Michael Felice’s research while affiliated with Loyola University Medical Center and other places

Purpose: Lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) affects quality of life. Convective water vapor thermal therapy (CWVTT - Rezum) is a minimally invasive surgical treatment for LUTS/BPH which produces significant improvement of LUTS in men with prostates between 30cc-80 cc with minimal de-novo sexual dysfunction. However, outcomes across the prostate volume (PV) spectrum are incompletely described. We aim to elucidate the relationship between PV and outcomes post-CWVTT in men with LUTS/BPH. Materials and methods: Patients undergoing CWVTT at a tertiary care center were included. The primary outcome was change in IPSS pre-CWVTT compared post-CWVTT between PV tertiles - small (≤38.5 cc), medium (38.5 - ≤55.6cc), and large (>55.6cc). Secondary outcome was time to a minimally clinically important difference (MCID) of 25% decrease in IPSS. Results: 171 patients were divided into small (n=56), medium (n=54), and large (n=61) PV tertiles. The change in IPSS pre-operatively to 3-months was significant for all tertiles with mean difference of [-7.51 (-10.14, -4.83)], [-10.12 (-12.71, -7.53)], and [-11.72 (-14.14, -9.29)] for small, medium, and large PV, respectively (p=<0.001). In multivariable analysis, having diabetes was associated with increased IPSS after 3mo with average increase (95% CI) of [3.67 (0.23,7.11), p=0.037] compared to not having diabetes The median time (Q1, Q3) to -25% in IPSS for small, medium, and large PV were 16.1 (12.1, 17.5), 12.3 (7.1, 15.7), and 13.8 (10.8, 16.3) months, respectively. In multivariable analysis, medium PV had significantly increased incidence of 25% decrease compared to small PV [HR (95%CI): 2.10 (1.19, 3.72), p=0.011]. Conclusions: CWVTT results in significant and durable LUTS improvement across the prostate volume spectrum. All prostate volumes experience the same improvement in LUTS post-CWVTT. However, medium and large glands may improve more quickly than small glands.

Introduction and Objectives: Robotic-assisted radical prostatectomy (RARP) is associated with postoperative hernias at the extraction site, in the inguinal region, and at port sites. We explored hernia rates as well as risk factors for extraction site hernias after RARP based on specimen extraction location in this context. Patients and Methods: We queried a prospectively maintained database of all patients undergoing RARP from November 2006 to June 2023. We collected demographic features, oncologic and pathologic data, 30-day postoperative complications, and postoperative hernia incidence. Specimens were extracted via a midline periumbilical or a Pfannenstiel incision at the conclusion of the case per surgeon preference. Clinically relevant hernias were defined as hernias identified by symptoms or exam findings rather than imaging alone. Univariable and multivariable logistic regressions were used to identify risk factors for postoperative extraction site hernias. Results: In total, 1465 patients underwent radical prostatectomy. Around 23.7% had specimen extraction via Pfannenstiel incision, whereas 76.3% were via extended midline periumbilical port. Patients with a Pfannenstiel extraction had a lower extraction site hernia rate (0.6% vs 7.4%) and clinically significant hernia rate (10.1% vs 14.5%, p = 0.04). On multivariable logistic regression, Hispanic race and Pfannenstiel extraction site were associated with significantly reduced odds of clinically relevant extraction site hernias. Conclusions: Use of a separate Pfannenstiel extraction site is associated with reduced risk of postoperative hernias for patients undergoing RARP. Surgeons should consider extracting the prostate via a Pfannenstiel incision during RARP given this potential benefit.

Background The standard approach to hemostasis during partial nephrectomy (PN) is to perform suture renorrhaphy (SR). Application of a hemostatic bandage (HB) is an alternative to minimize blood loss and devitalized renal parenchyma. We aim to evaluate perioperative outcomes of PN with tumor enucleation (TE) comparing SR to HB. Methods We analyzed a retrospective cohort of 195 patients undergoing robot‐assisted laparoscopic PN with TE performed at a tertiary referral center (2012–2022). Hemostasis was obtained with SR in 54 patients while 141 patients underwent application of HB consisting of Surgicel®, Gelfoam® soaked in thrombin, and Floseal®. Results SR patients had tumors of greater complexity by RENAL nephrometry score compared to HB patients ( p < 0.001). Operative time (141 vs. 183 min, p < 0.001), warm ischemia time (11.6 vs. 24.2 min, p < 0.001), estimated blood loss (37 vs. 214 mL, p < 0.001), and length of stay (1.2 vs. 1.8 days, p < 0.001) favored HB. There was no significant difference in Clavien–Dindo grade ≥3 complications ( p = 0.22). Renal function was comparable with mean estimated glomerular filtration rate decrease of 0.66 and 0.54 mL/min/1.73 m ² at 3 months postoperatively for HB and SR, respectively ( p = 0.93). Conclusions Application of an HB is a safe alternative to SR for hemostasis following PN with TE in appropriately selected patients.

Robotic nephron-sparing surgery is traditionally performed via a transperitoneal (TP) approach. However, the retroperitoneal (RP) approach has gained popularity, particularly for posterolateral renal masses. The RP approach is associated with shorter operative time, less blood loss, and shorter length of stay, while preserving oncologic outcomes in selected masses. Here, we aim to assess the feasibility of the RP approach in excising anterior renal masses. Patients ≥ 18 years of age who underwent robotic nephron-sparing surgery for anterior renal masses were retrospectively identified (2008–2022). Baseline demographics, tumor characteristics, and perioperative data were collected and characterized based on TP vs RP approaches. Wilcoxon rank sum test and Pearson’s Chi-squared test were used to compare continuous and categorical variables, respectively. Two hundred and sixteen patients were included—178 (82.4%) underwent TP approach and 38 (17.6%) underwent RP approach. Baseline demographics, preoperative tumor size, and renal nephrometry scores were similar. The RP approach was associated with shorter operative (150 vs 203 min, p < 0.001) and warm ischemia time (12 vs 21 min, p < 0.001), and less blood loss (20 vs 100 cc, p = 0.002) (Table 1). The RP approach was associated with shorter length of stay (1 vs 2 days, p < 0.001) and less total complications (5.3% vs 19.1%, p = 0.038). Major complication (Clavien–Dindo Grade > 3) rates were similar. There was no difference in positive surgical margin rates or pathologic characteristics. Robotic RP approach for nephron-sparing surgery is feasible for eligible anterior tumors and is associated with favorable perioperative outcomes with preserved negative surgical margin rates. Table 1Patient baseline demographics Overall Transperitoneal Retroperitoneal p value Median/N IQR/% Median/N IQR/% Median/N IQR/% N 216 178 82.4% 38 17.6% Age (years) 60.5 (52.1–67.7) 60.4 (52.8–67.7) 61.6 (49.1–69.2) 0.393 Sex Male 126 58.3% 100 56.2% 26 68.4% Female 90 41.7% 78 43.8% 12 31.6% 0.165 Race White 162 75.0% 137 77.0% 25 65.8% Asian 4 1.9% 2 1.1% 2 5.3% Black 21 9.7% 18 10.1% 3 7.9% Hispanic 26 12.0% 18 10.1% 8 21.1% Other 2 0.9% 2 1.1% 0 0.0% 0.197 Body mass index (kg/m²) < 25 32 14.8% 25 14.0% 7 18.4% 25–30 68 31.5% 55 30.9% 13 34.2% 30–35 60 27.8% 50 28.1% 10 26.3% 35 + 56 25.9% 48 27.0% 8 21.1% 0.808 Prior abdominal surgery Yes 118 54.6% 104 58.4% 14 36.8% No 98 45.4% 74 41.6% 24 63.2% 0.015 Prior kidney surgery Yes 10 4.6% 9 5.1% 1 2.6% No 206 95.4% 169 94.9% 37 97.4% 0.518 Chronic kidney disease stage ≥ 3 Yes 45 20.8% 38 21.3% 7 18.4% No 171 79.2% 140 78.7% 31 81.6% 0.687 Charlson comorbidity index 0 138 63.9% 116 65.2% 22 57.9% 1 46 21.3% 38 21.4% 8 21.1% 2 19 8.8% 13 7.3% 6 15.8% ≥ 3 13 6.0% 11 6.2% 2 5.3% 0.412 Tumor size (cm) 2.7 (2–3.6) 2.8 (2–3.5) 2.55 (2–3.7) 0.796 Tumor laterality Left 100 46.3% 78 43.8% 22 57.9% Right 116 53.7% 100 56.2% 16 42.1% 0.114 Clinical T stage cT1a 186 86.1% 152 85.4% 34 89.5% cT1b 30 13.9% 26 14.6% 4 10.5% 0.509 RENAL Nephrometry score Low (4 to 6) 94 43.5% 76 42.7% 18 47.4% Intermediate (7 to 9) 112 51.9% 94 52.8% 18 47.4% High (≥ 10) 19 4.6% 8 4.5% 2 5.3% 0.829 TE tumor enucleation, SPN standard margin partial nephrectomy, IQR interquartile range

Background The standard approach to hemostasis during partial nephrectomy (PN) is to perform suture renorrhaphy (SR). Application of a hemostatic bandage (HB) is an alternative maneuver to minimize blood loss and devitalized renal parenchyma. We aim to evaluate perioperative outcomes of PN with tumor enucleation (TE) comparing SR to HB. Methods We analyzed a retrospective cohort of 195 patients undergoing robot-assisted laparoscopic PN with TE performed by a single surgeon at a tertiary referral center (2012–2022). Hemostasis of the enucleation bed was obtained with SR in 54 patients while 141 patients underwent application of HB consisting of Surgicel®, Gelfoam® soaked in thrombin, and Floseal®. Patient factors, tumor characteristics, and perioperative outcomes were compared using Student’s t-tests and chi-squared tests. Temporal trends were evaluated using Spearman coefficients. Results Over time, there was a significant decrease in utilization of SR in favor of HB (p < 0.001). SR patients had tumors of greater complexity by RENAL nephrometry score compared to HB patients (p < 0.001). Operative time (141 vs 183 min, p < 0.001), warm ischemia time (11.6 vs 24.2 min, p < 0.001), estimated blood loss (37 vs 214 mL, p < 0.001), and length of stay (1.2 vs 1.8 days, p < 0.001) favored the HB group. There was no significant difference in major Clavien-Dindo grade ≥ 3 complications (p = 0.22). Renal function was comparable with mean estimated glomerular filtration rate decrease of 0.66 and 0.54 mL/min/1.73m2 at 3-months postoperatively for HB and SR, respectively (p = 0.93). Conclusions Application of a HB is a safe alternative to SR for hemostasis following PN with TE in appropriately selected patients.

We aim to compare complications, readmission, survival, and prescribing patterns of opioids for post-operative pain management for Robotic-assisted laparoscopic radical cystectomy (RARC) as compared to open radical cystectomy (ORC). Patients that underwent RARC or ORC for bladder cancer at a tertiary care center from 2005 to 2021 were included. Recurrence-free survival (RFS) and overall survival (OS) were evaluated with Kaplan–Meier curves and multivariable Cox proportional hazards regression models. Comparisons of narcotic usage were completed with oral morphine equivalents (OMEQ). Multivariable linear regression was used to assess predictors of OMEQ utilization. A total of 128 RARC and 461 ORC patients were included. There was no difference in rates of Clavien-Dindo grade ≥ 3 complications between RARC and ORC (36.7 vs 30.1%, p = 0.16). After a mean follow up of 3.4 years, RFS (HR 0.96, 95%CI 0.58–1.56) and OS (HR 0.69, 95%CI 0.46–1.05) were comparable between RARC and ORC. There was no difference in the narcotic usage between patients in the RARC and ORC groups during the last 24 h of hospitalization (median OMEQ: 0 vs 0, p = 0.33) and upon discharge (median OMEQ: 178 vs 210, p = 0.36). Predictors of higher OMEQ discharge prescriptions included younger age [(− )3.46, 95%CI (−)5.5–(−)0.34], no epidural during hospitalization [− 95.85, 95%CI (− )144.95−(− )107.36], and early time-period of surgery [(− )151.04, 95%CI (− )194.72–(− )107.36]. RARC has comparable 90-day complication rates and early survival outcomes to ORC and remains a viable option for bladder cancer. RARC results in comparable levels of opioid utilization for pain management as ORC.

Introduction: Malignant ureteral obstruction is associated with a poor prognosis, with a median survival of 3 to 7 months. These patients are ideal candidates for concurrent palliative care services, consistent with American Society of Clinical Oncology guidelines. We aimed to characterize palliative care, hospice, and end-of-life health care utilization in patients with malignant ureteral obstruction. Methods: Patients ≥ 18 years old at our institution and diagnosed with malignant ureteral obstruction between May 2014 and August 2020 were retrospectively identified and pertinent data extracted. Palliative care, hospice, and end-of-life health care utilization was described, and factors associated with each were assessed with logistic regression models. Overall survival was assessed with Cox proportional hazard regression models. Results: One hundred fifteen patients qualified for analysis; 39.1% (45/115) utilized palliative care and spent a median of 12.5 days (IQR 3-52 days) on nonhospice palliative care. On adjusted analysis Black ethnicity (aOR 3.44, 95% CI: 1.08-10.94) was associated with palliative care utilization. Of the patients, 53.9% (62/115) utilized hospice. The median time from hospice initiation to death was 12 days (IQR 5-23 days). On adjusted analysis, prior extirpative surgery (aOR 3.63, 95% CI 1.01-13.05) and palliative care utilization (aOR 4.38, 95% CI 1.70-11.31) were associated with hospice utilization. Median survival following diagnosis was 141 days (IQR 37.5-442.5). Of the patients, 43.0% (37/86) had high end-of-life health care utilization. On multivariable analysis, only hospice (aOR 0.03, 95% CI 0.01-0.14) was associated with less end-of-life health care utilization. Conclusions: Palliative care is underutilized in malignant ureteral obstruction. Hospice, but not palliative care utilization, was associated with decreased end-of-life health care utilization.