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Incontinence after robot-assisted radical prostatectomy (RARP) significantly impacts quality of life. This study aims to compare the age-stratified continence outcomes in Canadian men undergoing RARP.A retrospective review was performed on a prospectively maintained database of 1737 patients who underwent RARP for localized prostate cancer between 2007 and 2019. Patients were stratified into five groups based on age: group 1, ≤ 54 years (n = 245); group 2, 55-59 years (n = 302) ; group 3, 60-64 years (n = 386); group 4, 65-69 years (n = 348); and group 5, ≥ 70 years (n = 116). Functional outcomes were assessed up to 36 months. Log-rank and multivariable Cox regression analyses were performed to compare the time to recovery of pad-free continence by age group.Continence rates of groups 1 to 5 were respectively 90.2%, 79.1%, 80.4%, 71.4%, and 59.8% at 1-year follow up (p0.001). After 3 years, groups 1 through 5 had continence rates of 97%, 91.7%, 89.3%, 81.4%, and 77.6%, respectively (p0.001). Median time to recovery of continence was 58, 135, 140, 152 and 228 days, respectively. Among men who remained incontinent, older patients consistently required more pads. In Cox proportional hazard model, groups 2, 3, 4 and 5 were respectively 33% (p0.001), 34% (p0.001), 33% (p = 0.001), and 41% (p = 0.005) more likely to remain incontinent compared to group 1.Age is associated with significantly lower rates of continence recovery, longer time to recovery of continence, and more severe cases of incontinence after RARP.

Most Canadian hospitals face significant reductions in operating room access during the summer. We sought to assess the impact of longer wait times on the oncological outcomes of localized prostate cancer patients following robotic-assisted radical prostatectomy (RARP). We conducted a retrospective review of a prospectively maintained RARP database in two high-volume academic centers, between 2010 and 2019. Assessed outcomes included the difference between post-biopsy UCSF-CAPRA and post-surgical CAPRA-S scores, Gleason score upgrade and biochemical recurrence rates (BCR). Multivariable regression analyses (MVA) were used to evaluate the effect of wait times. A total of 1057 men were included for analysis. Consistent over a 10 year period, summer months had the lowest surgical volumes despite above average booking volumes. The lowest surgical volume occurred during the month of July (7.1 cases on average), which was 35% less than the cohort average. The longest average wait times occurred for patients booked in June (93 ± 69 days, p

Testosterone replacement therapy (TRT) remains controversial in men with treated prostate cancer. We assessed its safety and functional impacts in patients after definitive surgical treatment with robotic-assisted radical prostatectomy (RARP). We performed a retrospective analysis of 1303 patients who underwent RARP during the years 2006–2019. We identified men with symptoms of andropause and low serum testosterone who received TRT post-RARP; then we divided the cohort into two groups accordingly for comparison. Biochemical recurrence (BCR) was the primary endpoint. Secondary endpoints included functional outcomes. Predictors of BCR, including the effect of TRT on BCR, were evaluated using univariable and multivariable logistic regression. Among the forty-seven men who received TRT, the mean age was 60.83 years with a median follow-up of 48 months. Three (6.4%) and 157 (12.56%) patients experienced BCR in TRT and non-TRT groups, respectively. Baseline characteristics were similar between both groups except for higher mean BMI in the TRT group (p = 0.03). In the multivariate analysis (MVA), higher pre-RARP prostate-specific antigen (PSA) (p = 0.043), higher International Society of Urological Pathology score (p

Novel laser technologies have been developed for the minimally invasive surgical management of benign prostatic hyperplasia (BPH). The objective of this study was to assess the safety and efficacy of MOSESTM technology versus the thulium fiber laser (TFL) in patients with BPH undergoing transurethral enucleation of the prostate.We conducted a retrospective review of prospectively collected data of eighty-two patients who underwent transurethral enucleation of the prostate using MOSESTM or TFL technologies from August 2020 to September 2021. Preoperative and intraoperative parameters, in addition to postoperative outcomes, were collected and analyzed.Twenty patients underwent transurethral enucleation of the prostate with TFL, while 62 had MOSESTM HoLEP. No statistically significant difference in preoperative characteristics was observed between the groups. Patients in the TFL group had longer median enucleation, hemostasis, and morcellation times (p0.001) than those in the MOSESTM cohort. The longer morcellation time of TFL is mostly related to less visibility. The postoperative outcomes IPSS, QoL, Qmax, and post void residual (PVR), were comparable between the groups at 1, 3 and 6 months. The incidence of urge urinary incontinence (p = 0.79), stress urinary incontinence (p = 0.97), and hospital readmission rates (p = 0.1) were comparable between the two groups.A satisfactory safety and efficacy profile with comparable postoperative outcomes was demonstrated for both techniques; though, MOSESTM technology was superior to TFL in terms of shorter overall operative time.

Background: In 2018, our Institute launched the Diagnostic Assessment Program (DAP) for prostate cancer. It enabled quick access to a urologist for patients presented to family physician with elevated PSA and allowed fast multidisciplinary patient care. We aim to document our data over 2 years in comparison to data before implementation of DAP and its impact on the degree of adherence to Canadian guidelines. Methods: From April 2016 to April 2020, 880 patients who were evaluated for prostate cancer at Thunder Bay Regional Health Sciences Centre (TBRHSC) were included in this study. Patients’ characteristics, clinical data, waiting times and line of treatment before and after implementation of DAP were calculated and statistically analysed. Results: The median waiting time to urology consultation was significantly reduced from 68 (IQR 27-168) days to 34 (23-44) days (p < 0.001). The time from patient’s referral to prostate biopsy decreased substantially from 34 (20-66) days to 18(11- 25) days after DAP (p < 0.001). After DAP, the percentage of Gleason 6 detected prostate cancers were significantly increased (19.7% to 30%) (p = 0.02). After DAP, rate for intermediate-risk patients elected for external beam radiotherapy (from 53.5% to 57.9%, p = 0.53) and radical prostatectomy (from 34.5% to 39.4%, p = 0.47) increased. More compliance to Canadian guidelines was observed in intermediate risk patients (88% vs 97.3%, p =.008). Conclusions: Implementation of DAP has led to a notable reduction of waiting time to urology consult and prostate biopsy. There is significant increase in Gleason 6 detected prostate cancer. Increased compliance to Canadian guidelines was detected in intermediate risk patients.

Purpose To evaluate changes in global perioperative data of GreenLight-XPS 180-Watt photo-selective vaporization of the prostate (GL-XPS) of the Global Greenlight Group (GGG) database. Methods 3441 men, who underwent GL-XPS for symptomatic BPH between 2011 and 2019 at seven high volume international centers, were included. Primary outcome measurements were operative time (OT; min), effective laser time (LT; min of OT), as well as intraoperative and postoperative adverse events (AEs), all analyzed by year of surgery (2011–2019) and prostate volume (PV) group ( 150 ml). Results The median age was 70 years (interquartile range 64–77), the median PV was 64 ml (IQR 47–90). The OT and LT slightly increased but stayed highly efficient all in all. Median OT was 60 min (IQR 45–83) and LT was 33 min (IQR 23–46). Median energy use was 253 kJ (IQR 170–375) with an energy density of 3.94 kJ/ml (IQR 2.94–5.02). The relative probability of perioperative AEs decreased by 17% each year (p p = 0.007). The early postoperative complications (within 30 days after surgery) decreased significantly from 48.8% (n = 106) in 2011 to 24.7% (n = 20) in 2019 (p > 0.001). Conclusion These findings from the GGG demonstrate significant improvement secondary to growing experience with GL-XPS between 2011 and 2019 in intraoperative AEs, including transfusions, and postoperative AEs. While staying highly efficient in OT and LT of GL-XPS within a 9-year period of experience.

To determine the safety and efficacy of same-day urethral catheter removal after laser vaporization of the prostate and to identify factors contributing to a successful trial of void (TOV).We conducted a retrospective analysis of 98 patients who underwent laser vaporization of the prostate using GreenLight or Holmium Xpeeda laser fibers from April 2018 to March 2021. All patients included in the study were offered a same-day TOV and had their catheters removed 3 hours postoperatively. Patient demographics, intraoperative parameters, and postoperative outcomes were collected and analyzed. Patients who were medically unfit or those on antiplatelet or anticoagulant medications were excluded. Multivariate logistic regression analyses were used to determine potential predictors of a failed TOV.The median age of included patients was 69 years (56-86) with a prostate size of 54 grams (40-78.4). The median operative time was 50 minute (20-93). 72 patients (73.5%) had a successful TOV without the need for urethral catheter reinsertion. The median hospital stay for patients was 5 hours. Preoperative post-void residual (PVR) urine was the only predictor of a successful TOV on both univariate and multivariate logistic regression analyses.Same-day catheter removal following laser vaporization of the prostate is a feasible option with a 73.5% success rate.

Introduction and Objectives: The GreenLight™ MoXy® laser fiber has been used since 2010 for benign prostatic hyperplasia procedures. We tested a novel principle to increase the saline irrigation fl...

Previous analyses of the impact of median lobe presence on Greenlight photoselective vaporization of the prostate (PVP) outcomes were limited by their small sample size and the ability to adjust for important confounders. As such, we sought to investigate the impact of prostate median lobe presence on the operative outcomes of 180 W XPS GreenLight PVP using a large international database. Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. All men with established benign prostatic hyperplasia who underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019 were eligible for the study. Patients were assigned to two groups based on presence or absence of median lobes. Analyses were adjusted for patient age, prostate volume, body mass index, and American Society of Anesthesia (ASA) score. A total of 1650 men met the inclusion criteria. A median lobe was identified in 621 (37.6%) patients. Baseline prostate volume, patient age, and ASA score varied considerably between the two groups. In adjusted analyses, the operative and lasing time of patients with median lobes was 6.72 (95% CI 3.22–10.23; p

The aim of the study is to evaluate the impact of having a nadir and persistently detectable ultrasensitive prostate-specific antigen (uPSA) between 0.01 and 0.1 ng/ml post-robot-assisted radical prostatectomy (RARP), on future biochemical recurrence (BCR). We conducted a retrospective analysis of a prospectively maintained cohort of 1359 men who underwent RARP, between 2006 and 2019. Patients were followed with uPSA at 1, 3, 6, 9, 12, 18, 24, 30, 36 months and annually thereafter. We included patients with PSA nadir values between 0.01 and 0.1 ng/ml within 6 months of surgery and with at least 2 follow-up measurements within the same range. We divided patients based on their BCR status and analyzed uPSA changes. Multivariable Cox-regression models (CRMs) were used to analyze variables predicting BCR-free survival (BCR-FS). We identified 167 (12.3%) patients for analyses, with a mean follow-up time of 60.2 ± 31.4 months. In our cohort, 5-year BCR-FS rate was 86%. Overall, 32 (19.1%) patients had BCR, with a mean time to BCR of 43.7 ± 24.3 months. BCR-free patients had stable mean uPSA values ≤ 0.033 ng/ml, while patients who developed BCR showed a slowly rising trend over time, with a significant difference between groups starting at 9 months (p

In the current review, we will discuss the state of the literature of vaporization of the prostate for the treatment of benign prostatic enlargement (BPE). We discuss two methods of vaporization of the prostate: Transurethral Vaporization of the Prostate (TUVP) and Greenlight Photo-selective Vaporization of the Prostate (PVP). A comprehensive review of the literature was performed on TUVP and PVP. The literature on transurethral resection of the prostate (TURP) was also extensively reviewed as a comparative surgical method. The evidence shows that TUVP appears to be the safer choice, as compared to TURP due to less intra- and peri-operative complications. PVP was associated with less bleeding complications than TURP with outpatient discharge. Importantly, PVP was not associated with serious bleeding events requiring blood transfusions or medical treatment in patients under anticoagulation or antiplatelet therapies. PVP was also shown to be a cost-effective option compared to TURP. Prostate vaporization for the treatment of BPE appears to be an efficient and safer alternative to TURP. Vaporization techniques, particularly Greenlight PVP, should be offered to most men, especially those under anticoagulation therapy, as well as patients at risk of bleeding complications.

In this review, we will discuss the state of the literature regarding Rezūm and opportunities for its application in the treatment of BPH.A comprehensive review of original research on convective water vapor thermal therapy (Rezūm) was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, Aquablation, and greenlight photoselective vaporization of the prostate were reviewed for discussion.Rezūm distinguishes itself from other treatment options by its durable improvement in objective clinical outcomes such as IPSS and BPH Impact Index, while being cost-effective and versatile in its ability to treat a variety of prostate gland morphologies. This treatment option shows good lower urinary tract symptom relief, especially in small-to-moderate prostate sizes (30-80 cc). The use of convective heat transfer is unique and allows for localized treatment, avoiding damage to surrounding structures, thus providing an excellent safety profile and sexual function preservation.The current evidence on Rezūm warrants its consideration as a therapeutic alternative to transurethral surgery in selected patients.

Background and aims: Bariatric surgery (BS) reduces long-term mortality in comparison with medical treatment of obesity. Some studies indicate that this effect is significant for patients above mean age in different cohorts, but not for younger patients. These findings raise the question whether morbid obese patients should undergo BS as soon as possible, or whether patients might undergo surgery later in their life. Methods: We performed a post hoc analysis of two studies; we evaluated surgery-related long-term mortality in: (1) the whole cohort [857 surgery patients (163 diabetes) vs. 2086 controls (512 diabetes)]; (2) patients above mean age [> 43 years, 427 surgery patients (133 diabetes) vs. 1054 controls (392 diabetes)]; (3) patients below mean age [≤ 43 years, 432 surgery patients (30 diabetes) vs. 1032 controls (120 diabetes]. Then, we analyzed age-related long-term mortality in the whole cohort, as well as in surgery patients and in controls. Finally, we analyzed incident diseases (diabetes, cardiovascular disease, and cancer) as a function of surgery versus no-surgery and of mean age. Results: Surgery patients, compared with controls receiving standard medical/dietary treatment, had reduced mortality in the whole cohort (HR = 0.45, 95% CI 0.33–0.62, p = 0.001) and in the study group aged > 43 years (HR = 0.39, 95% CI 0.28–0.56, p = 0.001), but not in the study group aged ≤ 43 years (HR = 0.87, 95% CI 0.42–1.80, p = 0.711). Reduced mortality was observed in non-diabetic and diabetic patients aged > 43 years (HR = 0.37, 95% CI 0.23–0.62, p = 0.001 and HR = 0.45, 95% CI 0.27–0.74, p = 0.002, respectively) who underwent bariatric surgery. In contrast, in patients aged ≤ 43 years, no significant protective effect of bariatric surgery appeared in non-diabetic patients (HR = 0.64, 95% CI 0.24–1.71, p = 0.371), and mortality increased, almost significantly, in diabetic patients aged < 43 years (HR = 2.87, 95% CI 0.96–8.56, p = 0.058), and even more in diabetic patients aged 33–43years; HR = 4.99, 95% CI 1.18–21.09, p = 0.029). As expected, age-related mortality was increased in the whole cohort (HR = 7.23, 95% CI 5.14–10.17, p = 0.001), in non-diabetic and diabetic controls (HR = 8.55, 95% CI 5.77–12.68, p = 0.001, and HR = 3.76, 95% CI 1.97–7.18, p = 0.001, respectively). The effect of aging was slightly reduced in surgery patients (HR = 3.76, 95% CI 1.87–7.58, p = 0.001), while it was not significant in diabetic surgery patients (HR = 0.70, 95% CI 0.26–1.90, p = 0.88), further emphasizing that diabetes per se has a strong negative effect on survival, also with concomitant bariatric surgery. In a supplementary analysis, HRs did not change when surgery and control parents were matched for the presence of diabetes. Incident diseases (cardiovascular, diabetes, and cancer) were less frequent in surgery than in control patients, irrespective of age. Conclusion: Bariatric surgery reduces long-term mortality in comparison with medical treatment when performed in patients aged > 43 years, but not in younger patients, where it is neutral or could even increase mortality; reduction in morbidity occurs at any age.

Bariatric surgeries such as gastric banding (LAGB), gastric bypass (RYGB), vertical banded gastroplasty (VBG), and sleeve gastrectomy (LSG) decrease body weight in morbid obesity, leading to the resolution of coexisting diabetes mellitus and arterial hypertension in the majority of cases as well as improvements of renal function and liver steatosis. BS (LAGB, RYGB, VBG, and LSG) also reduce incident cases of diabetes, of cardiovascular diseases, and of cancer; these therapeutic and preventive effects on comorbidities of obesity have not been analyzed for malabsorptive surgeries such as biliopancreatic diversion (BPD) or biliointestinal bypass (BIBP). The aim of this study was to analyze the incidence of comorbidities, i.e., diabetes, cardiovascular diseases, and cancer, in obese subjects undergoing BPD and BIBP, in comparison with standard medical treatment of obesity. Medical records of 1983 obese patients (body mass index (BMI) > 35 kg/m2, aged 18–65 years, undergoing surgery (n = 472, of which 111 with diabetes) or medical treatment (n = 1511, of which 422 with diabetes), during the period 1999–2008 (visit 1)) were collected; incident cases of comorbidities were ascertained through December 31, 2016. Observation period was 12.0 ± 3.48 years (mean ± SD). Compared to non-surgical patients matched for age, body mass index, and blood pressure, malabsorptive surgeries were associated with reduced new incident cases of diabetes (p = 0.001), cardiovascular diseases (p = 0.001), hyperlipidemia (p = 0.001), oculopathy (p = 0.021), and cancer (p = 0.001). The preventive effect of BS was similar in both nondiabetic and diabetic patients for cardiovascular diseases and hyperlipidemia (both p = 0.001). The preventive effect was significant in nondiabetic subjects for coronary heart disease and for cancer, not significant in diabetic subjects. Patients undergoing malabsorptive bariatric surgery show less incident cases of diabetes, cardiovascular diseases, hyperlipidemia, oculopathy, and cancer than controls receiving medical treatment.

Long-term comparisons between bariatric surgical techniques have been performed for gastric bypass (RYGB), sleeve gastrectomy (LSG), and biliopancreatic diversion (BPD) vs gastric banding (LAGB), but short-term studies (6 months–4 years) have only compared biliointestinal bypass (BIBP) and LAGB. The participating institutions regularly perform both BIBP and LAGB with a common protocol, and the aim of this retrospective study was to compare long-term effects of the two procedures on body weight, on clinical and metabolic variables, and on resolution of obesity and of diabetes. All procedures performed between 01/01/1998 and 31/12/2005 were considered; 73 out of 91 patients undergoing BIBP, and 154 out of 249 patients undergoing LAGB were evaluable up to 9 years. BIBP was significantly more effective than LAGB in terms of weight loss and of resolution of obesity (BMI

To characterize testosterone profile changes over time in a cohort of prostate cancer (PCa) patients managed with active surveillance (AS) and to assess its correlation with the initial disease characteristics and further progression. We conducted retrospective chart review of PCa patients managed with AS. Patients were followed with PSA, total, free and bioavailable testosterone measurements, physical examination, and by repeat biopsies or periodic magnetic resonance imaging. Disease progression was identified by follow-up biopsy changes or by imaging. A Cox proportional hazard regression models were used to assess the association between testosterone profile at baseline and the risk of progression. For the 122 patients included in analyses, the mean age at diagnosis was 65.8 years; the mean follow-up time was 7.8 years. At baseline, 108 (88.5%) patients had a Gleason score of ≤ 6. In all, 45 (36.8%) patients had disease progression, with a mean time to progression of 4.6 years. During follow-up, PSA levels showed a rising trend, while testosterone profile levels showed a trend of decrease over time. There was no significant correlation between PSA and testosterone profile (total, free, and bioavailable) level changes over time (ρ = − 0.14, − 0.11 and − 0.16, P = 0.16, 0.34, and 0.20, respectively). In addition, multivariable analysis showed that serum-free testosterone was an independent predictor of disease progression (HR 0.93, 95% CI 0.88–0.99, P = 0.029). Our study results showed that testosterone profile measurements tended to decrease over time in PCa patients managed with AS. Free testosterone was a significant independent variable of disease progression.

We aimed to compare postoperative functional outcomes following robotic-assisted radical prostatectomy (RARP) in elderly men with localized prostate cancer.A retrospective review of a prospectively maintained database of men who underwent RARP between January 2007 and November 2018 was performed. Patients over 65 years of age were selected (N = 302) and then stratified by age group: 66-69 years old (N = 214) and ≥ 70 years old (N = 88). Full continence was defined as strict 0-pad per day usage. Preoperative potency included those with a Sexual Health Inventory for Men score ≥ 17. Preoperative and postoperative functional outcomes were assessed. Kaplan-Meier analysis was used to estimate time to recovery of continence in both groups.Both groups had comparable preoperative parameters. Continence rates at 1, 3, 6, 9, 12, 18 and 24 months in the 66-69-year-old group were 6%, 34%, 61%, 70%, 74%, 80% and 87%, respectively. Comparatively in the ≥ 70-year-old group, continence rates were significantly lower at all time points (3%, 22%, 50%, 56%, 66%, 69% and 75%, respectively). Men in the 66-69-year-old group were significantly more likely to be continent after RARP when compared to patients 70 years of age and above [(Hazards ratio (HR) 0.73; 95%confidence interval 0.54-0.97, (p = 0.035)].Our results suggest that RARP is feasible in elderly patients. Nevertheless, elderly patients in the ≥ 70-year-old group had significantly inferior postoperative continence rates compared to patients aged 66-69 years. Such information is valuable when counselling men during preoperative RARP planning to ensure that they have realistic postoperative expectations.

BACKGROUND AND OBJECTIVES We evaluated the short- and long-term outcome in bladder cancer (BC) patients treated with radical cystectomy (RC) in Quebec (Canada). METHODS Data were collected from provincial registries on all BC patients who underwent RC in Quebec province in 2000-2015. Outcomes were hospitalization rates and survival. Survival analyses were conducted using log-rank tests and Cox proportional hazards models. RESULTS In total, 4450 patients were included in our analysis. RC was increasingly conducted by higher-volume surgeons in larger, higher-volume, academic hospitals. Comparing patients treated in 2010-2015 to 2000-2009, recently treated patients had shorter postoperative hospital stays (absolute difference, 0.9 days, P

Introduction and Objectives: The aim of this study was to assess if there is a difference in survival after radical cystectomy (RC) when examined in relation to prior non-muscle invasive bladder cancer (NMIBC) disease vs. invasive cancer de novo at time of diagnosis. Methods: We conducted a retrospective study of all patients who underwent RC within Quebec health insurance medical services database during the years (2000-2009). Overall survival (OS) outcome was assessed with Kaplan-Meier curves and hazard ratios (HRs) adjusted for age and gender. Results: A total of 2,671 subjects met the eligibility criteria. Among them, 19.8% had presumed prior NMIBC that further progressed to invasive disease. Median survival after RC for patients with presumed prior NMIBC was 4.3 years as compared to patients with presumed invasive disease de novo 3.7 years (p = 0.007, Wilcoxon test). Patients with presumed NMIBC at the time of diagnosis had a 16% decrease in the risk of mortality after RC, when compared to patients with presumed invasive BC de novo (HR 0.84, 95% CI 0.73-0.96 (p = 0.0166)). Conclusion: Our results suggest a slightly better prognosis, regarding OS after RC for patients with presumed NMIBC who progressed to invasive disease, when compared to patients with presumed invasive disease de novo at the time of diagnosis.

Aim of this study was to analyze long-term mortality in obese patients receiving malabsorptive bariatric surgery (BS)[biliopancreatic diversion (BPD) and biliointestinal bypass (BIBP)] in comparison to medical treatment of obesity. Medical records of 1877 obese patients [body mass index (BMI) > 35 kg/m2, aged 18–65 years, undergoing BS (n = 472, 111 with diabetes) or non-surgical medical treatment (n = 1405, 385 with diabetes), during the period 1999–2008 (visit 1)] were collected; non-surgical patients were matched for age, sex, BMI, and blood pressure, and life status and causes of death were ascertained through December 2016. Survival was compared across surgery patients and non-surgical patients using Kaplan–Meier plots and Cox regression analyses. Observation period was 12.1 ± 3.41 years (mean ± SD). Compared to non-surgical patients, BS patients had reduced all-cause mortality (34/472 (7.2%) vs 181/1,405 (12.9%) patients, χ2 = 11.25, p = 0.001; HR = 0.64, 95% C.I. 0.43–0.93, p = 0.019). Cardiovascular and cancer causes of death were significantly less frequent in surgery vs no-surgery (HR = 0.26, 95% C.I. 0.09–0.72, p = 0.003; HR = 0.21, 95% C.I. 0.09–0.45, p

Introduction and objectives Management of bladder cancer imposes a great economic challenge on the health care system; with the greatest share of this burden attributed to radical cystectomy (RC) and prolonged postoperative follow-up. Our aim was to characterize health care services utilization and evaluate associated cost predictors during the last 6 months of life in patients who had RC. Methods We conducted a retrospective study within a cohort of 2,988 patients who had RC from 2000 to 2009. Data were obtained from the Quebec health insurance medical services database. We included patients who deceased during the study period, and survived at least 6 months after the first 90 postoperative days. Services billing codes were used to retrieve hospital, outpatient and imaging services. Linear regression models were used to assess predictors of costs. Results From the 1,355 patients who deceased during the study period, we analyzed data of 799 subjects. Men formed 77.3% and 52.8% of patients were between 60 and 75 years of age at the time of RC. In their last 6 months of life, 17.2% of patients had surgery for major urinary tract complications, 25% had chemotherapy whereas 27.6% had radiotherapy. Also, 3.5% of patients had hemodialysis. Imaging was performed in 94.6% of patients. Urologist (specialist) visits ranked first where 72.3% of patients had 3,481 visits (average = 6 visits/pt) followed by medical subspecialist where 69% of patients had 10,010 visits (average = 18 visits/pt). For supportive care, 97% of patients had 25,560 family physician visits (average = 31 visits/pt) whereas only 16% of them had highly specialized care. Services utilization kept increasing with time especially during the last 2 months before death. Post-RC complications were significant predictor associated with increased costs at all assessed services ( P Conclusion Our study results suggest that health care services utilization varies in the assessed period. Urologists involvement in the process of care tends to decrease over time, in favor of other medical specialties, however, some health care services, such as highly specialized supportive care, may be underutilized.

Viability testing can be used to avoid the transplantation of nonheart beating donor organs that are likely to have primary nonfunction. Such testing also identifies a second group of kidneys which, although unsuitable for solitary transplantation, may be considered for dual transplantation. In kidneys in this group solitary transplants would be unlikely to produce a sufficient glomerular filtration rate to support the recipient. However, if used together as a dual transplant, they have the potential to produce sufficient renal function in 1 patient.The group at our unit has performed 23 dual nonheart beating donor renal transplants from 2003 to date. Using 3 and 12-month post-transplantation recipient glomerular filtration rates as primary end points we compared our dual transplant group with our series of 115 single nonheart beating donor transplants from 1998 to 2006.At 3 and 12 months mean glomerular filtration rates in the dual group were 46.2 and 45.5 ml per minute per 1.73 m(2), respectively. These values were not significantly different from the mean glomerular filtration rates of 40.7 and 43.0 ml per minute per 1.73 m(2), respectively, in the single transplant group.We have observed that a subset of nonheart beating donor kidneys that do not satisfy the viability criteria for single organ transplantation may become successful dual organ grafts, thus, avoiding unnecessary organ nonuse and maximizing organ resources.

Background and aim Aim of this retrospective study was to compare long-term mortality and incidence of new diseases [diabetes and cardiovascular (CV) disease] in morbidly obese diabetic and nondiabetic patients, undergoing gastric banding (LAGB) in comparison to medical treatment. Patients and methods Medical records of obese patients [body mass index (BMI) > 35 kg/m2 undergoing LAGB (n = 385; 52 with diabetes) or medical treatment (controls, n = 681; 127 with diabetes), during the period 1995–2001 (visit 1)] were collected. Patients were matched for age, sex, BMI, and blood pressure. Identification codes of patients were entered in the Italian National Health System Lumbardy database, that contains life status, causes of death, as well as exemptions, drug prescriptions, and hospital admissions (proxies of diseases) from visit 1 to September 2012. Survival was compared across LAGB patients and matched controls using Kaplan–Meier plots adjusted Cox regression analyses. Results Observation period was 13.9 ± 1.87 (mean ± SD). Mortality rate was 2.6, 6.6, and 10.1 % in controls at 5, 10, and 15 years, respectively; mortality rate was 0.8, 2.5, and 3.1 % in LAGB patients at 5, 10, and 15 years, respectively. Compared to controls, surgery was associated with reduced mortality [HR 0.35, 95 % CI 0.19–0.65, p

Limited information is available on weight loss, metabolic control, cardiovascular disease and diabetic complications in morbidly obese patients undergoing gastric banding (LAGB) compared with morbidly obese patients receiving medical treatment.To assess the long-term effects of laparoscopic adjustable gastric banding (LAGB) on glucose tolerance, arterial hypertension, and cardiovascular disease and prevention of diabetic complications (retinopathy and renal function) in morbidly obese patients.University hospitals, Italy.In this retrospective study, 87 morbidly obese patients who underwent LAGB (20 with diabetes) and 87 morbidly obese patients who did not undergo surgery (36 with diabetes) for the treatment of obesity during the period 1995 to 2003 consented for re-examination after a mean (±standard deviation) period of 13.8±2.04 years. At baseline, all mobidly obese patients had a body mass index (BMI)≥35 kg/m(2) and were aged 18 to 65 years.At follow-up, LAGB patients maintained a lower weight compared with baseline values and demonstrated significant decreases in both blood pressure and heart rate measurements compared with control patients. LAGB patients also experienced greater improvement of glucose tolerance than did control patients (28% versus 10%, respectively; P.01) and reduction of insulin and homeostasis model assessment for insulin resistance. Fewer LAGB patients developed carotid plaques than did control patients (10% versus 26%, respectively; P.01). Intensification of antihypertensive therapy was required in 31% of surgery versus 60% of control patients (P.05). Among diabetic patients, improved glucose tolerance occurred in 55% of surgery patients versus 0% in the control group (P.01). In addition, insulin treatment was necessary in 9 control patients versus 0 in the surgery group (P.05), and carotid plaques occurred in 10% of LAGB patients versus 50% of control patients (P.01). Creatinine levels and the estimated glomerular filtration rate improved in LAGB diabetic patients but not in control patients (P.05).Despite a very small weight loss over the long term (i.e., 2.2 kg/m(2)), improvement of glucose tolerance persisted for long periods after LAGB, with no unfavorable effect on kidney function and retinopathy. In contrast, no effect was observed on prevention of arterial hypertension or cardiovascular disease.

There is paucity of studies on the predictors of bladder cancer (BC) management costs. We aimed to determine predictors of costs associated with radical cystectomy (RC) for BC.We conducted a retrospective analysis in a cohort of 2,759 patients who underwent RC for BC between 2000 and 2009. We analyzed predictors of pre-surgery, RC, post-surgery, and total costs. The following variables were considered as potential predictors: age, gender, hospital/surgeon case load, academic hospital, and geo-administrative region. Multivariate linear regression was used to determine predictors.Predictors of pre-surgery costs were: age (β = 808.64, P 0.0001) and having surgery in an academic hospital (β = 511.42, P = 0.003). Increased RC costs were associated with age (β = 196.73, P = 0.0006), hospital/surgeon annual load (β = 484.45 and β = 254.21, P 0.0001, respectively). Having surgery in academic hospitals and geographic region were significant predictors of low RC costs (β = -1085.82 and β = -449.31, P 0.0001, respectively). Increasing age and the presence of post-operative complications were predictors of high post-operative costs (β = 623.48, β = 5781.44, P = 0.01, respectively), while hospital load was associated with low post-surgery costs (β = -949.79, P 0.0001).Patients' age and surgery performed by high-volume health providers were predictive factors of high RC costs. Low RC costs were associated with surgeries performed in academic hospitals.

To document radical cystectomy (RC) outcomes in patients over 80 years old across Quebec during the years 2000-2009 and to examine potentially related factors.Within Quebec health insurance medical services database, we identified patients over 80 years who underwent RC. The outcomes analyzed were post-operative complications, mortality rates at 30, 60 and 90 days and overall survival.A total of 275 patients over 80 years old had RC performed in 38 hospitals across Quebec. Among them, 33% had major post-operative complications with 16% having more than one complication. Mortality rates at 30, 60 and 90 days were 5.8%, 9.8% and 13% respectively. 44.3% of RCs were performed in seven academic hospitals with mortality rates of 2.5%, 6.5% and 9% respectively. Community hospitals had mortality of 8.5%, 12.4% and 16.3% respectively (P 0.001). The cohort 5-year overall survival rate was 27%. The presence of post-operative complications and the number of complications negatively affected overall survival (P 0.001) CONCLUSION: Patients over 80 years of age have high post-RC mortality rates, especially at 90 days. In addition, it appears that they have lower post-operative mortality if their RCs were performed in academic centers. Mortality rates and complications can be used when obtaining informed consent.

Previous studies reported improved outcomes for bladder cancer patients who had radical cystectomy (RC) performed by surgeons and hospitals with high annual RC volumes. The objective of this study was to determine the effect of high hospital and surgeon volume on overall survival after RC for bladder cancer in Quebec. We conducted a retrospective cohort study using data of patients who underwent RC for bladder cancer from 2000 to 2009. The cohort was obtained with the linkage of two health databases: the RAMQ database (data on medical services) and the ISQ database (vital status data). Hospital and surgeon volumes were defined as the average annual number of RC performed at an institution or by surgeon, respectively, during the study period. We considered high hospital and surgeon volume those found in the third and fourth quartiles of the distribution of hospital and surgeon volumes. The effect of high hospital and surgeon volume on survival was assessed by multivariate Cox proportional hazards models. We analyzed a total of 2,778 patients who met inclusion criteria (75 % males). High hospital volume and surgeons were found to be significantly associated with improved overall survival (HR = 0.87, 95 % CI: 0.78–0.97 and HR = 0.81, 95 % CI: 0.71–0.91, respectively). The combined effect of high-volume hospital and high-volume surgeon decreased by 20 % the risk of long-term mortality (HR = 0.80, 95 % CI: 0.70–0.91). Compared to low-volume providers, having RC for bladder cancer performed in high-volume hospitals or by high-volume surgeon was associated with improved overall survival.

Even if limited to one biopsy core, most urologists and radiation oncologists use the highest Gleason score (GS) to guide therapy. To evaluate the suitability of using biopsy characteristics to predict tumor characteristics at radical prostatectomy (RP) in men with high biopsy GS (BGS) cancer to better select men who will most benefit from various local therapies, we retrospectively reviewed the biopsy and RP findings of 144 men with a BGS 8-10. One hundred six and 38 patients with a BGS of 8 and 9-10, respectively, were included. Forty-eight percent of cases were downgraded to a final GS of 7 at RP, including 54% of BGS 8, and 32% of BGS 9-10 group. Overall, 31% had pT2 disease at RP. Multiple biopsy features, including the GS, the number of positive cores, the number of cores with high-GS cancer, and the maximum volume of high-grade cancer per core (MVPC) consistently predicted final GS and RP tumor stage. Multivariate analysis showed that biopsy GS and MVPC were independent predictors of final GS, while MVPC was also an independent predictor for final pT stage. Patients with high BGS are not a homogeneous group in terms of local tumor characteristics. In addition to BGS (9-10 being worse than 8), other biopsy findings, especially the number of involved cores, number of cores with high-BGS cancer, and MVPC are important predictors of findings at RP that should be incorporated in the decision treatment planning. Most patients with only one core BGS 8 cancer harbor GS 7 cancer.

To the Editor: We read with interest the original contribution by Zoppini et al.(1), because of the great number of subjects involved and the use of death certificates as a reliable source of information. Nevertheless, they claim some limitation, such as the follow-up duration (maximum 7 years) and the lack of data on diabetes type, treatment, and complications. We carried out a similar study, a prospective cohort record-linked study, analyzing data of 969 morbidly obese (BMI >35 kg/m2) outpatients first visited in the period 1995–2001 (221 patients with diabetes mellitus type 2, 101 men and 120 women; 748 patients without diabetes, 222 men and 526 women); we collected clinical and pharmacological story, anthropometric data, and we completed a full panel of blood exams at baseline. Then, we evaluated the development of complications after a mean 15-year follow-up and, where applicable, mortality data. All these data were retrieved through the Lombardy Region Administrative Database, which lists death causes and exemptions; as described by Zoppini et al.(1), in Italy subjects with chronic diseases are entitled to free disease-specific care, and these patients are listed in a regional electronic database (2). In particular, we analyzed data regarding exemption for chronic liver disease (CLD) and for diabetes mellitus (DM). The same method was used to collect mortality data, according to ICD 10 classification. Our data showed at baseline that diabetic obese patients had hypertransaminasemia in a higher percentage of cases compared with nondiabetic obese patients (17.9% vs. 4.06%, P=0.0001 for aspartate aminotransferase and 55.5% vs. 34.1%, P=0.0001 for alanine aminotransferase); moreover, after a 15-year follow-up, diabetic subjects were more prone to develop an exemption for CLD than nondiabetic subjects (4.52% vs. 1.47%), regardless of aspartate aminotransferase and alanine aminotransferase levels at baseline. Mortality data were similar to those collected by Zoppini et al., with a higher mortality rate among diabetic patients, especially for neoplasia (11.3% vs. 2.6% P=0.001), followed by cardiovascular diseases (6.7% vs. 2.1%, P=0.0001), liver disease (2.7% vs. 0% P=0.0001), and renal (0.9% vs. 0%, P=0.05) and lung diseases (0.9% vs. 0.1%, P=NS). Although minding some limitations, our study’s strengths are the long follow-up period and the collection of patients’ complete information at baseline, which helps define patients at increased risk of comorbidities and mortality on the basis of anthropometric and blood examinations. Limitations are represented by the fact that in the exemption category for CLD, diseases different from NAFLD are also accounted for, and by the fact that we only examined obese patients.

Background Bladder cancer (BC) has the highest lifetime treatment costs per patient of all cancers. The objective of this study was to characterize the use of health-care services and costs associated with BC among patients who underwent radical cystectomy (RC) in the province of Quebec. Methods We conducted a descriptive study in a retrospective cohort of patients who underwent RC for BC between 2000 and 2009. Data was obtained from two health administrative databases (RAMQ and ISQ). We calculated average costs per patient and total costs in 2014 Canadian dollars for the following components of costs: 1) Pre-surgery costs (pre and post-urologist consultations, urologist consultations, cystoscopies, TURBTs, imaging procedures); 2) Costs of radical cystectomy and 3) Post-surgery costs (urologist consultations, post-operative consultations, medical oncologist consultations, imaging procedures and post-operative complication management). ARIMA models were used to evaluate trends in average costs per patient over the study period. Results Among 2759 patients included in the study (75 % men), average pre-surgery costs, RC costs, and post-surgery costs were estimated at 3762$, 18979$ and 4770$, respectively. RC cost was responsible for 69 % of total costs, followed by post-operative consultations (7.8 %), post-operative complications and TURBTs (6 % of total costs, each). Academic hospitals performed RC at a lower average cost, compared to community hospitals (difference of $1000, p