR $9419), respectively. Significant predictors of overall complications include higher Charlson comorbidity index (CCI) (CCI?2: OR 2.08, p<0.001) and more recent year of surgery (2007-2010: OR 3.20, 2011-2014: OR 4.39, both p<0.001). Higher surgeon volume was significantly associated with decreased overall (OR 0.992, p<0.001) and major (OR 0.991, p=0.01) complications.Our contemporary analysis shows a decrease in utilization of PCNL in recent years, along with an increase in complication rates. Numerous patient, hospital and surgical characteristics affect complication rates.

  View details for DOI 10.1089/end.2017.0225

  View details for PubMedID 28557565

• The Impact of Surgeon Volume on Perioperative Outcomes and Cost for Patients Receiving Robotic Partial Nephrectomy. Journal of endourology Khandwala, Y. S., Jeong, I. G., Kim, J. H., Han, D. H., Li, S., Wang, Y., Chang, S. L., Chung, B. I. 2017

  Abstract

  Little is known about the impact of surgeon volume on the success of the robot-assisted partial nephrectomy (RAPN). The objective of this study was to compare the perioperative outcomes and cost related to RAPN by annual surgeon volumes.Using the Premier Hospital Database, we retrospectively analyzed 39,773 patients who underwent RAPN between 2003 and 2015 in the United States. Surgeons for each index case were grouped into quintiles for each respective year. Outcomes were 90-day postoperative complications, operating room time (ORT), blood transfusion, length of stay, and direct hospital costs. Logistic regression and generalized linear models were used to identify factors predicting complications and cost.After accounting for patient and hospital demographics, high- and very high-volume surgeons had 40% and 42% decreased odds of having major complications (p?=?0.045 and p?=?0.027, respectively). Surgeons with higher volumes were associated with fewer odds of prolonged ORT (0.68 for low, 0.72 for intermediate, 0.56 for high, 0.44 for very high volume, all p?

  View details for DOI 10.1089/end.2017.0207

  View details for PubMedID 28537505

• Androgen Deprivation Therapy and Subsequent Dementia. JAMA oncology Kim, J. H., Chung, B. I. 2017

  View details for DOI 10.1001/jamaoncol.2017.0509

  View details for PubMedID 28472205

• The Decline of the Open Ureteral Reimplant in the United States: National Data From 2003 to 2013. Urology Kurtz, M. P., Leow, J. J., Varda, B. K., Logvinenko, T., McQuaid, J. W., Yu, R. N., Nelson, C. P., Chung, B. I., Chang, S. L. 2017; 100: 193-197

  Abstract

  To examine trends in the number of cases of primary vesicoureteral reflux managed by ureteral reimplantation nationally over the last decade. Substantial changes have occurred in management of vesicoureteral reflux (VUR) over time, but trends in use of ureteral reimplantation have yet to be investigated on a national scale with annualized data.Using the Premier Healthcare Database, we extracted hospital discharge data for pediatric patients (age???18 years) with a procedure code for ureteroneocystostomy (International Classification of Diseases, Ninth Revision, 56.74) between January 1, 2003 and December 31, 2013. We excluded patients with secondary VUR. The presence of a temporal trend in reimplantation was examined via regression using generalized estimating equations.In 4301 cases of primary VUR (23,602 weighted), there was a substantial decrease in the number of reimplantations performed, with an estimated decline in the rate of 0.239 cases per attending per year (P?=?.006). Average patient age declined 1.2 months in each year (P?

  View details for DOI 10.1016/j.urology.2016.07.024

  View details for PubMedID 27473557

• Contemporary Use of Partial Nephrectomy: Are Older Patients With Impaired Kidney Function Being Left Behind? UROLOGY Leppert, J. T., Mittakanti, H. R., Thomas, I., Lamberts, R. W., Sonn, G. A., Chung, B. I., Skinner, E. C., Wagner, T. H., Chertow, G. M., Brooks, J. D. 2017; 100: 65-71

  View details for DOI 10.1016/j.urology.2016.08.044

  View details for Web of Science ID 000397168900017

• The Prognostic Role of Circulating Tumor Cells (CTC) in High-risk Non-muscle-invasive Bladder Cancer. Clinical genitourinary cancer Busetto, G. M., Ferro, M., Del Giudice, F., Antonini, G., Chung, B. I., Sperduti, I., Giannarelli, D., Lucarelli, G., Borghesi, M., Musi, G., De Cobelli, O., De Berardinis, E. 2017

  Abstract

  The purpose of this study was to evaluate the impact of circulating tumor cells (CTCs) as a prognostic marker in patients with high-risk non-muscle-invasive bladder cancer (NMIBC) and assess the efficacy and reliability of 2 different CTC isolation methods.Globally, 155 patients with a pathologically confirmed diagnosis of high-risk NMIBC were included (pT1G3 with or without carcinoma in situ) and underwent transurethral resection of bladder tumor (TURB) after a blood withdrawal for CTC evaluation. A total of 101 patients (Group A) had their samples analyzed with the CellSearch automated system, and 54 (Group B) had their samples analyzed with the CELLection Dynabeads manual system.Patients were followed for 28 months, and during this interval, there were a total of 65 (41.9%) recurrences, 27 (17.4%) disease progressions, and 9 (5.8%) lymph node and/or bone metastasis. In our CTC analysis, there were 20 (19.8%) positive patients in Group A and 24 in Group B (44.4%). In our analysis, we found a strong correlation between CTC presence and time to first recurrence; in Group A, we observed an incidence of recurrence in 75% of CTC-positive patients and in Group B of 83% of CTC-positive patients. The time to progression was also strongly correlated with CTCs: 65% and 29%, respectively, of those patients who progressed in those with CTCs in Group A and B.The study demonstrates the potential role of CTCs as a prognostic marker for risk stratification in patients with NMIBC, to predict both recurrence and progression.

  View details for DOI 10.1016/j.clgc.2017.01.011

  View details for PubMedID 28188046

• Expected Next-Generation Drugs Under Development in Relation to Voiding Symptoms. International neurourology journal Chung, K. J., Chung, B. I. 2017; 21 (2): 97?101

  Abstract

  New drug development is a high-risk venture, but if successful, will bring great revenues to those willing to accept the risk. In the field of urology, in particular for lower urinary tract symptoms (LUTS), the recent successful landing of drugs (e.g., mirabegron, botulinum toxin A, and tadalafil) has resulted in increased interest in new drug development. Benign prostatic hyperplasia and overactive bladder syndrome, representative LUTS diseases, are attractive targets because of their prevalence and market size in the field of urology. Additionally, the awareness about new stream of research is very important not only because of the market size and economic factors, but also because to keep steady attention to these research for the researcher's. We have reviewed a selection of new drugs currently under development for the treatment of the two aforementioned diseases and hope to offer urologists an overview of the current situation and future directions in the field of urology.

  View details for PubMedID 28673067

  View details for PubMedCentralID PMC5497200

• Re: Suppressed Recurrent Bladder Cancer after Androgen Suppression with Androgen Deprivation Therapy or 5?-Reductase Inhibitor: M. Shiota, K. Kiyoshima, A. Yokomizo, A. Takeuchi, E. Kashiwagi, T. Dejima, R. Takahashi, J. Inokuchi, K. Tatsugami and M. Eto J Urol 2017;197:308-313. The Journal of urology Kim, J. H., Chung, B. I. 2017; 198 (1): 211?12

  View details for PubMedID 28365365

• Re: Maria Carmen Mir, Ithaar Derweesh, Francesco Porpiglia, Homayoun Zargar, Alexandre Mottrie, Riccardo Autorino. Partial Nephrectomy Versus Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-analysis of Comparative Studies. Eur Urol 2017;71:606-17. European urology Kim, J. H., Chung, B. I. 2017; 72 (5): e127?e128

  View details for PubMedID 28545840

• Re: Julien Dagenais, Matthew J. Maurice, Pascal Mouracade, Onder Kara, Ercan Malkoc, Jihad J. Kaouk. Excisional Precision Matters: Understanding the Influence of Excisional Volume Loss on Renal Function After Partial Nephrectomy. Eur Urol 2017;72:168-70. European urology Kim, J. H., Chung, B. I. 2017; 72 (5): e131?e132

  View details for PubMedID 28549807

• Comparative rates of upstaging and upgrading in Caucasian and Korean prostate cancer patients eligible for active surveillance. PloS one Jeon, H. G., Yoo, J. H., Jeong, B. C., Seo, S. I., Jeon, S. S., Choi, H. Y., Lee, H. M., Ferrari, M., Brooks, J. D., Chung, B. I. 2017; 12 (11): e0186026

  Abstract

  To investigate the impact of race on the risk of pathological upgrading and upstaging at radical prostatectomy (RP) in an Asian (Korean) and Western (Caucasian) cohort eligible for active surveillance (AS).We performed a retrospective cohort study of 854 patients eligible for AS who underwent RP in United States (n = 261) and Korea (n = 593) between 2006 and 2015. After adjusting for age, PSA level, and prostate volume, we utilized multivariate logistic regression analysis to assess the effect of race on upgrading or upstaging.There were significant differences between Caucasian and Korean patients in terms of age at surgery (60.2 yr. vs. 64.1 yr.), PSA density (0.115 ng/mL/mL vs. 0.165 ng/mL/mL) and mean number of positive cores (3.5 vs. 2.4), but not in preoperative PSA values (5.11 ng/mL vs. 5.05 ng/mL). The rate of upstaging from cT1 or cT2 to pT3 or higher was not significantly different between the two cohorts (8.8% vs. 11.0%, P = 0.341). However, there were higher rates of upgrading to high-grade cancer (Gleason 4+3 or higher) in Korean patients (9.1%) when compared to Caucasian counterparts (2.7%) (P = 0.003). Multivariate logistic regression analysis showed that age (OR 1.07, P < 0.001) and smaller prostate volume (OR 0.97, P < 0.001), but not race, were significantly associated with upstaging or upgrading.There were no differences in rates of upgrading or upstaging between Caucasian and Korean men eligible for active surveillance.

  View details for PubMedID 29136019

• Adoption of Robot-Assisted Partial Nephrectomies: A Population-Based Analysis of U.S. Surgeons from 2004 to 2013. Journal of endourology Cheung, H., Wang, Y., Chang, S. L., Khandwala, Y., Del Giudice, F., Chung, B. I. 2017; 31 (9): 886?92

  Abstract

  Urological surgeries have contributed to the increasing prevalence of minimally invasive robotic procedures. Although factors influencing the adoption of robot-assisted radical prostatectomy have previously been identified, the explanation for the rapid rise in robotic partial nephrectomies remains unknown. Using a retrospective population-based sample, we attempt to determine hospital and surgeon-specific factors influencing a surgeon's decision to utilize robotic assistance for partial nephrectomies.A nationally representative weighted sample of all men who underwent a partial nephrectomy in the United States between 2003 and 2014 was identified within the Premier Hospital Database. Hospital, surgeon, and patient characteristics for each operation were analyzed. Descriptive statistics and a multivariate regression model stratified according to the Law of Diffusion of Innovation were performed.A weighted sample of 14,890 nephrectomies was included in the study. Patient demographics were similar between the two groups. The adoption of robotic technology followed the Law of Diffusion of Innovation with the percentage of partial nephrectomies with robotic assistance increasing yearly, reaching 64.1% by 2013. Surgical volume was a significant factor driving the use of robotic assistance, with high volume surgeons (>5 partial nephrectomies/year) performing 23.2% more robotic partial nephrectomies per year than their low volume colleagues (

  View details for PubMedID 28699357

• The incidence of unsuccessful partial nephrectomy within the United States: A nationwide population-based analysis from 2003 to 2015. Urologic oncology Khandwala, Y. S., Jeong, I. G., Kim, J. H., Han, D. H., Li, S., Wang, Y., Chang, S. L., Chung, B. I. 2017

  Abstract

  Partial nephrectomy (PN) remains underutilized within the United States and few reports have attempted to explain this trend. The aim of this study is to evaluate the nationwide incidence of unsuccessful PN and factors that predict its occurrence.Using the Premier Healthcare Database, we retrospectively analyzed a weighted sample of 66,432 patients undergoing curative surgery for renal mass between 2003 and 2015. PN intent was denoted by presence of insurance claims for the administration of mannitol. Unsuccessful PN was defined as an event in which patients were administered mannitol but received radical nephrectomy. A multivariate logistic regression model was generated to identify factors predicting unsuccessful PN.Overall rates of unsuccessful PN declined from 33.5% to 14.5% since 2003. Conversion to radical nephrectomy occurred most frequently during laparoscopic (34.7%) and least frequently during robotic approach (13.6%). There was significant difference in the rate of unsuccessful PN between very high and very low volume surgeons (open: 39.4% vs. 13.3%, laparoscopic: 51.2% vs. 32.2%, and robot assisted: 27.1% vs. 9.4%, all P<0.001). After adjustment for patient- and hospital-related factors, surgical approach (laparoscopic vs. open, odds ratio = 1.74, 95% CI: 1.31-2.30, P<0.001) and annual surgeon volume (very high vs. very low, odds ratio = 0.27, 95% CI: 0.21-0.34 P<0.001) were associated with unsuccessful PN.Although the rate of unsuccessful PN appears to be declining, it still remains common for low volume surgeons and with the laparoscopic surgical approach. Further evaluation of its effect on health care outcomes is necessary.

  View details for PubMedID 28889920

• Discrepancies on the association between androgen deprivation therapy for prostate cancer and subsequent dementia: meta-analysis and meta-regression. Oncotarget Kim, J. H., Lee, B., Han, D. H., Chung, K. J., Jeong, I. G., Chung, B. I. 2017; 8 (42): 73087?97

  Abstract

  Limited literature exists on the association between androgen deprivation therapy (ADT) for prostate cancer (PCa) and subsequent dementia and the study conclusions are in conflicts with one another. We searched several cohort databases from 1960 to 2017 for observational or prospective studies that reported on an association between ADT for PCa and subsequent dementia. A meta-analysis was performed to cumulatively determine the association between ADT and dementia including Alzheimer's disease using an incidence rate ratio (IRR), crude hazard ratio (HR), and adjusted HR. Seven studies were eligible for the meta-analysis, with the inclusion of a total of 90, 543 prostate cancer patients. The pooled overall IRR, crude HR, and adjusted HR were 1.78 [95% confidence interval (CI): 1.51-2.10)], 1.80 (95% CI: 1.05-3.10), and 1.59 (95% CI: 1.16-2.18), respectively. A meta-regression analysis showed that the crude HR was affected by both follow -up duration and lag time in the univariate model (p = < 0.001). However, IRR and adjusted HR were not affected by these moderators. The overall outcomes of IRR, crude HR, and adjusted HR were found to be balanced in the sensitivity analysis. A positive association was demonstrated between ADT and the subsequent incidence of dementia in this meta-analysis. Methodological difference including follow-up duration and the time lag could be related with the discrepancies.

  View details for PubMedID 29069851

• Adrenalectomy for benign and malignant disease: utilization and outcomes by surgeon specialty and surgical approach from 2003-2013. The Canadian journal of urology Faiena, I., Tabakin, A., Leow, J., Patel, N., Modi, P. K., Salmasi, A. H., Chung, B. I., Chang, S. L., Singer, E. A. 2017; 24 (5): 8990?97

  Abstract

  Data on the utilization of open, laparoscopic and robotic adrenalectomy on a national level is limited.Data on patients who underwent open, laparoscopic, or robotic adrenalectomy for benign or malignant disease in the US from 2003-2013 were extracted using ICD-9 codes from the Premier Hospital Database. Surgeon specialty, patient demographics, hospital characteristics, and complications were compared. Data were analyzed using univariate and multivariable logistic regression analyses.A total of 8,831 adrenalectomies were performed for benign and malignant tumors. There was no significant difference in rate of adrenalectomy with regards to comorbidities, insurance status, or hospital characteristics. Non-urologists performed adrenalectomy more often for both benign (57% versus 43%; p = 0.011) and malignant disease (66% versus 34%; p = 0.011). Across all indications, non-urologists performed open surgery most often followed by laparoscopic and robotic approaches (56.3% versus 37.4% versus 6.4%, respectively), compared to urologists (48.8% versus 38.4% versus 12.9%, respectively). Overall, urologists were more likely to use laparoscopic or robotic approaches (p = 0.001). There was no difference in complication rates or operative times between surgical specialties or by surgeon/hospital case volume. On multivariable regression analysis, the best predictor of major complication was a Charlson Comorbidity Index (CCI) ? 2 (OR 3.9, 95%CI 2.1-7.1; p = < 0.001). Compared to open surgery, laparoscopy had significantly reduced odds of major complication (OR 0.6, 95%CI 0.3-0.9; p = 0.03). Patients undergoing robotic procedures had the shortest length of stay.In this retrospective study, adrenalectomy was more commonly performed by non-urologists via an open approach. Patients with CCI ? 2 were more likely to have postoperative complications while surgeon volume, hospital volume, and surgical approach did not influence complication rates.

  View details for PubMedID 28971785

• Re: Philipp Mandel, Felix Preisser, Markus Graefen, et al. High Chance of Late Recovery of Urinary and Erectile Function Beyond 12 Months After Radical Prostatectomy. Eur Urol 2017;71:848-50. European urology Kim, J. H., Lee, B., Chung, B. I. 2017

  View details for PubMedID 28709728

• Variations in the Costs of Radical Cystectomy for Bladder Cancer in the USA. European urology Leow, J. J., Cole, A. P., Seisen, T., Bellmunt, J., Mossanen, M., Menon, M., Preston, M. A., Choueiri, T. K., Kibel, A. S., Chung, B. I., Sun, M., Chang, S. L., Trinh, Q. D. 2017

  Abstract

  Radical cystectomy (RC) for muscle-invasive bladder cancer (BCa) has potential for serious complications, prolonged length of stay and readmissions-all of which may increase costs. Although variations in outcomes are well described, less is known about determinants driving variation in costs.To assess surgeon- and hospital-level variations in costs and predictors of high- and low-cost RC.Cohort study of 23 173 patients who underwent RC for BCa in 208 hospitals in the USA from 2003 to 2015 in the Premier Healthcare Database.Ninety-day direct hospital costs; multilevel hierarchal linear models were constructed to evaluate contributions of each variable to costs.Mean 90-d direct hospital costs per RC was $39 651 (standard deviation $34 427), of which index hospitalization accounted for 87.8% ($34 803) and postdischarge readmission(s) accounted for 12.2% ($4847). Postoperative complications contributed most to cost variations (84.5%), followed by patient (49.8%; eg, Charlson Comorbidity Index [CCI], 40.5%), surgical (33.2%; eg, year of surgery [25.0%]), and hospital characteristics (8.0%). Patients who suffered minor complications (odds ratio [OR] 2.63, 95% confidence interval [CI]: 2.03-3.40), nonfatal major complications (OR 12.7, 95% CI: 9.63-16.8), and mortality (OR 13.5, 95% CI: 9.35-19.4, all p<0.001) were significantly associated with high costs. As for low-cost surgery, sicker patients (CCI=2: OR 0.41, 95% CI: 0.29-0.59; CCI=1: OR 0.58, 95% CI: 0.46-0.75, both p<0.001), those who underwent continent diversion (vs incontinent diversion: OR 0.29, 95% CI: 0.16-0.53, p<0.001), and earlier period of surgery were inversely associated with low costs.This study provides insight into the determinants of costs for RC. Postoperative morbidity, patient comorbidities, and year of surgery contributed most to observed variations in costs, while other hospital- and surgical-related characteristics such as volume, use of robot assistance, and type of urinary diversion contribute less to outlier costs.Efforts to address high surgical cost must be tailored to specific determinants of high and low costs for each operation. In contrast to robot-assisted radical prostatectomy where surgeon factors predominate, high costs in radical cystectomy were primarily determined by postoperative complication and patient comorbidities.

  View details for PubMedID 28803034

• Surgeon preference of surgical approach for partial nephrectomy in patients with baseline chronic kidney disease: a nationwide population-based analysis in the USA. International urology and nephrology Khandwala, Y. S., Jeong, I. G., Han, D. H., Kim, J. H., Li, S., Wang, Y., Chang, S. L., Chung, B. I. 2017; 49 (11): 1921?27

  Abstract

  To examine trends in utilization of open, laparoscopic and robot-assisted surgical approaches for treatment of patients with chronic kidney disease (CKD) undergoing partial nephrectomy (PN) within the USA.We analyzed a weighted sample of 112,117 patients from the Premier administrative dataset who underwent PN for renal mass between 2003 and 2015. Proportions of surgical approach utilization were evaluated by CKD status and further stratified by surgery year and surgeon volume. A multivariate logistic regression model was created to predict receipt of minimally invasive PN.Seven thousand five hundred and sixty-five (6.7%) patients with CKD were identified. The proportion of CKD patients receiving open PN decreased from 72.4% in 2003-2007 to 36.1% in 2012-2015 (p < 0.001). Although the robot-assisted PN was the dominant surgical approach for both patients with and without CKD in 2012-2015, the proportion receiving open PN was higher in patients with CKD compared to those without CKD (p = 0.018). Multivariate analysis showed that the presence of CKD was independently associated with lower odds of receiving a minimally invasive approach (OR 0.47 for the entire study cohort, OR 0.27 for high volume robot-assisted PN surgeons, and OR 0.51 for recent years, all p < 0.001). These trends remained when CKD stages were evaluated individually.Patients with CKD undergoing PN were preferentially treated with open surgery despite an overall increase in robot-assisted PN use over the past 13 years. Further studies evaluating surgical outcomes in this population are warranted for determination of optimal approach and construction of evidence-based guidelines.

  View details for PubMedID 28852937

• Incident CKD after Radical or Partial Nephrectomy. Journal of the American Society of Nephrology : JASN Leppert, J. T., Lamberts, R. W., Thomas, I. C., Chung, B. I., Sonn, G. A., Skinner, E. C., Wagner, T. H., Chertow, G. M., Brooks, J. D. 2017

  Abstract

  The comparative effectiveness of partial nephrectomy versus radical nephrectomy to preserve kidney function has not been well established. We determined the risk of clinically significant (stage 4 and higher) CKD after radical or partial nephrectomy among veterans treated for kidney cancer in the Veterans Health Administration (2001-2013). Among patients with preoperative eGFR?30 ml/min per 1.73 m(2), the incidence of CKD stage 4 or higher after radical (n=9759) or partial nephrectomy (n=4370) was 7.9% overall. The median time to stage 4 or higher CKD after surgery was 5 months, after which few patients progressed. In propensity score-matched cohorts, partial nephrectomy associated with a significantly lower relative risk of incident CKD stage 4 or higher (hazard ratio, 0.34; 95% confidence interval [95% CI], 0.26 to 0.43, versus radical nephrectomy). In a parallel analysis of patients with normal or near-normal preoperative kidney function (eGFR?60 ml/min per 1.73 m(2)), partial nephrectomy was also associated with a significantly lower relative risk of incident CKD stage 3b or higher (hazard ratio, 0.15; 95% CI, 0.11 to 0.19, versus radical nephrectomy) in propensity score-matched cohorts. Competing risk regression models produced consistent results. Finally, patients treated with a partial nephrectomy had reduced risk of mortality (hazard ratio, 0.55; 95% CI, 0.49 to 0.62). In conclusion, compared with radical nephrectomy, partial nephrectomy was associated with a marked reduction in the incidence of clinically significant CKD and with enhanced survival. Postoperative decline in kidney function occurred mainly in the first year after surgery and appeared stable over time.

  View details for PubMedID 29018140

• Robotic versus open pediatric ureteral reimplantation: Costs and complications from a nationwide sample JOURNAL OF PEDIATRIC UROLOGY Kurtz, M. P., Leow, J. J., Varda, B. K., Logvinenko, T., Yu, R. N., Nelson, C. P., Chung, B. I., Chang, S. L. 2016; 12 (6)

  Abstract

  We sought to compare complications and direct costs for open ureteral reimplantation (OUR) versus robot-assisted laparoscopic ureteral reimplantation (RALUR) in a sample of hospitals performing both procedures. Anecdotal reports suggest that use of RALUR is increasing, but little is known of the outcomes and costs nationwide.The aim was to determine the costs and 90-day complications (of any Clavien grade) in a nationwide cohort of pediatric patients undergoing OUR or RALUR.Using the Premier Hospital Database we identified pediatric patients (age < 21 years) who underwent ureteral reimplantation from 2003 to 2013. We compared 90-day complication rates and cost data for RALUR versus OUR using descriptive statistics and hierarchical models.We identified 17 hospitals in which both RALUR and OURs were performed, resulting in a cohort of 1494 OUR and 108 RALUR cases. The median operative time was 232 min for RALUR vs. 180 min for OUR (p = 0.0041). Incidence of any 90-day complications was higher in the RALUR group: 13.0% of RALUR vs. 4.5% of OUR (OR = 3.17, 95% CI: 1.46-6.91, p = 0.0037). The difference remained significant in a multivariate model accounting for clustering among hospitals and surgeons (OR, 3.14; 95% CI, 1.46-6.75; p = 0.0033) (Figure). The median hospital cost for OUR was $7273 versus $9128 for RALUR (p = 0.0499), and the difference persisted in multivariate analysis (p = 0.0043). Fifty-one percent (55/108) of the RALUR cases occurred in 2012-2013.We present the first nationwide sample comparing RALUR and OUR in the pediatric population. There is currently wide variation in the probability of complication reported in the literature. Some variability may be due to differential uptake and experience among centers as they integrate a new procedure into their practice, while some may be due to reporting bias. A strength of the current study is that cost and 90-day postoperative complication data are collected at participating hospitals irrespective of outcomes, providing some immunity from the reporting bias to which individual center surgical series' may be susceptible.Compared with OUR, RALUR was associated with a significantly higher rate of complications as well as higher direct costs even when adjusted for demographic and regional factors. These findings suggest that RALUR should be implemented with caution, particularly at sites with limited robotic experience, and that outcomes for these procedures should be carefully and systematically tracked.

  View details for DOI 10.1016/j.jpurol.2016.06.016

  View details for PubMedID 27593917

• Robot-assisted Versus Open Radical Prostatectomy: A Contemporary Analysis of an All-payer Discharge Database EUROPEAN UROLOGY Leow, J. J., Chang, S. L., Meyer, C. P., Wang, Y., Hanske, J., Sammon, J. D., Cole, A. P., Preston, M. A., Dasgupta, P., Menon, M., Chung, B. I., Quoc-Dien Trinh, Q. D. 2016; 70 (5): 837-845

  Abstract

  More than a decade since its inception, the benefits and cost efficiency of robot-assisted radical prostatectomy (RARP) continue to elicit controversy.To compare outcomes and costs between RARP and open RP (ORP).A cohort study of 629 593 men who underwent RP for localized prostate cancer at 449 hospitals in the USA from 2003 to 2013, using the Premier Hospital Database.RARP was ascertained through a review of the hospital charge description master for robotic supplies.Outcomes were 90-d postoperative complications (Clavien), blood product transfusions, operating room time (ORT), length of stay (LOS), and direct hospital costs. Propensity-weighted regression analyses accounting for clustering by hospitals and survey weighting ensured nationally representative estimates.RARP utilization rapidly increased from 1.8% in 2003 to 85% in 2013 (p<0.001). RARP patients (n=311 135) were less likely to experience any complications (odds ratio [OR] 0.68, p<0.001) or prolonged LOS (OR 0.28, p<0.001), or to receive blood products (OR 0.33, p=0.002) compared to ORP patients (n=318 458). The adjusted mean ORT was 131min longer for RARP (p=0.002). The 90-d direct hospital costs were higher for RARP (+$4528, p<0.001), primarily attributed to operating room and supplies costs. Costs were no longer signficantly different between ORP and RARP among the highest-volume surgeons (?104 cases/yr; +$1990, p=0.40) and highest-volume hospitals (?318 cases/yr; +$1225, p=0.39). Limitations include the lack of oncologic characteristics and the retrospective nature of the study.Our contemporary analysis reveals that RARP confers a perioperative morbidity advantage at higher cost. In the absence of large randomized trials because of the widespread adoption of RARP, this retrospective study represents the best available evidence for the morbidity and cost profile of RARP versus ORP.In this large study of men with prostate cancer who underwent either open or robotic radical prostatectomy, we found that robotic surgery has a better morbidity profile but costs more.

  View details for DOI 10.1016/j.eururo.2016.01.044

  View details for PubMedID 26874806

• Contemporary Trends in the Management of Renal Trauma in the United States: A National Community Hospital Population-based Analysis UROLOGY Dagenais, J., Leow, J. J., Haider, A. H., Wang, Y., Chung, B. I., Chang, S. L., Eswara, J. R. 2016; 97: 98-104

  Abstract

  To better define the shift in the management of renal trauma throughout the United States, with a population-based assessment of community hospital practice patterns. To investigate how hospital, patient, and injury-specific factors influence management strategy by both urologists and nonurologists.Using the Premier Hospital database, we performed a retrospective study of all patients with renal trauma between 2003 and 2013. We identified patients using International Classification of Diseases, Ninth Revision diagnosis codes (866.0x, 866.1x), determined management strategy by International Classification of Diseases, Ninth Revision procedure codes, and dichotomized grouping by surgeon specialty. We stratified hospitals by annual renal trauma volume categorized a priori into low, <10 cases per year; intermediate, 10-20 cases per year; and high, >20 cases per year. We performed descriptive statistics and univariate and multivariate regression analyses adjusting for survey weighting and for patient, hospital, and injury-specific characteristics.Our study cohort included a weighted sample size of 21,531 patients. Higher renal trauma hospitals (12.6%) were significantly less likely than low (26.4%) and intermediate (31.3%) volume hospitals to undergo surgical intervention for renal trauma on adjusted models. There was a statistically significant increase in nonoperative management from 65.2% in 2003 to 81.8% in 2013.National rates of surgical intervention for renal trauma are significantly higher than those frequently quoted by the literature, especially among low- and intermediate-volume renal trauma hospitals. Although operative rates are decreasing, further consideration may need to be given to centralization of care in higher-volume teaching hospitals to improve renal salvage.

  View details for DOI 10.1016/j.urology.2016.06.051

  View details for Web of Science ID 000389550300035

  View details for PubMedID 27421783

• Variation in the Intensity of Care for Patients with Uncomplicated Renal Colic Presenting to U.S. Emergency Departments. journal of emergency medicine Elder, J. W., Delgado, M. K., Chung, B. I., Pirrotta, E. A., Wang, N. E. 2016

  Abstract

  Renal colic results in > 1 million ED visits per year, yet there exists a gap in understanding how the majority of these visits, namely uncomplicated cases, are managed.We assessed patient- and hospital-level variation for emergency department (ED) management of uncomplicated kidney stones.We identified ED visits from non-elderly adults (aged 19-79 years) with a primary diagnosis indicating renal stone or colic from the 2011 Nationwide Emergency Department Sample. Patients with additional diagnostic codes indicating infection, sepsis, and abdominal aortic aneurysm were excluded. We used sample-weighted logistic regression to determine the association between hospital admission and having a urologic procedure with patient and hospital characteristics.Of the 1,061,462 ED visits for uncomplicated kidney stones in 2011, 8.0% of visits resulted in admission and 6.3% resulted in an inpatient urologic procedure. Uninsured patients compared to Medicaid insured patients were less likely to be admitted or have an inpatient urologic procedure (odds ratio [OR] = 0.72; 95% confidence interval [CI] 0.65-0.81 and OR = 0.80; 95% CI 0.72-0.87, respectively). Private- and Medicare-insured patients compared to Medicaid-insured patients were more likely to have an inpatient urologic procedure (OR = 1.20; 95% CI 1.11-1.30 and OR = 1.14; 95% CI 1.04-1.25, respectively).For patients with uncomplicated renal colic, there is variation in the management associated with nonclinical factors, namely insurance. No consensus guidelines exist yet to address when to admit or utilize inpatient urologic procedures.

  View details for DOI 10.1016/j.jemermed.2016.05.037

  View details for PubMedID 27720288

• Surgeon and Hospital Level Variation in the Costs of Robot-Assisted Radical Prostatectomy JOURNAL OF UROLOGY Cole, A. P., Leow, J. J., Chang, S. L., Chung, B. I., Meyer, C. P., Kibel, A. S., Menon, M., Nguyen, P. L., Choueiri, T. K., Reznor, G., Lipsitz, S. R., Sammon, J. D., Sun, M., Quoc-Dien Trinh, Q. D. 2016; 196 (4): 1090-1095

  Abstract

  We assessed surgeon and hospital level variation in robot-assisted radical prostatectomy costs and predictors of high and low cost surgery.The study population consisted of a weighted sample of 291,015 men who underwent robot-assisted radical prostatectomy for prostate cancer by 667 surgeons at 197 U.S. hospitals from 2003 to 2013. We evaluated 90-day direct hospital costs (2014 USD) in the Premier Hospital Database. High costs per robot-assisted radical prostatectomy were those above the 90th percentile and low costs were those below the 10th percentile.Mean hospital cost per robot-assisted radical prostatectomy was $11,878 (95% CI $11,804-$11,952). Mean cost was $2,837 (95% CI $2,805-$2,869) in the low cost group vs $25,906 (95% CI $24,702-$25,490) in the high cost group. Nearly a third of the variation in robot-assisted radical prostatectomy cost was attributable to hospital characteristics and more than a fifth was attributable to surgeon characteristics (R-squared 30.43% and 21.25%, respectively). High volume surgeons and hospitals (90th percentile or greater) had decreased odds of high cost surgery (surgeons: OR 0.24, 95% CI 0.11-0.54; hospitals: OR 0.105, 95% CI 0.02-0.46). The performance of robot-assisted radical prostatectomy at a high volume hospital was associated with increased odds of low cost robot-assisted radical prostatectomy (OR 839, 95% CI 122-greater than 999).This study provides insight into the role of surgeons and hospitals in robot-assisted radical prostatectomy costs. Given the substantial variability, identifying and remedying the root cause of outlier costs may yield substantial benefits.

  View details for DOI 10.1016/j.juro.2016.04.087

  View details for PubMedID 27157376

• Contemporary Use of Partial Nephrectomy: Are Older Patients With Impaired Kidney Function Being Left Behind? Urology Leppert, J. T., Mittakanti, H. R., Thomas, I., Lamberts, R. W., Sonn, G. A., Chung, B. I., Skinner, E. C., Wagner, T. H., Chertow, G. M., Brooks, J. D. 2016

  Abstract

  To assess whether patient factors, such as age and preoperative kidney function, were associated with receipt of partial nephrectomy in a national integrated healthcare system.We identified patients treated with a radical or partial nephrectomy from 2002 to 2014 in the Veterans Health Administration. We examined associations among patient age, sex, race or ethnicity, multimorbidity, baseline kidney function, tumor characteristics, and receipt of partial nephrectomy. We estimated the odds of receiving a partial nephrectomy and assessed interactions between covariates and the year of surgery to explore whether patient factors associated with partial nephrectomy changed over time.In our cohort of 14,186 patients, 4508 (31.2%) received a partial nephrectomy. Use of partial nephrectomy increased from 17% in 2002 to 32% in 2008 and to 38% in 2014. Patient race or ethnicity, age, tumor stage, and year of surgery were independently associated with receipt of partial nephrectomy. Black veterans had significantly increased odds of receipt of partial nephrectomy, whereas older patients had significantly reduced odds. Partial nephrectomy utilization increased for all groups over time, but older patients and patients with worse baseline kidney function showed the least increase in odds of partial nephrectomy.Although the utilization of partial nephrectomy increased for all groups, the greatest increase occurred in the youngest patients and those with the highest baseline kidney function. These trends warrant further investigation to ensure that patients at the highest risk of impaired kidney function are considered for partial nephrectomy whenever possible.

  View details for DOI 10.1016/j.urology.2016.08.044

  View details for PubMedID 27634733

• Overall Survival in Patients with Localized Prostate Cancer in the US Veterans Health Administration: Is PIVOT Generalizable? EUROPEAN UROLOGY Barbosa, P. V., Thomas, I., Srinivas, S., Buyyounouski, M. K., Chung, B. I., Chertow, G. M., Asch, S. M., Wagner, T. H., Brooks, J. D., Leppert, J. T. 2016; 70 (2): 227-230

  Abstract

  A better understanding of overall survival among patients with clinically localized prostate cancer (PCa) in the US Veterans Health Administration (VHA) is critical to inform PCa treatment decisions, especially in light of data from the Prostate Intervention Versus Observation Trial (PIVOT). We sought to describe patterns of survival for all patients with clinically localized PCa treated by the VHA. We created an analytic cohort of 35 954 patients with clinically localized PCa diagnosed from 1995 to 2001, approximating the PIVOT inclusion criteria (age of diagnosis ?75 yr and clinical stage T2 or lower). Mean patient age was 65.9 yr, and median follow-up was 161 mo. Overall, 22.5% of patients were treated with surgery, 16.6% were treated with radiotherapy, and 23.1% were treated with androgen deprivation. Median survival of the entire cohort was 14 yr (25th, 75th percentiles, range: 7.9-20 yr). Among patients who received treatment with curative intent, median survival was 17.9 yr following surgery and 12.9 yr following radiotherapy. One-third of patients died within 10 yr of diagnosis compared with nearly half of the participants in PIVOT. This finding sounds a note of caution when generalizing the mortality data from PIVOT to VHA patients and those in the community.More than one-third of patients diagnosed with clinically localized prostate cancer treated through the US Veterans Health Administration from 1995 to 2001 died within 10 yr of their diagnosis. Caution should be used when generalizing the estimates of competing mortality data from PIVOT.

  View details for DOI 10.1016/j.eururo.2016.02.037

  View details for PubMedID 26948397

• Trends in utilisation, perioperative outcomes, and costs of nephroureterectomies in the management of upper tract urothelial carcinoma: a 10-year population-based analysis BJU INTERNATIONAL Tinay, I., Gelpi-Hammerschmidt, F., Leow, J. J., Allard, C. B., Rodriguez, D., Wang, Y., Chung, B. I., Chang, S. L. 2016; 117 (6): 954-960

  Abstract

  To perform a population-based study to evaluate contemporary utilization trends, morbidity and costs associated with nephroureterectomies (NU). Contemporary data for NU are largely derived from single academic institution series describing the experience of high-volume surgeons. It is unclear if the same favorable results occur on a national level.Using the Premier Hospital Database, we captured patients undergoing a NU with diagnoses of renal pelvis or ureteral neoplasms from 2004 to 2013. We fitted regression models, adjusting for clustering by hospitals and survey weighting to evaluate 90-day postoperative complications, operating-room-time (OT), prolonged length-of-stay (pLOS) and direct hospital costs among open, laparoscopic (LNU) and robotic (RNU) approaches.After applying sampling and propensity weights we derived a final study cohort of 17,254 ONU, 13,317 LNU and 3,774 RNU for UTUC in the US between 2004 and 2013. During that period, minimally invasive NU (miNU) increased from 36%-to-54% while the total number of NUs decreased by nearly 20%. No differences were noted in perioperative outcomes between three surgical approaches, including when the analysis was restricted to highest-volume hospitals and highest-volume surgeons. OT was longer for LNU and RNU (p<0.001), where the pLOS rates were decreased for LNU and RNU (p <0.001). Adjusted 90-day median direct-hospital-costs were higher for LNU and RNU (p<0.001), which disappear when adjusting for the highest-volume groups except in RNUs performed by high-volume surgeons.During this contemporary 10-year study, miNU is replacing open surgery for UTUC with a recent surge in RNU, along with a concurrent reduction in total NUs performed. Despite not being associated with a clinically significant improvement in perioperative outcomes, the costs for miNU were consistently higher. However, higher hospital volumes suggest a potential cost containment strategy when performing miNUs. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/bju.13375

  View details for Web of Science ID 000376009800021

  View details for PubMedID 26573216

• Robot-assisted versus open radical prostatectomy utilization in hospitals offering robotics CANADIAN JOURNAL OF UROLOGY Yanamadala, S., Chung, B. I., Hernandez-Boussard, T. M. 2016; 23 (3): 8280-8285

  Abstract

  Prostate cancer is an extremely prevalent cause of morbidity and mortality among American men. Several different treatments exist, but differences in utilization between these treatments are not well understood.We performed an observational study using administrative datasets linked to hospital survey data, which included non-metastatic prostate cancer patients receiving robot-assisted radical prostatectomy (RARP) or open radical prostatectomy (ORP) in California, Florida, or New York from 2009-2011. We developed two hierarchical regression models with fixed effect accounting for hospital clustering and physician clustering to determine factors associated with utilization of RARP versus ORP at hospitals offering robotic surgery.A total of 36,694 patients were identified, with 77.13% receiving RARP and 22.87% receiving ORP. African American patients had lower RARP rates than White patients (OR = 0.80, p < 0.001). Patients using Medicare (OR = 0.91, p = 0.028), Medicaid (OR = 0.68, p < 0.001), or self-pay (OR = 0.72, p = 0.046) had lower RARP rates than patients using private insurance. Patients in Florida had lower RARP rates than patients in California (OR = 0.48, p = 0.010). Patients treated at teaching hospitals had lower RARP rates than patients treated at non-teaching hospitals (OR = 0.50, p = 0.006). The average cost of RARP was $13,614.83, and the average cost of ORP was $12,167.44 (p < 0.001).This population based study suggests that both patient and hospital characteristics are associated with utilization of RARP versus ORP in hospitals where robotic surgery is offered.

  View details for Web of Science ID 000379635800006

• Robot-assisted versus open radical prostatectomy utilization in hospitals offering robotics. Canadian journal of urology Yanamadala, S., Chung, B. I., Hernandez-Boussard, T. M. 2016; 23 (3): 8279-8284

  Abstract

  Prostate cancer is an extremely prevalent cause of morbidity and mortality among American men. Several different treatments exist, but differences in utilization between these treatments are not well understood.We performed an observational study using administrative datasets linked to hospital survey data, which included non-metastatic prostate cancer patients receiving robot-assisted radical prostatectomy (RARP) or open radical prostatectomy (ORP) in California, Florida, or New York from 2009-2011. We developed two hierarchical regression models with fixed effect accounting for hospital clustering and physician clustering to determine factors associated with utilization of RARP versus ORP at hospitals offering robotic surgery.A total of 36,694 patients were identified, with 77.13% receiving RARP and 22.87% receiving ORP. African American patients had lower RARP rates than White patients (OR = 0.80, p < 0.001). Patients using Medicare (OR = 0.91, p = 0.028), Medicaid (OR = 0.68, p < 0.001), or self-pay (OR = 0.72, p = 0.046) had lower RARP rates than patients using private insurance. Patients in Florida had lower RARP rates than patients in California (OR = 0.48, p = 0.010). Patients treated at teaching hospitals had lower RARP rates than patients treated at non-teaching hospitals (OR = 0.50, p = 0.006). The average cost of RARP was $13,614.83, and the average cost of ORP was $12,167.44 (p < 0.001).This population based study suggests that both patient and hospital characteristics are associated with utilization of RARP versus ORP in hospitals where robotic surgery is offered.

  View details for PubMedID 27347621

• The Contemporary Incidence and Sequelae of Rhabdomyolysis Following Extirpative Renal Surgery: A Population Based Analysis JOURNAL OF UROLOGY Gelpi-Hammerschmidt, F., Tinay, I., Allard, C. B., Su, L., Preston, M. A., Quoc-Dien Trinh, Q. D., Kibel, A. S., Wang, Y., Chung, B. I., Chang, S. L. 2016; 195 (2): 399-405

  Abstract

  To evaluate the contemporary incidence and consequences of postoperative rhabdomyolysis (PRM) following extirpative renal surgery (ERS).We conducted a population-based, retrospective cohort study of patients who underwent ERS with a diagnosis of a renal mass or renal cell carcinoma in the United States between 2004 and 2013. Regression analysis was performed to evaluate 90-day mortality (Clavien grade 5), non-fatal major complications (Clavien grade 3-4), readmission rates, direct costs and length of stay (LOS).The final weighted cohort included 310,880 open, 174,283 laparoscopic, and 69,880 robotic ERS during the 10-year study period, with 745 (0.001%) experiencing PRM. Presence of PRM led to a significantly higher incidence of 90-day non-fatal major complications (34.7% vs. 7.3%, p<0.05) and higher 90-day mortality (4.4% vs. 1.02%, p<0.05). LOS was twice as long for patients with PRM (incidence risk ratio: 1.83, 95% CI: 1.56-2.15, p<0.001). Robotic approach was associated with a higher likelihood for PRM (vs. laparoscopic approach, odds ratio: 2.43, p<0.05). Adjusted 90-day median direct hospital costs were USD 7515 higher for patients with PRM (p<0.001). Our model revealed that the combination of obesity and prolonged surgery (>5 hours) was associated with a higher likelihood of developing PRM.Our study confirms that PRM is an uncommon complication among patients undergoing ERS but has a potentially detrimental impact on surgical morbidity, mortality and costs. Male gender, comorbidities as well as obesity, prolonged surgery (>5 hours), and a robotic approach appear to place patients at a higher risk for PRM.

  View details for DOI 10.1016/j.juro.2015.08.084

  View details for Web of Science ID 000368054800052

• Accuracy of Prostate-Specific Antigen Values in Prostate Cancer Registries. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Mittakanti, H. R., Thomas, I. C., Shelton, J. B., Makarov, D. V., Skolarus, T. A., Cooperberg, M. R., Chung, B. I., Sonn, G. A., Brooks, J. D., Leppert, J. T. 2016

  View details for PubMedID 27458297

• Contemporary rends in high-dose interleukin-2 use for metastatic renal cell carcinoma in the United States UROLOGIC ONCOLOGY-SEMINARS AND ORIGINAL INVESTIGATIONS Allard, C. B., Gelpi-Hammerschmidt, F., Harshman, L. C., Choueiri, T. K., Faiena, I., Modi, P., Chung, B. I., Tinay, I., Singer, E. A., Chang, S. L. 2015; 33 (11)

  Abstract

  Targeted therapies (TTs) have revolutionized metastatic renal cell carcinoma (mRCC) treatment in the past decade, largely replacing immunotherapy including high-dose interleukin-2 (HD IL-2) therapy. We evaluated trends in HD IL-2 use for mRCC in the TT era.Our cohort comprised a weighted estimate of all patients undergoing HD IL-2 treatment for mRCC from 2004 to 2012 using the Premier Hospital Database. We assessed temporal trends in HD IL-2 use including patient, disease, and hospital characteristics stratified by era (pre-TT uptake: 2004-2006, uptake: 2007-2009, and post-TT uptake: 2010-2012) and fitted multivariable regression models to identify predictors of treatment toxicity and tolerability.An estimated 2,351 patients received HD IL-2 therapy for mRCC in the United States from 2004 to 2012. The use decreased from 2004 to 2008. HD IL-2 therapy became increasingly centralized in teaching hospitals (24% of treatments in 2004 and 89.5% in 2012). Most patients who received HD IL-2 therapy were men, white, younger than 60 years, had lung metastases, and were otherwise healthy. Vasopressors, intensive care unit admission, and hemodialysis were necessary in 53.4%, 33.0%, and 7.1%, respectively. Factors associated with toxicities in multivariable analyses included being unmarried, male sex, and multiple metastatic sites. African Americans and patients with single-site metastases were less likely to receive multiple treatment cycles.HD IL-2 therapy is used infrequently for mRCC in the United States, and its application has diminished with the uptake of TT. Patients are being increasingly treated in teaching hospitals, suggesting a centralization of care and possible barriers to access. A recent slight increase in HD IL-2 therapy use likely reflects recognition of the inability of TT to effect a complete response.

  View details for DOI 10.1016/j.urolonc.2015.06.014

  View details for Web of Science ID 000364404400013

  View details for PubMedID 26210683

• The impact of robotic surgery on the surgical management of prostate cancer in the USA BJU INTERNATIONAL Chang, S. L., Kibel, A. S., Brooks, J. D., Chung, B. I. 2015; 115 (6): 929-936

  Abstract

  To describe the surgeon characteristics associated with RARP adoption and determine the possible impact of this adoption on practice patterns and cost.A retrospective cohort study with a weighted sample size of 489,369 men who underwent non-RARP (i.e., open or laparoscopic radical prostatectomy [RP]) or RARP in the United States from 2003 to 2010 was performed. We evaluated predictors for RARP adoption, defined as performing >50% of annual RP with the robotic approach. Additionally, we identified the resulting changes in prostate cancer surgery practice patterns and expenditures.From 2003 to 2010, RARP adoption increased from 0.7% to 42% of surgeons performing RP. High-volume surgeons, defined as performing >24 RP annually, had statically significantly higher odds of adopting RARP throughout the study period. From 2005 to 2007, adoption was more common among surgeons at teaching (OR: 2.4; 95% CI: 1.7-3.4), intermediate- (200-399 beds; OR: 5.96; 95% CI: 1.3-26.5) and large-sized hospitals (?400 beds; OR: 6.1; 95% CI: 1.4-25.8); after 2007, adoption was more common among surgeons at urban hospitals (OR: 3.3; 95% CI: 1.7 to 6.4). RARP adoption was generally associated with increased RP volume, greatest for high-volume surgeons and least for low-volume surgeons (<5 RP annually). The annual number of surgeons performing RP decreased from approximately 10,000 to 8,200, with the proportion of cases performed by high-volume surgeons increasing from 10% to 45%. RARP was more costly, disproportionally contributing to the 40% increase in annual prostate cancer surgery expenditures. RARP costs generally decreased plateauing at over $10,000 while non-RARP costs increased to nearly $9,000 by the end of the study.There was widespread RARP adoption in the United States between 2003 and 2010, particularly among high-volume surgeons. The diffusion of RARP was associated with a centralization of care and an increased economic burden for prostate cancer surgery.

  View details for DOI 10.1111/bju.12850

  View details for Web of Science ID 000355275600019

  View details for PubMedID 24958338

• Racial Disparities in Postoperative Complications After Radical Nephrectomy: A Population-based Analysis UROLOGY Chung, B. I., Leow, J. J., Gelpi-Hammerschmidt, F., Wang, Y., Del Giudice, F., De, S., Chou, E. P., Song, K. H., Almario, L., Chang, S. L. 2015; 85 (6): 1411-1416

  Abstract

  To perform a population-based study that evaluates contemporary racial disparities in the morbidity profile of patients undergoing radical nephrectomy in the United States.Using the Premier hospital database (Premier Inc, Charlotte, NC), which collects data from over 600 nonfederal hospitals throughout the United States, we identified patients undergoing a total nephrectomy as their primary procedure and also had a concurrent diagnosis of a kidney mass or cancer from 2003 to 2010. The primary outcome was 90-day major complication rates, based on the Clavien classification system. Multivariate logistic regression models were performed, adjusting for clustering by hospitals and survey weighting to ensure nationally representative estimates.The study population included 25,517 patients translating into a weighted sample of 185,135 radical nephrectomies. In a multivariate model including patient, hospital, and surgical characteristics, blacks were more commonly associated with a major complication (odds ratio, 2.1; P <.0001). When we incorporated Charlson comorbidity score into the model, the racial disparity in major complications was attenuated by 36% (odds ratio, 1.7; P <.0001). Adjusting for annual surgical volume in the multivariate model did not alter results.Our contemporary evaluation of patients undergoing radical nephrectomy in the United States demonstrates that blacks are associated with a markedly elevated rate of major complications as compared to whites. This disparity is possibly a result of unequal access to routine health care.

  View details for DOI 10.1016/j.urology.2015.03.001

  View details for Web of Science ID 000360158900054

• Re: Nationwide prevalence of lymph node metastases in Gleason score 3?+?3?=?6 prostate cancer: authors' reply. Pathology Sieh, W., Lichtensztajn, D. Y., Gomez, S. L., Liu, J., Chung, B. I., Cheng, I., Brooks, J. D. 2015; 47 (4): 394-395

  View details for DOI 10.1097/PAT.0000000000000264

  View details for PubMedID 25938367

• Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population-based analysis BJU INTERNATIONAL Leow, J. J., Reese, S., Quoc-Dien Trinh, Q. D., Bellmunt, J., Chung, B. I., Kibel, A. S., Chang, S. L. 2015; 115 (5): 713-721

  Abstract

  To evaluate the relationship between surgeon volume of radical cystectomy (RC) and postoperative morbidity as well as the economic burden of bladder cancer in the United States.We captured all patients who underwent a RC (ICD-9 code 57.71) from 2003 to 2010, using a nationwide hospital discharge database. Patient, hospital, and surgical characteristics were evaluated. Annual volume of RC for surgeons was divided into quintiles. Multivariable regression models were developed adjusting for clustering and survey weighting to evaluate the outcomes including 90-day major complications (Clavien 3-5) and direct patient costs. We adjusted for clustering and weighting to achieve a nationally representative analysis.The weighted cohort included 49,792 RC patients with an overall 90-day major complication rate of 16.2%. Compared to surgeons performing one RC annually, surgeons performing ?7 RC each year had a 45% decreased odds of major complications (OR: 0.55, p<0.001) and a reduction in costs by $1690 (p=0.02). Results were consistent when we analyzed surgeon volume as a continuous variable and when we examined the highest volume surgeons (?28 cases annually), which found a marked decreased odds of major complications compared to the lowest volume surgeons (OR: 0.45, 95% CI: 0.31-0.67, p<0.0001). Compared to patients who did not have any complications, those who suffered a major complication had significantly higher 90-day median direct hospital costs ($43965 vs. $24341, p<0.0001).We demonstrate an inverse relationship between surgeon volume and the development of postoperative 90-day major complication rates as well as direct hospital costs. Centralization of RC to higher volume surgeons may reduce the development of postoperative major complications thereby decreasing the burden of bladder cancer on the health care system.

  View details for DOI 10.1111/bju.12749

  View details for Web of Science ID 000353230500011

  View details for PubMedID 24674655

• The Contemporary Incidence and Sequelae of Rhabdomyolysis Following Extirpative Renal Surgery: A Population-Based Analysis. The Journal of urology Gelpi-Hammerschmidt, F., Tinay, I., Allard, C. B., Su, L. M., Preston, M. A., Trinh, Q. D., Kibel, A. S., Wang, Y., Chung, B. I., Chang, S. L. 2015

  Abstract

  To evaluate the contemporary incidence and consequences of postoperative rhabdomyolysis (PRM) following extirpative renal surgery (ERS).We conducted a population-based, retrospective cohort study of patients who underwent ERS with a diagnosis of a renal mass or renal cell carcinoma in the United States between 2004 and 2013. Regression analysis was performed to evaluate 90-day mortality (Clavien grade 5), non-fatal major complications (Clavien grade 3-4), readmission rates, direct costs and length of stay (LOS).The final weighted cohort included 310,880 open, 174,283 laparoscopic, and 69,880 robotic ERS during the 10-year study period, with 745 (0.001%) experiencing PRM. Presence of PRM led to a significantly higher incidence of 90-day non-fatal major complications (34.7% vs. 7.3%, p<0.05) and higher 90-day mortality (4.4% vs. 1.02%, p<0.05). LOS was twice as long for patients with PRM (incidence risk ratio: 1.83, 95% CI: 1.56-2.15, p<0.001). Robotic approach was associated with a higher likelihood for PRM (vs. laparoscopic approach, odds ratio: 2.43, p<0.05). Adjusted 90-day median direct hospital costs were USD 7515 higher for patients with PRM (p<0.001). Our model revealed that the combination of obesity and prolonged surgery (>5 hours) was associated with a higher likelihood of developing PRM.Our study confirms that PRM is an uncommon complication among patients undergoing ERS but has a potentially detrimental impact on surgical morbidity, mortality and costs. Male gender, comorbidities as well as obesity, prolonged surgery (>5 hours), and a robotic approach appear to place patients at a higher risk for PRM.

  View details for PubMedID 26321407

• Racial Disparities in Postoperative Complications After Radical Nephrectomy: A Population-based Analysis. Urology Chung, B. I., Leow, J. J., Gelpi-Hammerschmidt, F., Wang, Y., Del Giudice, F., De, S., Chou, E. P., Song, K. H., Almario, L., Chang, S. L. 2015

  Abstract

  To perform a population-based study that evaluates contemporary racial disparities in the morbidity profile of patients undergoing radical nephrectomy in the United States.Using the Premier hospital database (Premier Inc, Charlotte, NC), which collects data from over 600 nonfederal hospitals throughout the United States, we identified patients undergoing a total nephrectomy as their primary procedure and also had a concurrent diagnosis of a kidney mass or cancer from 2003 to 2010. The primary outcome was 90-day major complication rates, based on the Clavien classification system. Multivariate logistic regression models were performed, adjusting for clustering by hospitals and survey weighting to ensure nationally representative estimates.The study population included 25,517 patients translating into a weighted sample of 185,135 radical nephrectomies. In a multivariate model including patient, hospital, and surgical characteristics, blacks were more commonly associated with a major complication (odds ratio, 2.1; P <.0001). When we incorporated Charlson comorbidity score into the model, the racial disparity in major complications was attenuated by 36% (odds ratio, 1.7; P <.0001). Adjusting for annual surgical volume in the multivariate model did not alter results.Our contemporary evaluation of patients undergoing radical nephrectomy in the United States demonstrates that blacks are associated with a markedly elevated rate of major complications as compared to whites. This disparity is possibly a result of unequal access to routine health care.

  View details for PubMedID 25881864

• Propensity-Matched Comparison of Morbidity and Costs of Open and Robot-Assisted Radical Cystectomies: A Contemporary Population-Based Analysis in the United States EUROPEAN UROLOGY Leow, J. J., Reese, S. W., Jiang, W., Lipsitz, S. R., Bellmunt, J., Quoc-Dien Trinh, Q. D., Chung, B. I., Kibel, A. S., Chang, S. L. 2014; 66 (3): 569-576

  View details for DOI 10.1016/j.eururo.2014.01.029

  View details for Web of Science ID 000340260900038

• Nationwide prevalence of lymph node metastases in Gleason score 3?+?3?=?6 prostate cancer. Pathology Liu, J., Lichtensztajn, D. Y., Gomez, S. L., Sieh, W., Chung, B. I., Cheng, I., Brooks, J. D. 2014; 46 (4): 306-310

  Abstract

  Based on revisions of Gleason scoring in 2005, it has been reported that nodal metastases at radical prostatectomy in Gleason 3?+?3?=?6 (GS6) prostate cancer are extremely rare, and that GS6 cancers with nodal metastases are invariably upgraded upon review by academic urological pathologists. We analysed the prevalence and determinants of nodal metastases in a national sample of patients with GS6 cancer.We utilised the SEER database to identify patients diagnosed with GS6 prostate cancer during 2004-2010 who had radical prostatectomy and ?1 lymph node(s) examined. We calculated the prevalence of nodal metastases and constructed a multivariable logistic regression model to identify factors associated with nodal metastases.Among 21,960 patients, the prevalence of nodal metastases was 0.48%. Older age, preoperative PSA >10?ng/mL, and advanced stage were positively associated with nodal metastases.Lymph node metastases in GS6 cancer are more prevalent in a nationwide population compared to academic centres. Revised guidelines for Gleason scoring have made GS6 cancer a more homogeneously indolent disease, which may be relevant in the era of active surveillance. We submit that lymph node metastases in GS6 cancer be used as a proxy for adherence to the 2005 ISUP consensus on Gleason grading.

  View details for DOI 10.1097/PAT.0000000000000097

  View details for PubMedID 24798166

• Trends and perioperative outcomes for laparoscopic and robotic nephrectomy using the National Surgical Quality Improvement Program (NSQIP) database UROLOGIC ONCOLOGY-SEMINARS AND ORIGINAL INVESTIGATIONS Liu, J., Leppert, J. T., Maxwell, B. G., Panousis, P., Chung, B. I. 2014; 32 (4): 473-479

  Abstract

  We sought to examine the trends in perioperative outcomes of kidney cancer surgery stratified by type (radical nephrectomy [RN] vs. partial nephrectomy [PN]) and approach (open vs. minimally invasive).We queried the National Surgical Quality Improvement Program database to identify kidney cancer operations performed from 2005 to 2011. We examined 30-day perioperative outcomes including operative time, transfusion rate, length of stay, major morbidity (cardiovascular, pulmonary, renal, and infectious), and mortality.A total of 2,902 PN and 5,459 RN cases were identified. The use of PN increased over time, accounting for 39% of all nephrectomies in 2011. Minimally invasive approaches also increased over time for both RN and PN. Open surgery was associated with increased length of stay, receipt of transfusion, major complications, and perioperative mortality. Resident involvement and open approach were independent predictors of major complications for both PN and RN. Additionally, the presence of a medical comorbidity was also a risk factor for complications after RN. The overall complication rates decreased for all approaches over the study period.Minimally invasive approaches to kidney cancer renal surgery have increased with favorable outcomes. The safety of open and minimally invasive PN improved significantly over the study period. Although pathologic features cannot be determined from this data set, these data show that complications from renal surgical procedures are decreasing in an era of increasing use.

  View details for DOI 10.1016/j.urolonc.2013.09.012

  View details for Web of Science ID 000335422300015

  View details for PubMedID 24332644

• Prostate cancer risk profiles of asian-american men: disentangling the effects of immigration status and race/ethnicity. journal of urology Lichtensztajn, D. Y., Gomez, S. L., Sieh, W., Chung, B. I., Cheng, I., Brooks, J. D. 2014; 191 (4): 952-956

  Abstract

  Asian-American men with prostate cancer have been reported to present with higher grade and later stage disease than White Americans. However, Asian Americans comprise a heterogeneous population with distinct health outcomes. We compared prostate cancer risk profiles among the diverse racial and ethnic groups in California.We used data from the California Cancer Registry for 90,845 Non-Hispanic White, Non-Hispanic Black, and Asian-American men diagnosed with prostate cancer between 2004 and 2010. Patients were categorized into low, intermediate, or high-risk groups based on clinical stage, Gleason score, and PSA value at diagnosis. Using polytomous logistic regression, we estimated adjusted odds ratios for the association of race/ethnicity and nativity with risk group.In addition to Non-Hispanic Blacks, six Asian-American groups (US-born Chinese, foreign-born Chinese, US-born Japanese, foreign-born Japanese, foreign-born Filipino, and foreign-born Vietnamese) were more likely to have an unfavorable risk profile compared to Non-Hispanic Whites. The odds ratios for high vs. intermediate-risk disease ranged from 1.23 (95% CI, 1.02-1.49) for US-born Japanese to 1.45 (95% CI, 1.31-1.60) for foreign-born Filipinos. These associations appeared to be driven by higher grade and PSA values, rather than advanced clinical stage at diagnosis.In this large, ethnically diverse population-based cohort, we found that Asian-American men were more likely to have unfavorable risk profiles at diagnosis. This association varied by racial/ethnic group and nativity, and was not attributable to later stage at diagnosis, suggesting that Asian men may have biological differences that predispose to the development of more severe disease.

  View details for DOI 10.1016/j.juro.2013.10.075

  View details for PubMedID 24513166

• Relating prognosis in chromophobe renal cell carcinoma to the chromophobe tumor grading system. Korean journal of urology Weinzierl, E. P., Thong, A. E., McKenney, J. K., Jeon, S. H., Chung, B. I. 2014; 55 (4): 239-244

  Abstract

  The chromophobe subtype of renal cell carcinoma (chRCC) has generally been associated with a better prognosis than the clear cell type; however, debate continues as to absolute prognosis as well as the significance of certain prognostic variables. We investigated the significance of pathologic stage and a recently proposed chromophobe tumor grading (CTG) scheme in predicting chRCC outcomes.All available chRCCs were identified from our surgical pathology archives from 1987-2010. Original slides were reviewed to verify diagnoses and stage, and each case was graded following a novel chromophobe tumor grade system criteria. Disease status was obtained from a clinical outcome database, and cancer specific deaths and recurrences were recorded.Eighty-one cases of chRCC were identified, and 73 had adequate follow-up information available. There were only 3 instances of cancer related recurrence or mortality, which included 1 disease specific mortality and 2 disease recurrences. Pathologic stage and CTG 3 were found to be significantly associated with the recurrences or death from chRCC, but there was no association with CTG 1 and CTG 2.chRCC is associated with a very low rate of cancer specific events (4.1%) even at a tertiary referral center. In our study, pathologic stage and CTG 3, but not CTG 1 or 2, were significantly associated with the development of these events.

  View details for DOI 10.4111/kju.2014.55.4.239

  View details for PubMedID 24741411

• Utilization of renal mass biopsy in patients with renal cell carcinoma. Urology Leppert, J. T., Hanley, J., Wagner, T. H., Chung, B. I., Srinivas, S., Chertow, G. M., Brooks, J. D., Saigal, C. S. 2014; 83 (4): 774-780

  Abstract

  To examine the patient, tumor, and temporal factors associated with receipt of renal mass biopsy (RMB) in a contemporary nationally representative sample.We queried the Surveillance, Epidemiology, and End Results-Medicare data set for incident cases of renal cell carcinoma diagnosed between 1992 and 2007. We tested for associations among receipt of RMB and patient and tumor characteristics, type of therapy, and procedure type. Temporal trends in receipt of RMB were characterized over the study period.Approximately 1 in 5 (20.7%) patients diagnosed with renal cell carcinoma (n = 24,702) underwent RMB before instituting therapy. There was a steady and modest increase in RMB utilization, with the highest utilization (30%) occurring in the final study year. Of patients who underwent radical (n = 15,666) or partial (n = 2211) nephrectomy, 17% and 20%, respectively, underwent RMB in advance of surgery. Sixty-five percent of patients who underwent ablation (n = 314) underwent RMB before or in conjunction with the procedure. Roughly half of patients (50.4%) treated with systemic therapy alone underwent RMB. Factors independently associated with use of RMB included younger age, black race, Hispanic ethnicity, tumor size <7 cm, and metastatic disease at presentation.At present, most patients who eventually undergo radical or partial nephrectomy do not undergo RMB, whereas most patients who eventually undergo ablation or systemic therapy do. The optimal use of RMB in the evaluation of kidney tumors has yet to be determined.

  View details for DOI 10.1016/j.urology.2013.10.073

  View details for PubMedID 24529579

• National Trends of Perioperative Outcomes and Costs for Open, Laparoscopic and Robotic Pediatric Pyeloplasty JOURNAL OF UROLOGY Varda, B. K., Johnson, E. K., Clark, C., Chung, B. I., Nelson, C. P., Chang, S. L. 2014; 191 (4): 1090-1095

  Abstract

  We performed a population based study comparing trends in perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty. Specific billing items contributing to cost were also investigated.Using the Perspective database (Premier, Inc., Charlotte, North Carolina), we identified 12,662 pediatric patients who underwent open, laparoscopic and robotic pyeloplasty (ICD-9 55.87) in the United States from 2003 to 2010. Univariate and multivariate statistics were used to evaluate perioperative outcomes, complications and costs for the competing surgical approaches. Propensity weighting was used to minimize selection bias. Sampling weights were used to yield a nationally representative sample.A decrease in open pyeloplasty and an increase in minimally invasive pyeloplasty were observed. All procedures had low complication rates. Compared to open pyeloplasty, laparoscopic and robotic pyeloplasty had longer median operative times (240 minutes, p <0.0001 and 270 minutes, p <0.0001, respectively). There was no difference in median length of stay. Median total cost was lower among patients undergoing open vs robotic pyeloplasty ($7,221 vs $10,780, p <0.001). This cost difference was largely attributable to robotic supply costs.During the study period open pyeloplasty made up a declining majority of cases. Use of laparoscopic pyeloplasty plateaued, while robotic pyeloplasty increased. Operative time was longer for minimally invasive pyeloplasty, while length of stay was equivalent across all procedures. A higher cost associated with robotic pyeloplasty was driven by operating room use and robotic equipment costs, which nullified low room and board cost. This study reflects an adoption period for robotic pyeloplasty. With time, perioperative outcomes and cost may improve.

  View details for DOI 10.1016/j.juro.2013.10.077

  View details for PubMedID 24513164

• Reply. Urology Leppert, J. T., Hanley, J., Wagner, T. H., Chung, B. I., Brooks, J. D., Srinivas, S., Chertow, G. M., Saigal, C. S. 2014; 83 (4): 779-780

  View details for DOI 10.1016/j.urology.2013.10.077

  View details for PubMedID 24529590

• Editorial comment. Urology Liu, J., Chung, B. I. 2014; 83 (2): 356-?

  View details for DOI 10.1016/j.urology.2013.09.057

  View details for PubMedID 24468510

• Risk factors for postoperative hemorrhage after partial nephrectomy. Korean journal of urology Jung, S., Min, G. E., Chung, B. I., Jeon, S. H. 2014; 55 (1): 17-22

  Abstract

  To evaluate the frequency and clinical characteristics of postoperative hemorrhage as a complication of partial nephrectomy.The demographics, physical statistics, tumor size, R.E.N.A.L. nephrometry score, operative method, warm ischemic time, and presence of postoperative hemorrhage and its severity and method of intervention were examined in 300 partial nephrectomy patients in two medical centers (Stanford Medical Center and Kyung Hee University Medical Center) between March 2000 and March 2012.Of the 300 subjects, 13 (4.3%) experienced postoperative hemorrhage severe enough to require intervention more invasive than transfusion (Clavien grade III or higher). Univariate analysis of the bleeding and nonbleeding groups showed that whereas age, ischemic time, tumor size and stage, body mass index, American Society of Anesthesiologists class, and operative method did not differ significantly, the exophyticity (E) score was significantly higher for severe postoperative hemorrhage (p=0.04). However, multivariate analysis showed none of the factors to differ significantly. In most of the cases requiring intervention, selective embolization was sufficient, but in one case explorative laparotomy and nephrectomy were required. Clinical characteristics varied significantly among severe hemorrhage cases, with time of onset ranging from the first to the 30th postoperative day and symptoms presenting in a diverse manner, such as gross hematuria and pleuritic chest pain. Computed tomography and angiographic findings were consistent with either arteriovenous fistula or pseudoaneurysms.Severe hemorrhage after partial nephrectomy is rare. Nonetheless, with the great variability in presenting symptoms and time of onset after surgery, surgeons should exercise great vigilance during the postoperative care of partial nephrectomy patients.

  View details for DOI 10.4111/kju.2014.55.1.17

  View details for PubMedID 24466392

• Propensity-Matched Comparison of Morbidity and Costs of Open and Robot-Assisted Radical Cystectomies: A Contemporary Population-Based Analysis in the United States. European urology Leow, J. J., Reese, S. W., Jiang, W., Lipsitz, S. R., Bellmunt, J., Trinh, Q. D., Chung, B. I., Kibel, A. S., Chang, S. L. 2014

  Abstract

  Radical cystectomy (RC) is a morbid procedure associated with high costs. Limited population-based data exist on the complication profile and costs of robot-assisted RC (RARC) compared with open RC (ORC).To evaluate morbidity and cost differences between ORC and RARC.We conducted a population-based, retrospective cohort study of patients who underwent RC at 279 hospitals across the United States between 2004 and 2010.Multivariable logistic and median regression was performed to evaluate 90-d mortality, postoperative complications (Clavien classification), readmission rates, length of stay (LOS), and direct costs. To reduce selection bias, we used propensity weighting with survey weighting to obtain nationally representative estimates.The final weighted cohort included 34 672 ORC and 2101 RARC patients. RARC use increased from 0.6% in 2004 to 12.8% in 2010. Major complication rates (Clavien grade ?3; 17.0% vs 19.8%, p=0.2) were similar between ORC and RARC (odds ratio [OR]: 1.32; p=0.42). RARC had 46% decreased odds of minor complications (Clavien grade 1-2; OR: 0.54; p=0.03). RARC had $4326 higher adjusted 90-d median direct costs (p=0.004). Although RARC had a significantly shorter LOS (11.8 d vs 10.2 d; p=0.008), no significant differences in room and board costs existed (p=0.20). Supply costs for RARC were significantly higher ($6041 vs $3638; p<0.0001). Morbidity and cost differences were not present among the highest-volume surgeons (?7 cases per year) and hospitals (?19 cases per year). Limitations include use of an administrative database and lack of oncologic characteristics.The use of RARC has increased between 2004 and 2010. Compared with ORC, RARC was associated with decreased odds of minor but not major complications and with increased expenditures attributed primarily to higher supply costs. Centralization of ORC and RARC to high-volume providers may minimize these morbidity and cost differences.Using a US population-based cohort, we found that robotic surgery for bladder cancer decreased minor complications, had no impact on major complications and was more costly than open surgery.

  View details for PubMedID 24491306

• Estimating the risk of chronic kidney disease after nephrectomy CANADIAN JOURNAL OF UROLOGY Ngo, T. C., Hurley, M. P., Thong, A. E., Jeon, S. H., Leppert, J. T., Chung, B. I. 2013; 20 (6): 7035-7041

  Abstract

  To identify factors associated with the development of chronic kidney disease (CKD) after nephrectomy and to create a clinical model to predict CKD after nephrectomy for kidney cancer for clinical use.We identified 144 patients who had normal renal function (eGFR > 60) prior to undergoing nephrectomy for kidney cancer. Selected cases occurred between 2007 and 2010 and had at least 30 days follow up. Sixty-six percent (n = 95) underwent radical nephrectomy and 62.5% (n = 90) developed CKD (stage 3 or higher) postoperatively. We used univariable analysis to screen for predictors of CKD and multivariable logistic regression to identify independent predictors of CKD and their corresponding odds ratios. Interaction terms were introduced to test for effect modification. To protect against over-fitting, we used 10-fold cross-validation technique to evaluate model performance in multiple training and testing datasets. Validation against an independent external cohort was also performed.Of the variables associated with CKD in univariable analysis, the only independent predictors in multivariable logistic regression were patient age (OR = 1.27 per 5 years, 95% CI: 1.07-1.51), preoperative glomerular filtration rate (GFR), (OR = 0.70 per 10 mL/min, 95% CI: 0.56-0.89), and receipt of radical nephrectomy (OR = 4.78, 95% CI: 2.08-10.99). There were no significant interaction terms. The resulting model had an area under the curve (AUC) of 0.798. A 10-fold cross-validation slightly attenuated the AUC to 0.774 and external validation yielded an AUC of 0.930, confirming excellent model discrimination.Patient age, preoperative GFR, and receipt of a radical nephrectomy independently predicted the development of CKD in patients undergoing nephrectomy for kidney cancer in a validated predictive model.

  View details for Web of Science ID 000328717300007

  View details for PubMedID 24331345

• Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era 12th International Kidney Cancer Symposium Conti, S. L., Thomas, I., Hagedorn, J. C., Chung, B. I., Chertow, G. M., Wagner, T. H., Brooks, J. D., Srinivas, S., Leppert, J. T. WILEY-BLACKWELL. 2013: 14?16

  View details for Web of Science ID 000325992100026

• Utilization of renal mass biopsy in patients with renal cell carcinoma 12th International Kidney Cancer Symposium Leppert, J. T., Hanley, J., Wagner, T. H., Chung, B. I., Srinivas, S., Chertow, G. M., Brooks, J. D., Saigal, C. S. WILEY-BLACKWELL. 2013: 14?14

  View details for Web of Science ID 000325992100024

• Reply. Urology Liu, J., Chung, B. I. 2013; 82 (3): 583-?

  View details for DOI 10.1016/j.urology.2013.03.083

  View details for PubMedID 23876587

• Perioperative Outcomes for Laparoscopic and Robotic Compared With Open Prostatectomy Using the National Surgical Quality Improvement Program (NSQIP) Database UROLOGY Liu, J., Maxwell, B. G., Panousis, P., Chung, B. I. 2013; 82 (3): 579-583

  Abstract

  To examine contemporary outcomes of minimally invasive radical prostatectomy (MIRP) compared with open prostatectomy, using a national, prospective perioperative database reflecting diverse practice settings.The National Surgical Quality Improvement Program database was queried from 2005 to 2010 for laparoscopic or robotic prostatectomy (Current Procedural Terminology code 55866) and open retropubic prostatectomy (Current Procedural Terminology codes 55840, 55842, 55845). Perioperative outcomes examined were surgical and total operation duration, transfusion rates, length of stay, major morbidity (cardiovascular, pulmonary, renal, and infectious), and mortality.The study identified 5319 radical prostatectomies: 4036 MIRP and 1283 open. Although operative time was significantly longer in the MIRP group, there were significantly fewer perioperative blood transfusions and shorter mean length of stay. Major postoperative morbidity and mortality were 5% in the MIRP group and 9% in the open group (P <.001). Age, body mass index, presence of medical comorbidities, and open surgical technique were all independently predictive of major complications and mortality on multivariate analysis.In a nationwide database of diverse medical centers, MIRP was associated with longer operative time, but a significantly decreased rate of blood transfusions, length of stay, perioperative complication rate, and mortality compared with open prostatectomy. The minimally invasive surgical approach was independently associated with significantly fewer complications and deaths on multivariate analysis. Compared with other administrative databases that capture only inpatient events, the National Surgical Quality Improvement Program identifies complications up to 30 days postoperatively, providing more detailed characterization of complications after prostatectomy. These data reflect contemporary practice patterns and suggest that MIRP can be performed with low perioperative morbidity.

  View details for DOI 10.1016/j.urology.2013.03.080

  View details for Web of Science ID 000323790800031

  View details for PubMedID 23876584

• Photoacoustic imaging of the bladder: a pilot study. Journal of ultrasound in medicine Kamaya, A., Vaithilingam, S., Chung, B. I., Oralkan, O., Khuri-Yakub, B. T. 2013; 32 (7): 1245-1250

  Abstract

  Photoacoustic imaging is a promising new technology that combines tissue optical characteristics with ultrasound transmission and can potentially visualize tumor depth in bladder cancer. We imaged simulated tumors in 5 fresh porcine bladders with conventional pulse-echo sonography and photoacoustic imaging. Isoechoic biomaterials of different optical qualities were used. In all 5 of the bladder specimens, photoacoustic imaging showed injected biomaterials, containing varying degrees of pigment, better than control pulse-echo sonography. Photoacoustic imaging may be complementary to diagnostic information obtained by cystoscopy and urine cytologic analysis and could potentially obviate the need for biopsy in some tumors before definitive treatment.

  View details for DOI 10.7863/ultra.32.7.1245

  View details for PubMedID 23804347

• The unidirectional barbed suture for renorrhaphy during laparoscopic partial nephrectomy: stanford experience. Journal of laparoendoscopic & advanced surgical techniques. Part A Jeon, S. H., Jung, S., Son, H., Kimm, S. Y., Chung, B. I. 2013; 23 (6): 521-525

  Abstract

  Abstract Purpose: Using barbed suture represents a novel technical modification in the performance of minimally invasive partial nephrectomy. Our purpose of this study was to evaluate the safety and efficacy of this suture for renorrhaphy during laparoscopic partial nephrectomy (LPN). Patients and Methods: Thirteen consecutive patients underwent LPN using V-Loc? 180 (Covidien, Dublin, Ireland) suture, and a nonconsecutive control group of 24 patients, matched according to tumor size and R.E.N.A.L. nephrometry score, underwent LPN using absorbable polyglactin suture. All 37 patients underwent LPN performed by a single surgeon. Perioperative and postoperative indicators of morbidity, estimated blood loss, and warm ischemia time (WIT) were compared between the groups. Results: Baseline characteristics including age, body mass index, American Society of Anesthesiologists score, tumor size, laterality, and R.E.N.A.L nephrometry score were identical between the groups. On multivariable analysis, there were no significant differences between the two groups with regard to operative time, estimated blood loss, transfusion rates, rates of surgical complications, and length of hospital stay. However, mean WIT was significantly shorter in the V-Loc group compared with the control group (24.5±5.3 minutes versus 31.9±8.9 minutes, P=.01). Conclusions: The use of V-Loc sutures for renorrhaphy during LPN is safe and feasible and, in our series, significantly reduces WIT. Further studies are needed to corroborate these findings, but these results indicate a promising development in reducing WIT during minimally invasive partial nephrectomy.

  View details for DOI 10.1089/lap.2012.0405

  View details for PubMedID 23414123

• Surgical outcomes and complications associated with presurgical tyrosine kinase inhibition for advanced renal cell carcinoma (RCC) UROLOGIC ONCOLOGY-SEMINARS AND ORIGINAL INVESTIGATIONS Harshman, L. C., Yu, R. J., Allen, G. I., Srinivas, S., Gill, H. S., Chung, B. I. 2013; 31 (3): 379-385

  Abstract

  Tyrosine kinase inhibitors (TKI) have dramatically changed the management paradigm of advanced renal cell carcinoma (RCC) and are increasingly being used preoperatively to achieve cytoreduction.To review our case series of post-TKI surgical procedures to add to the current perioperative efficacy and complication profile.Between October 2006 and February 2010, 14 cytoreductive nephrectomies, radical nephrectomies, and metastectomies were performed after neoadjuvant sunitinib or sorafenib for advanced RCC. During the same time frame, a control group of 73 consecutive patients underwent radical nephrectomy, cytoreductive nephrectomy, or metastectomy in the absence of prior systemic therapy. We compared the incidence of perioperative complications and outcomes after surgical procedures between the two cohorts.Median preoperative renal mass size was 11 cm (6.7-24.2 cm). Primary tumor shrinkage was seen in 57%; median shrinkage was 18% (8%-25%). The median treatment period was 17 weeks, and the median time from TKI discontinuation was 2 weeks. Compared with a control group and after adjusting for confounding covariates, presurgical TKI use was not associated with a significant increase in perioperative complications (50% vs. 40%, P = 0.25) or perioperative bleeding (36% vs. 34%, P = 0.97) but was associated with increased incidence and grade of intraoperative adhesions (86% vs. 58%, P = 0.001; grade 3 vs. 1, P = 0.002).Compared with the published reports, we observed less hemorrhagic and wound healing issues but a significant increase in incidence and severity of intraoperative adhesions, which can present a formidable technical challenge. Potential reasons for our lower complication rate could be increased time from TKI discontinuation to surgery, longer time to postoperative TKI re-initiation, increased use of preoperative angioembolization, and the lack of preoperative bevacizumab administration. Presurgical TKI therapy can permit effective surgical cytoreduction with a safety and complication profile equivalent to that of non-TKI-nephrectomy; however safety data continue to evolve, and preoperative TKI use requires further prospective investigation.

  View details for DOI 10.1016/j.urolonc.2011.01.005

  View details for PubMedID 21353796

• TEMPORAL TRENDS IN UTILIZATION OF CYTOREDUCTIVE NEPHRECTOMY AND PATIENT SURVIVAL IN THE TARGETED THERAPY ERA Annual Meeting of the American-Urological-Association (AUA) Conti, S. L., Hagedorn, J., Chung, B. I., Srinivas, S., Leppert, J. ELSEVIER SCIENCE INC. 2013: E753?E753

  View details for Web of Science ID 000320281602402

• The Accordion Antiretropulsive Device Improves Stone-Free Rates During Ureteroscopic Laser Lithotripsy JOURNAL OF ENDOUROLOGY Wu, J. A., Ngo, T. C., Hagedorn, J. C., Macleod, L. C., Chung, B. I., Shinghal, R. 2013; 27 (4): 438-441

  Abstract

  The Accordion is a novel endoscopic device that prevents retropulsion of ureteral stones and their fragments during ureteroscopic laser lithotripsy. We describe our experience with its use focusing on three main endpoints: operating time, fluoroscopy time, and stone-free rates.Of 308 consecutive cases of unilateral ureteroscopic laser lithotripsy from 2006-2010, we analyzed 235 cases of ureteral stones. Chart review was performed to document patient demographics (age, sex, and race), stone characteristics (stone size, density, laterality, location, and multiplicity), operative characteristics (use of preoperative and/or postoperative stents, ureteral balloon dilators, ureteral access sheaths, the Holmium laser, and the Accordion device), and surgical outcomes (operative time, fluoroscopy time, stone-free status, and complications).The baseline characteristics between the Accordion and non-Accordion group were statistically similar. In univariate nonparametric tests of medians, Accordion device usage was not associated with a significant reduction in fluoroscopy time (median 1.68 vs. 1.95 minutes, p=0.28) or operating time (median 52.5 vs. 61 minutes, p=0.19). However, the stone-free rate for the Accordion group was significantly higher compared to the non-Accordion group (84.2% vs. 53.6%, p=0.001). In multivariate generalized linear models, Accordion usage was not associated with decreased operating or fluoroscopy times. Accordion use was associated with statistically significant greater odds of stone-free status (odds ratio 4.35, 95% confidence interval 2.36-8.00). Complication severity and rates were comparable between the two groups.The Accordion antiretropulsive device improves stone-free rates during ureteroscopic laser lithotripsy. Prospective studies are needed to validate these results.

  View details for DOI 10.1089/end.2012.0332

  View details for Web of Science ID 000317353000009

  View details for PubMedID 23387558

• Three differentiation states risk-stratify bladder cancer into distinct subtypes PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Volkmer, J., Sahoo, D., Chin, R. K., Ho, P. L., Tang, C., Kurtova, A. V., Willingham, S. B., Pazhanisamy, S. K., Contreras-Trujillo, H., Storm, T. A., Lotan, Y., Beck, A. H., Chung, B. I., Alizadeh, A. A., Godoy, G., Lerner, S. P., van de Rijng, M., Shortliffe, L. D., Weissman, I. L., Chan, K. S. 2012; 109 (6): 2078-2083

  Abstract

  Current clinical judgment in bladder cancer (BC) relies primarily on pathological stage and grade. We investigated whether a molecular classification of tumor cell differentiation, based on a developmental biology approach, can provide additional prognostic information. Exploiting large preexisting gene-expression databases, we developed a biologically supervised computational model to predict markers that correspond with BC differentiation. To provide mechanistic insight, we assessed relative tumorigenicity and differentiation potential via xenotransplantation. We then correlated the prognostic utility of the identified markers to outcomes within gene expression and formalin-fixed paraffin-embedded (FFPE) tissue datasets. Our data indicate that BC can be subclassified into three subtypes, on the basis of their differentiation states: basal, intermediate, and differentiated, where only the most primitive tumor cell subpopulation within each subtype is capable of generating xenograft tumors and recapitulating downstream populations. We found that keratin 14 (KRT14) marks the most primitive differentiation state that precedes KRT5 and KRT20 expression. Furthermore, KRT14 expression is consistently associated with worse prognosis in both univariate and multivariate analyses. We identify here three distinct BC subtypes on the basis of their differentiation states, each harboring a unique tumor-initiating population.

  View details for DOI 10.1073/pnas.1120605109

  View details for PubMedID 22308455

• Laparoscopic Partial Nephrectomy for Completely Intraparenchymal Tumors JOURNAL OF UROLOGY Chung, B. I., Lee, U. J., Kamoi, K., Canes, D. A., Aron, M., Gill, I. S. 2011; 186 (6): 2182-2187

  Abstract

  Management for intraparenchymal renal tumors represents a technical challenge during laparoscopic partial nephrectomy since, unlike exophytic tumors, there are no external visual cues on the renal surface to guide tumor localization or excision. Also, hemostatic renorrhaphy and pelvicalyceal suture repair in these completely intrarenal tumors create additional challenges. We examined the safety and technical feasibility of this procedure in this cohort.Of 800 patients who underwent laparoscopic partial nephrectomy 55 (6.9%) had completely intraparenchymal tumors. Technical steps included intraoperative ultrasound guidance of tumor resection, en bloc hilar clamping, cold excision of tumor and sutured renal reconstruction.Mean tumor size was 2.3 cm (range 1.0 to 4.5), mean blood loss was 236 cc (range 25 to 1,000) and mean warm ischemia time was 29.9 minutes (range 7 to 57). There were no positive margins. When we compared laparoscopic partial nephrectomy for intraparenchymal tumors to the same procedure in another 3 tumor groups, including completely exophytic tumors, tumors infiltrating up to sinus fat and tumors infiltrating but not up to sinus fat, there were no statistically significant differences among the groups in complications, positive margin rate, blood loss, or tumor excision or warm ischemia time.Laparoscopic partial nephrectomy for completely intrarenal tumors is a technically advanced but effective, safe procedure. Facility and experience with the technique, effective use of intracorporeal laparoscopic ultrasound and adherence to sound surgical principles are the keys to success. Most recently we have performed laparoscopic and robotic partial nephrectomy for such completely intrarenal tumors using a zero ischemia technique.

  View details for DOI 10.1016/j.juro.2011.07.106

  View details for Web of Science ID 000296758600009

  View details for PubMedID 22014808

• Editorial comment. journal of urology Chung, B. I. 2011; 186 (5): 1848-?

  View details for DOI 10.1016/j.juro.2011.07.120

  View details for PubMedID 21944988

• Management of intraoperative splenic injury during laparoscopic urological surgery BJU INTERNATIONAL Chung, B. I., Desai, M. M., Gill, I. S. 2011; 108 (4): 572-576

  Abstract

  Study Type - Therapy (case series). Level of Evidence: 4. What's known on the subject? and What does the study add? The exact incidence of splenic injury during laparoscopic urologic procedures is not known; however, it is an uncommon occurrence. Also, the optimal treatment algorithm is not well delineated and the efficacy of successfully treating minor injuries to the spleen without resorting to splenectomy is not well described in the urologic literature. This study outlines the rate of splenic injury during a variety of laparoscopic urologic procedures and we outline a treatment algorithm that has been successfully employed in the management of these patients, which in all cases, did not lead to splenectomy. An important point is also that multiple adjunctive hemostatic measures should be used when a splenic injury is recognized and that a thorough search should ensue when suspicion of an occult splenic injury exists, as an unrecognized splenic injury may lead to severe post operative haemorrhagic complications.? To evaluate incidence, risk factors for, and management of intraoperative splenic injury in our laparoscopic patient cohort.? All patients undergoing laparoscopic urological upper tract procedures at two institutions between January 2001 and April 2006 and January 2000 and December 2008, respectively, were retrospectively examined for complications. ? From these patients, those with intraoperative splenic injuries were selected and examined. ? Possible factors predisposing patients to splenic injury were evaluated and the management plan for each patient was analysed to identify optimal treatment efficacy.? Of 2620 patients undergoing upper tract urological laparoscopic surgery, 14 patients (0.5%) sustained splenic injury and underwent left-sided surgery, 13 via a transperitoneal approach. ? In 12 of the 14 patients, the splenic injury was recognized intraoperatively and all were effectively managed laparoscopically with a combination of argon beam coagulation, biological haemostatic agent FloSeal(TM) (Baxter, Deerfield, IL, USA), and bio-absorbable Surgicel® (Johnson and Johnson, Somerville, NJ, USA); none of these patients required splenectomy or developed any postoperative complications. ? In two patients, the splenic injury was not recognized intraoperatively; both patients presented with delayed haemorrhage necessitating open splenectomy in each instance.? Splenic injuries are uncommon during laparoscopic urological surgery, but when a significant splenic injury occurs, it can be effectively managed laparoscopically, using conservative measures, without need for splenectomy. ? If the splenic injury is not recognized intraoperatively, delayed haemorrhage is likely to occur necessitating emergent re-exploration and splenectomy. ? Prompt and accurate intraoperative diagnosis of splenic injury is critical for achieving a good outcome.

  View details for DOI 10.1111/j.1464-410X.2010.09821.x

  View details for Web of Science ID 000294109500025

  View details for PubMedID 21062394

• Cost-Effectiveness Analysis of Nephron Sparing Options for the Management of Small Renal Masses JOURNAL OF UROLOGY Chang, S. L., Cipriano, L. E., Harshman, L. C., Garber, A. M., Chung, B. I. 2011; 185 (5): 1591-1597

  Abstract

  A recent increase in the detection of contrast enhancing renal masses 4 cm or smaller suspicious for malignancy has led to the widespread use of nephron sparing options. Limited data exist to help clinicians decide which of these competing nephron sparing therapies is most appropriate. We performed a cost-effectiveness analysis to evaluate the relative clinical and economic merits of commonly available nephron sparing strategies for small renal masses.We developed a decision analytic Markov model estimating the costs and health outcomes of treating a healthy 65-year-old patient with an asymptomatic unilateral small renal mass using competing nephron sparing options of immediate intervention (ie open and laparoscopic partial nephrectomy as well as laparoscopic and percutaneous ablation), active surveillance with possible delayed intervention and nonsurgical management with observation. Benefits were measured in quality adjusted life-years. We used a societal perspective, lifetime horizon and willingness to pay threshold of $50,000 per quality adjusted life-year gained. Model results were assessed with sensitivity analyses.In the base case scenario the least costly option was observation and the optimal option was immediate laparoscopic partial nephrectomy, which had an incremental cost-effectiveness ratio of $36,645 per quality adjusted life-year gained compared to surveillance with possible delayed percutaneous ablation. Results were sensitive to age at diagnosis, health status and tumor size.Immediate laparoscopic partial nephrectomy is the preferred nephron sparing option for healthy patients younger than 74 years old with a small renal mass. Surveillance with possible delayed percutaneous ablation is a cost-effective alternative for patients with advanced age or significant comorbidities. Observation maximizes quality adjusted life-years in patients who are poor surgical candidates or with limited life expectancy (less than 3 years).

  View details for DOI 10.1016/j.juro.2010.12.100

  View details for Web of Science ID 000289279600013

  View details for PubMedID 21419445

• Comparison of prostate cancer tumor volume and percent cancer in prediction of biochemical recurrence and cancer specific survival 103rd Annual Meeting of the American-Urological-Association Chung, B. I., Tarin, T. V., Ferrari, M., Brooks, J. D. ELSEVIER SCIENCE INC. 2011: 314?18

  Abstract

  Tumor volume and percent cancer (ratio of tumor volume/prostate volume) have been proposed as predictors of biochemical recurrence and cancer specific survival after radical prostatectomy. However, their relative merits as prognosticators have not been tested. We therefore evaluated and compared tumor volume and percent cancer as independent predictors of biochemical recurrence and prostate cancer specific death after radical prostatectomy.A retrospective review of 739 patients who underwent radical prostatectomy for prostate cancer between 1984 and 2004 was conducted. Median follow-up was 91.7 months, and 22 patients died of prostate cancer. Univariate and multivariate analysis evaluated the following factors in predicting biochemical recurrence and prostate cancer specific death: tumor volume, prostate volume, percent cancer, Gleason score, percentage of Gleason grade 4/5, margin status, capsular invasion status, seminal vesicle invasion status, preoperative PSA, and lymph node status.In univariate analysis, both tumor volume (P<0.001) and percent cancer (P<0.001) significantly correlated with biochemical recurrence. Since they are highly correlated, they did not predict outcome independently when included in the same model; however, both were highly predictive for biochemical recurrence in separate multivariate models (P=0.01 for both). Both also correlated with cancer specific survival as single variables; however, in separate multivariate models, only tumor volume (P=0.03) predicted death, while percent cancer did not (P=0.09).Tumor volume and percent cancer are independent predictors of recurrence after radical prostatectomy. However, in our series, tumor volume predicted cancer specific death better than percent cancer. Therefore, accurate determination of tumor volume, along with other accepted pathologic indices, is sufficient and preferred over percent cancer for prognostication after radical prostatectomy.

  View details for DOI 10.1016/j.urolonc.2009.06.017

  View details for Web of Science ID 000290779400016

  View details for PubMedID 19837617

• Comparison of Holding Strength of Suture Anchors on Human Renal Capsule JOURNAL OF ENDOUROLOGY Kimm, S., Tarin, T., Chung, B., Shinghal, R., Reese, J. 2010; 24 (2): 293-297

  Abstract

  The use of surgical clips as suture anchors has made laparoscopic partial nephrectomy (LPN) technically simpler by eliminating the need for intracorporeal knot tying. However, the holding strength of these clips has not been analyzed in the human kidney. Therefore, the safety of utilizing suture anchors is unknown as the potential for clip slippage or renal capsular tears during LPN could result in postoperative complications including hemorrhage and urinoma formation. With the above in mind, we sought to compare the ability of Lapra-Ty clips and Hem-o-lok clips to function as suture anchors on human renal capsule.Fresh human cadaveric kidneys with intact renal capsules were obtained. A Lapra-Ty clip (Ethicon, Cincinnati, OH) or a Hem-o-lok clip (Weck, Raleigh, NC) was secured to a no. 1 Vicryl suture (Ethicon) with and without a knot, as is typically utilized during the performance of LPN. The suture was then placed through the renal capsule and parenchyma and attached to an Imada Mechanical Force Tester (Imada, Northbrook, IL). The amount of force required both to violate the renal capsule and to dislodge the clip was recorded separately.Six Lapra-Ty clips and six Hem-o-lok clips were tested. The mean force in newtons required to violate the renal capsule for the Lapra-Ty group was 7.33 N and for the Hem-o-lok group was 22.08 N (p < 0.001). The mean force required to dislodge the clip from the suture for the Lapra-Ty group was 9.0 N and for the Hem-o-lok group was 3.4 N (p < 0.001). When two Hem-o-lok clips were placed on the suture in series, the mean force required to dislodge the clips was 10.6 N.When compared with Lapra-Ty clips, using two Hem-o-lok clips may provide a more secure and cost-effective method to anchor sutures on human renal capsule when performing LPN.

  View details for DOI 10.1089/end.2009.0211

  View details for Web of Science ID 000274423500021

  View details for PubMedID 20050785

• Laparoscopic Radical Nephrectomy in a Pelvic Ectopic Kidney: Keys to Success JSLS-JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS Chung, B. I., Liao, J. C. 2010; 14 (1): 126-129

  Abstract

  Laparoscopic radical nephrectomy of a pelvic kidney for renal cell carcinoma is a procedure with little precedent, but one that offers the advantages of the minimally invasive approach. We present our experience with this unique procedure.A 64-year-old male with a history of end-stage renal disease was diagnosed with a 2.6-cm enhancing mass in a pelvic left kidney with 2 separate sources of blood supply. He was offered either an open radical nephrectomy or a laparoscopic radical nephrectomy and opted for the minimally invasive approach.The procedure was performed successfully without complications and with minimal blood loss. The case was marked both by difficulty in mobilizing the sigmoid colon and the limited working space of the pelvis, which made localization of the numerous hilar vessels challenging.Laparoscopic radical nephrectomy for a pelvic ectopic kidney appears to be safe and efficacious. Success is dependent on familiarity with pelvic anatomy, optimal port placement, and preprocedure knowledge of the often-complicated vascular anatomy of the ectopic kidney. Preoperative imaging to delineate anomalous vascular anatomy is mandatory, and ureteral catheter placement is helpful for intraoperative identification purposes.

  View details for DOI 10.4293/108680810X12674612765623

  View details for Web of Science ID 000278761200023

  View details for PubMedID 20529537

  View details for PubMedCentralID PMC3021314

• Laparoscopic radical nephrectomy after shrinkage of a caval tumor thrombus with sunitinib NATURE REVIEWS UROLOGY Harshman, L. C., Srinivas, S., Kamaya, A., Chung, B. I. 2009; 6 (6): 338-343

  Abstract

  A 57-year-old woman presented to the emergency department at a community hospital with a 2-month history of fatigue and right-sided flank and abdominal pain. Noncontrast CT of the abdomen and pelvis revealed a 9.1 cm right renal mass.Contrast CT of the chest, abdomen and pelvis, MRI of the abdomen and pelvis with gadolinium, radionuclide bone scan, lung nodule biopsy, complete blood count, comprehensive metabolic profile, and measurement of serum lactate dehydrogenase.Stage IV, T3bN0M1 clear cell renal cell carcinoma, with an associated tumor thrombus extending into the vena cava.The patient was treated with neoadjuvant sunitinib, which resulted in a marked response in the primary tumor and metastatic lesions as well as regression of the tumor thrombus well into the renal vein. Thus, laparoscopic radical nephrectomy was feasible and was achieved without hemorrhagic or wound healing complications. One month after surgery, she had evidence of disease progression in the lung and a periaortic lymph node. She was restarted on sunitinib with resultant disease stabilization, but discontinued the drug owing to toxicity. Eight months after cessation of sunitinib, she received a dendritic cell vaccine. She remains alive without evidence of disease progression 2 years after her diagnosis.

  View details for DOI 10.1038/nrurol.2009.84

  View details for PubMedID 19498412

• Laparoscopic splenorenal venous bypass for nutcracker syndrome JOURNAL OF VASCULAR SURGERY Chung, B. I., Gill, I. S. 2009; 49 (5): 1319-1323

  Abstract

  Nutcracker syndrome is a rare entity caused by extrinsic compression on the left renal vein as it crosses between the superior mesenteric artery and the aorta. It can clinically present with flank pain and hematuria. Accepted treatments include open vascular bypass procedures or endoluminal stenting. We present the first description, to our knowledge, of a laparoscopic splenic vein-left renal vein bypass to relieve the outflow obstruction. The patient, a 29-year-old woman with debilitating left flank pain, presented with nutcracker syndrome. Left renal vein outflow was obstructed at the level of the intersection between the aorta and the superior mesenteric artery. The option of laparoscopic splenic to left renal vein bypass was discussed and performed. A five-port transperitoneal approach was used. Meticulous vascular control was achieved with numerous laparoscopic vascular bulldog clamps. With completely intracorporeal suturing techniques, the splenic vein was anastomosed to the superior aspect of the anterior left renal vein. Total warm ischemia time was 37 minutes. The anastomosis was watertight immediately upon unclamping. Interestingly, upon unclamping, the luminal diameter of the splenic vein appeared to increase to twice its native diameter. The proximal left renal vein appeared less distended, indicating preferential venous outflow through the newly created venous bypass. Blood loss was minimal, no intraoperative or postoperative complications occurred, and the patient's symptoms improved. This report continues to augment the indications for laparoscopic surgery in even complex, urologic vascular situations.

  View details for DOI 10.1016/j.jvs.2008.11.062

  View details for Web of Science ID 000265744700038

  View details for PubMedID 19307081

• Perioperative Efficacy of Laparoscopic Partial Nephrectomy for Tumors Larger than 4 cm EUROPEAN UROLOGY Simmons, M. N., Chung, B. I., Gill, I. S. 2009; 55 (1): 199-208

  Abstract

  Laparoscopic partial nephrectomy (LPN) is typically reserved for kidney tumors < or = 4 cm in size. The use of LPN in patients with larger tumors (> 4 cm) has not been systematically evaluated.To examine technical feasibility and perioperative safety and efficacy of LPN for clinical stage pT1b-T2 tumors > 4 cm.This is a retrospective review of data from an Institutional Review Board-approved, prospectively maintained database of 425 LPN procedures over a 6-yr period (September 1999 through December 2005). Patients were grouped according to tumor size: control group 1: < 2 cm (n=89; 21% of patients); control group 2: 2-4 cm (n=278; 65% of patients); and study group 3: > 4 cm (n=58; 14% of patients).Retroperitoneal and transperitoneal LPN.Serum creatinine levels, estimated glomerular filtration rates.For groups 1, 2, and 3, mean tumor size was 1.5 cm, 2.9 cm, and 6 cm in diameter, respectively (p<0.001). Study group 3 patients more often had an American Society of Anesthesiologists score > or = 3 (p<0.05), central tumors (p<0.001), pelvicalyceal repair (p=0.004), and heminephrectomy (p<0.001). Total operative time, estimated blood loss, and duration of hospital stay were equivalent. Mean warm ischemia time was 30 min, 32 min, and 38 min in groups 1, 2, and 3, respectively (p=0.007). Tumor size > 4 cm did not increase significant risk for positive tumor margins, intraoperative complications, or postoperative genitourinary complications. In each group preoperative stage > or = 3 chronic kidney disease (CKD) was present in 31%, 35%, and 44% of patients in groups 1, 2, and 3, respectively (p=0.15); postoperatively, stage 3-5 CKD incidence increased to 52%, 52%, and 63% in groups 1, 2, and 3, respectively (p=0.20). Patients with tumor size > 4 cm and preoperative stage 3-5 CKD had an 8-fold increase in risk for CKD stage progression. Limitations of the study include retrospective analysis and a relatively low number of patients in group 3.Given laparoscopic expertise and appropriate patient selection, LPN is feasible and efficacious for kidney tumors > 4 cm. Indications for LPN should be expanded to include patients with amenable tumors > 4 cm in order to maximally preserve kidney function in these patients.

  View details for DOI 10.1016/j.eururo.2008.07.039

  View details for Web of Science ID 000262066700023

  View details for PubMedID 18684555

• Laparoscopic Dismembered Pyeloplasty of a Retrocaval Ureter: Case Report and Review of the Literature EUROPEAN UROLOGY Chung, B. I., Gill, I. S. 2008; 54 (6): 1433-1436

  Abstract

  A retrocaval ureter is a rare entity that has traditionally been treated with open pyeloplasty techniques. In this paper, we describe the successful performance of a laparoscopic dismembered pyeloplasty for a retrocaval ureter and present important technical points. In reviewing the available literature about this technique, the laparoscopic approach should be considered to be first-line treatment for this anatomic anomaly due to the good track record, quick convalescence, and relative technical ease.

  View details for DOI 10.1016/j.eururo.2008.09.010

  View details for Web of Science ID 000261677600028

  View details for PubMedID 18805629

• Fellowship in endourology, the job search, and setting up a successful practice: An insider's view JOURNAL OF ENDOUROLOGY Chung, B. I., Matin, S. F., Ost, M. C., Winfield, H. N. 2008; 22 (3): 551-557

  Abstract

  The field of endourology, which encompasses genitourinary endoscopy and percutaneous, laparoscopic, and robotic surgery, has advanced rapidly over the past quarter century, causing endourology to be considered a subspecialty of urology. The Endourological Society, which is recognized by the American Urological Association, offers numerous clinical and research fellowship opportunities throughout the world. The decision to seek postresidency fellowship training in endourology is complex as is the process of seeking subsequent employment. We offer guidance on the decision-making process to obtain fellowship training as well as on early steps into subsequent academic or private practice settings.

  View details for DOI 10.1089/end.2007.0144

  View details for Web of Science ID 000254829500030

  View details for PubMedID 18307381

• Ureteroscopic versus percutaneous treatment for medium-size (1-2-cm) renal calculi JOURNAL OF ENDOUROLOGY Chung, B. I., Aron, M., Hegarty, N. J., Desai, M. M. 2008; 22 (2): 343-346

  Abstract

  To compare the outcomes of percutaneous nephrolithotomy (PCNL) and ureterorenoscopy (URS) for 1- to 2-cm renal calculi with specific reference to the stone clearance rate and morbidity.The records of 27 patients who underwent either PCNL (N = 15) or URS (N = 12) by standard techniques over an 8-month period for renal calculi between 1 and 2 cm were reviewed retrospectively. Demographic, intraoperative, and postoperative data were accrued and compared to identify any statistically significant differences. The median stone burden was slightly but not significantly higher in the PCNL group (1.8 cm v 1.25 cm; P = 0.19). Postoperative plain films were used to confirm stone clearance.The procedure was technically successful in all 27 patients. No patient in either group required a repeat session or ancillary procedure. All 15 PCNL procedures were completed through a single percutaneous tract. The PCNL and URS groups were equivalent with respect to operative time (79.0 minutes v 68.5 minutes) and incidence of complications (2 v 0). No patient in either group had significant hemorrhage or required blood transfusion. The overall stone-free rate was 87% for PCNL and 67% for URS (P = 0.36).Both PCNL and URS are effective options for renal calculi between 1 and 2 cm. The stonefree and complication rates for PCNL are higher, but the differences were not statistically significant in our series. The operative times are statistically equivalent, despite the potentially longer fragmentation times required for URS. The choice of treatment ultimately depends on the individual surgeon's preference and level of expertise.

  View details for DOI 10.1089/end.2006.9865

  View details for Web of Science ID 000253719900021

  View details for PubMedID 18294042

• Second prize: 2006 endourological society essay competition - Preliminary experience with the Niris (TM) optical coherence tomography system during laparoscopic and robotic prostatectomy JOURNAL OF ENDOUROLOGY Aron, M., Kaouk, J. H., Hegarty, N. J., Colombo, J. R., Haber, G., Chung, B. I., Zhou, M., Gill, I. S. 2007; 21 (8): 814-818

  Abstract

  To evaluate the feasibility of high-resolution optical coherence tomography (OCT) in the identification of neurovascular bundles (NVBs) during laparoscopic and robotic radical prostatectomy (LRP).Between November 2005 and March 2006, 24 patients undergoing transperitoneal laparoscopic or robotic radical prostatectomy were enrolled in this study. Once the bladder was taken down and the prostate mobilized, the Niris imaging system was deployed. In each patient, in-vivo images were obtained to determine the image characteristics of NVBs, adipose tissue, prostate capsule, and endopelvic fascia. The NVB was imaged again in vivo, after the prostate was excised. Ex-vivo images were obtained from the prostate surface to look for the presence or absence of the NVBs and correlated with the surgeon's assessment of the adequacy of nerve sparing.From 24 patients, we obtained more than 300 OCT images of tissue structures including endopelvic fascia, prostate capsule, NVBs, fat, lateral pedicles, and lymphatics. These images were found to correlate independently with the surgeon's impression of the tissue being imaged. Preliminary comparison with parallel histologic evaluation was performed in four patients that suggested OCT could help to identify the NVBs and prostate capsule during LRP.In our preliminary experience with the Niris system during LRP, OCT was able to image the NVB in all patients. This could enhance surgical precision during nerve sparing and positively impact potency rates after radical prostatectomy. Further research will be needed, including parallel histologic evaluation and follow-up, to validate the findings of OCT imaging.

  View details for DOI 10.1089/end.2006.9938

  View details for Web of Science ID 000249550800003

  View details for PubMedID 17867934

• The use of bowel for ureteral replacement for complex ureteral reconstruction: Long-term results JOURNAL OF UROLOGY Chung, B. I., Hamawy, K. J., Zinman, L. N., Libertino, J. A. 2006; 175 (1): 179-183

  Abstract

  Ileal and intestinal ureteral replacement remains a useful procedure for complex ureteral reconstruction. We examined the long-term safety and efficacy of this procedure, especially in regard to maintaining preoperative renal function and the avoidance of major complications.A total of 56 patients underwent intestinal ureteral substitution at our institution between 1979 and 2003, including 52 with an ileal ureteral replacement, 2 with colonic replacement alone and 2 with bilateral ureteral replacement, necessitating ileum and colon for 1 ureter each. The factors reviewed were indications for surgery, type of ureteral replacement, and the presence and type of complications. Followup data included excretory urogram or equivalent imaging results, and measurement of serum chloride, bicarbonate and creatinine before and after the procedure.Overall the complication rate remained low. Mean followup was 6.04 years (median 3.2). Most postoperative complications, which occurred in 10 patients (17.9%), were minor in nature, including pyelonephritis, fever of unknown origin, neuroma, hernia, recurrent urolithiasis and deep venous thrombosis. Major complications occurred in 6 patients (10.5%), including anastomotic stricture, ileal graft obstruction, wound dehiscence and chronic renal failure. Overall patients did not experience worsening renal function after the procedure with equivalent median creatinine before and after the procedure (1.0 mg/dl).During long-term followup major complications are rare and renal function remains preserved. Ileal and intestinal ureteral substitution remains a safe and efficacious procedure in patients with complex and difficult ureteral issues not amenable to more conservative measures.

  View details for DOI 10.1016/S0022-5347(05)00061-3

  View details for Web of Science ID 000234001100047

  View details for PubMedID 16406903

• Laparoscopic Retroperitoneal Lymph Node Dissection for Stage I Nonseminomatous Germ Cell Tumors ? Do We Meet the Standards of Open Surgery? American Journal of Urology Review Chung BI, Tuerk IA 2005; 3 (9): 411-415
• Laparoscopic Partial Nephrectomy : Alternative Surgical Approach for Renal Masses < 4 cm American Journal of Urology Review Chung BI, Tuerk IA 2004; 2 (10): 477-479
• Expression of the proto-oncogene Axl in renal cell carcinoma DNA AND CELL BIOLOGY Chung, B. I., Malkowicz, S. B., Nguyen, T. B., Libertino, J. A., McGarvey, T. W. 2003; 22 (8): 533-540

  Abstract

  In this investigation, we examined the role of the Axl proto-oncogene in renal cell carcinoma (RCC). Axl is a tyrosine kinase receptor implicated in myeloid leukogenesis, and has been found to be overexpressed in lung cancers and breast cancers. Axl has been described to act as a mitogenic factor along with its ligand Gas-6. Axl has also shown to have a role in apoptosis, cell adhesion, and chemotaxis. The differential expression of the Axl RNA transcript was examined in 20 pairs of matched normal kidney and clear cell RCC patient samples. We found that there was a significant increase in the steady-state levels of Axl mRNA in the RCC compared with the normal kidney pair (Student's paired t-test P < 0.001). There was also a significant increase in Axl expression overall in RCC compared to normal kidney (P < 0.03). Western blotting was utilized to determine Axl protein levels in six out of the 20 pairs of the normal/RCC matched pairs. Overall, the level of expression was not significantly different between the paired normal kidneys and kidney tumors, but the detected Axl protein appeared to be at slightly different molecular weights. Primers were constructed for the two known Axl variant, RT-PCR performed, but no differences were observed in the expression of each variant. Next, we performed a gene silencing experiment utilizing double-stranded RNA constructed to silence the Axl gene in the 293 transformed kidney cell line. There was a 50% decrease in Axl gene expression in the RNAi transfected over control cells. In addition, flow cytometry performed to determine DNA content showed a 30% increase in G1/G0 cells, which were transfected with axl RNAi compared to control. Altogether, these findings suggest an overexpression of Axl as part of a proliferative phenotype in RCC.

  View details for Web of Science ID 000185482300007

  View details for PubMedID 14565870

• The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux JOURNAL OF UROLOGY Cooper, C. S., Chung, B. I., Kirsch, A. J., Canning, D. A., Snyder, H. M. 2000; 163 (1): 269-272

  Abstract

  Accepted management of vesicoureteral reflux includes surgical correction or prophylactic antibiotics with the hope for resolution as the child grows. The physician must consider surgery when reflux does not resolve despite uneventful years on prophylactic antibiotics. An alternative is cessation of the antibiotics. We report on the outcome of children taken off antibiotics with persistent reflux.During a 14-year period 51 children with documented reflux were taken off antibiotic prophylaxis. Selection criteria included children who were old enough to verbalize the symptoms of a urinary tract infection, and had normal voiding patterns, a minor history of infections and minimal or no renal scarring. Routine followup included nuclear cystography and renal sonography.A total of 40 girls and 11 boys maintained on antibiotics for a mean of 4.8 years were taken off prophylaxis and followed for an average of 3.7 years. Mean patient age when prophylactic antibiotics were stopped was 8.6 years. Reflux resolved in 10 children (19.6%). A urinary tract infection developed in 5 girls and 1 boy (11.8%) (mean age 11) an average of 2.3 years (range 4 months to 9.4 years) after antibiotic discontinuation. One child had symptoms consistent with cystitis and 5 had febrile urinary tract infections. All were treated with oral antibiotics and 5 had subsequent operations. No new renal scars developed.The majority of children did well following cessation of antibiotic prophylaxis despite persistent vesicoureteral reflux. Cessation of antibiotic prophylaxis is a reasonable option in a highly select patient population with reflux.

  View details for Web of Science ID 000084324900091

  View details for PubMedID 10604374