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Introduction: The July effect is the widely held belief that medical care is compromised at the beginning of the academic year due to transitioning medical trainees. We determined its impact on surgical outcomes in urological surgery., Methods: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database and State Emergency Department Database for California were used for the years 2007 to 2011. Patients were identified who underwent surgery in July, August, April and May, and separated into early (July and August) and late (April and May) cohorts. Surgical outcomes for early vs late surgery were compared for academic centers. Adjusted multivariate models were fit to determine the effect of early surgery as a predictor of adverse outcomes., Results: For major urological surgery July/August timing had no impact on length of stay, 30-day readmission, 30-day emergency room visits, never events, perioperative complications or mortality (all values p >0.05). Similarly, for stone, groin, bladder outlet and cystoscopic bladder procedures, July/August surgery had no impact on rates of urinary retention, emergency room visits within 30 days, clot evacuations within 30 days, perioperative complications or 30-day readmissions (all values p >0.05). At the end of the year cystectomies had increased odds of intraoperative complications (OR 0.63, 95% CI 0.4-0.97) while nephrectomies had higher odds of major complications (OR 0.69, 95% CI 0.53-0.89)., Conclusions: Surgical outcomes are not compromised by having surgery at the beginning of the academic year, despite resident turnover, representing appropriate oversight during this potentially vulnerable time.

Purpose: Post-hospital syndrome is an acquired transient period of health vulnerability following inpatient admission. We assessed the impact of a preoperative hospitalization on outcomes following penile prosthesis surgery and sought to optimize surgical timing after inpatient admission., Materials and Methods: We used the Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery Database for California from 2007 to 2011 and for Florida from 2009 to 2014. Patients were identified as having undergone prosthesis placement by ICD-9 and CPT codes. The primary exposure was post-hospital syndrome, defined as any inpatient admission 90 days or less before prosthesis placement. Patients were further categorized by how recently the inpatient hospitalization occurred. The primary study outcome was 30-day hospital readmission. Secondary outcomes were length of stay, and device and postoperative complications., Results: We identified 16,923 patients who received a penile prosthesis, of whom 477 (3%) had post-hospital syndrome exposure 90 days or less before prosthesis placement. After risk adjustment patients with post-hospital syndrome had higher odds of 30-day readmission (OR 3.0, 95% CI 2.2-4.1), length of stay 2 days or longer (OR 1.7, 95% CI 1.3-2.3) and device complications (OR 1.7, 95% CI 1.2-2.5). When categorizing patients by 30-day intervals, we found a linear decrease in the risk of 30-day readmission as the interval increased between post-hospital syndrome exposure and prosthesis surgery., Conclusions: Post-hospital syndrome exposure is a risk adjusted predictor of 30-day readmissions, prolonged length of stay and device complications. Medical optimization and delayed surgery can help combat the adverse effects associated with post-hospital syndrome exposure and may improve surgical outcomes.

Purpose: Ureteral injury represents an uncommon but potentially morbid surgical complication. We sought to characterize the complications of iatrogenic ureteral injury and assess the effect of recognized vs delayed recognition on patient outcomes., Materials and Methods: Patients who underwent hysterectomy were identified in the Healthcare Cost and Utilization Project California State Inpatient Database for 2007 to 2011. Ureteral injuries were identified and categorized as recognized-diagnosed/repaired on the day of hysterectomy and unrecognized-diagnosed/repaired postoperatively. We assessed the outcomes of 90-day hospital readmission as well as 1-year outcomes of nephrostomy tube placement, urinary fistula, acute renal failure, sepsis and overall mortality. The independent effects of recognized and unrecognized ureteral injuries were determined on multivariate analysis., Results: Ureteral injury occurred in 1,753 of 223,872 patients (0.78%) treated with hysterectomy and it was unrecognized in 1,094 (62.4%). The 90-day readmission rate increased from a baseline of 5.7% to 13.4% and 67.3% after recognized and unrecognized injury, respectively. Nephrostomy tubes were required in 2.3% of recognized and 23.4% of unrecognized ureteral injury cases. Recognized and unrecognized ureteral injuries independently increased the risk of sepsis (aOR 2.0, 95% CI 1.2-3.5 and 11.9, 95% CI 9.9-14.3) and urinary fistula (aOR 5.9, 95% CI 2.2-16 and 124, 95% CI 95.7-160, respectively). During followup unrecognized ureteral injury increased the odds of acute renal insufficiency (aOR 23.8, 95% CI 20.1-28.2) and death (1.4, 95% CI 1.03-1.9, p = 0032)., Conclusions: Iatrogenic ureteral injury increases the risk of hospital readmission and significant, potentially life threatening complications. Unrecognized ureteral injury markedly increases these risks, warranting a high level of suspicion for ureteral injury and a low threshold for diagnostic investigation., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)