Gary Chien

Introduction: Rapid adoption of robotics has introduced a paradigm change in prostate cancer treatment, with more than 80% of prostatectomies performed robotically in 2015. For treatment of renal cell carcinoma (RCC), this change has not previously been reported. We evaluated trends in surgical management of RCC in Kaiser Permanente Southern California (KPSC) within the last 16 years, especially after adoption of robotics. Methods: From January 1999 to September 2015, all KPSC members who underwent surgical treatment of suspected RCC were included retrospectively. Surgical approach, patient age, sex, clinicopathology, Charlson Comorbidity Index, and chronic kidney disease status were analyzed using robust Poisson multivariate regression. Results: The study included 5237 patients. Partial nephrectomy was increasingly used during the study period, and its use surpassed radical nephrectomy in 2012. In a multivariate model, partial nephrectomy was associated with lower pathologic tumor ...

To compare perioperative outcomes in the three most common partial nephrectomy modalities: robotic (RPN), laparoscopic (LPN), and open (OPN), matched for nephrometry scores. Patients aged 16-85 who underwent RPN, LPN, or OPN from 2007 to 2014 for localized renal carcinoma within our healthcare system were enrolled. Age, sex, body mass index, and Charlson Comorbidity Index (CCI) as well as perioperative outcomes of estimated blood loss (EBL), length of hospital stay (LOS), ischemia time (IT), change in eGFR, positive margin rate, operative time (OT), and emergency room visit rates were compared between RPN, LPN, and OPN using the R.E.N.A.L nephrometry score. A total of 862 patients underwent partial nephrectomy (523 LPN, 176 OPN, and 163 RPN). Patients who underwent OPN were significantly older, and had higher nephrometry scores and CCI. When matched for nephrometry scores, minimally invasive (LPN and RPN) compared to OPN had lower EBL (< 0.0001), shorter LOS (< 0.0001), shorte...

treatment decision (p 1⁄4 0.0063), and were more likely to discuss treatment options (p 1⁄4 0.0052). The total SDM scores indicated that patients without evidence of decisional conflict reported more perceived shared decision making (p 1⁄4 0.0009). These patients also had higher Net Promoter Scores (higher intended physician loyalty) (p 1⁄4 0.0086). There was no significant difference between the two groups in health literacy scores or disease specific knowledge scores. CONCLUSIONS: This cross-sectional analysis of patients with nephrolithiasis suggests that lower decisional conflict after a urologic consultation for nephrolithiasis is associated with more shared decisionmaking and with higher levels of patient loyalty after consultation. Our data identifies specific areas that can be targeted with pre-consultation interventions aimed at building a solid foundation of shared decision making with the intent of improving decisional quality.

Many men diagnosed with prostate cancer are concerned with how the disease and its course of treatment could affect their health-related quality of life (HRQOL). To aid in the decision-making process on a course of treatment and to better understand how these treatments can affect HRQOL, knowledge of pretreatment HRQOL is essential. To assess the racial and ethnic variations in HRQOL scores in men newly diagnosed with prostate cancer before electing a course of treatment. Male members of the Kaiser Permanente of Southern California health plan who were newly diagnosed with prostate cancer completed the five-domain specific Expanded Prostate Index Composite-26 (EPIC-26) HRQOL questionnaire from March 1, 2011 through August 31, 2013 (N = 2,579). Domain scores were compared across racial and ethnic subgroups and multiple logistic regression analyses were used to assess the association after adjusting for sociodemographic and clinical characteristics. The five EPIC-26 domain scores (sex...

The purpose was to evaluate the efficacy of the Web-based, Personal Patient Profile-Prostate decision aid versus usual care with regard to decisional conflict in men with localized prostate cancer. A randomized (1:1) controlled, parallel-group, nonblinded trial was conducted in four US regions. Eligible men had clinically localized prostate cancer, an upcoming consult, and spoke/read English or Spanish. Participants answered questionnaires to report decision-making stage, personal characteristics, concerns and preferences plus baseline symptoms and decisional conflict. A randomization algorithm allocated participants to receive tailored education and communication coaching, generic teaching sheets and external websites plus a one-page summary to clinicians (intervention), or the links plus materials provided in clinic (usual care). Conflict outcomes and number of consults were measured at 1-month. Univariate and multivariable models were used to analyze outcomes. 392 men were random...

A skilled assistant surgeon is presumed necessary during robot-assisted partial nephrectomy (RAPN) to minimize warm ischemia time (WIT) and to facilitate complex renorrhaphy. Studies observing impact of resident participation have focused on robotic prostatectomies, showing no impact on core surgical outcomes. Herein, we evaluated the level of experience of the bedside assistant and its impact on perioperative outcomes in RAPN. All RAPN cases in our healthcare system from January 2011 to December 2013 were retrospectively reviewed. The cases were divided into teaching and nonteaching hospitals. There were 18 fellowship-trained attending surgeons. At teaching hospitals, surgeries were performed by an attending physician and postgraduate year (PGY)-2 or PGY-3 resident at bedside; at nonteaching hospitals, surgeries were performed by two attending surgeons. We compared age, gender, body mass index, Charlson comorbidity index, operative difficulty by R.E.N.A.L. nephrometry score, and op...

Abstract Purpose: Prostate cancer is the most common genitourinary malignancy to affect male renal transplant recipients, with a cumulative incidence rate of 3.1% in the U.S. We present our experience with robotic and laparoscopic-assisted radical prostatectomy for the treatment of localized prostate carcinoma in renal transplant recipients. Materials and Methods: We demonstrate our technique of robot-assisted radical prostatectomy with pelvic lymph node dissection in a 62-year-old patient after kidney transplantation. Results: We retrospectively identified five patients who had undergone robotic or laparoscopic-assisted prostatectomy for clinically localized prostate cancer between 1999 and 2011 at our institutions. We reviewed all available clinicopathological data. All five patients underwent successful robotic or laparoscopic radical prostatectomy without significant complications. The mean operative time was 246 minutes (range 180–310) with a mean estimated blood loss of 375 mL (range 75–1000 mL). No...

... Surgery, Department of Urology, Kaiser Permanente Medical Center, Los Angeles, California, USA Gary W. Chien Department of Urology, Kaiser Permanente Medical Center, Bellflower, California, USA Kirk Tamaddon and Timothy ... 5. Somers KD, Winters BA, Dawson DM, et al. ...

We describe a technique of blind percutaneous renal access when retrograde/intravenous imaging is not possible. We present the surgical technique, the patient population, and situations in which the technique is used. Following a review of 40 accesses, we concluded that this technique is safe, simple, and effective. It also allows the urologist to act autonomously in obtaining renal access.

Introduction and Objectives: Caliceal leak after partial nephrectomy (PN) typically resolves with conservative management. However, persistent fistulae pose a formidable challenge that may require additional therapeutic actions. Methods: We describe a case of a patient with a solitary kidney who suffered a persistent urine leak following PN. A novel retrograde ureteroscopic approach was taken that utilized the combined techniques of caliceal fulguration and fibrin glue injection. Results: Imaging demonstrated resolution of the caliceal fistula at 13 months postoperatively. Conclusions: Persistent urine leak after PN remains a burdensome complication that often requires creative steps to resolve. Our case presents a solution using a novel ureteroscopic technique.

Minimally invasive surgical therapies are growing in type and volume of interventions. As one of the largest health delivery organizations in the US, Kaiser Permanente staff must be aware that the proliferation of these technologies has occurred in parallel within many surgical specialties, with a large variation in level of implementation between different regions and even within regions. In Los Angeles, we have developed the Minimally Invasive Surgery Center, encompassing a multidisciplinary, integrated approach. It unites the effort and expertise of many outstanding practitioners within the organization and consolidates the achievements of many surgical specialties. It also brings together the elements needed to provide the highest level of care to our patients in a safe, efficient, cost-effective environment, with minimal morbidity and best long-term outcome.

The technical difficulty of laparoscopic partial nephrectomy (LPN) lies mainly in the steps required during warm ischemia time (WIT), which includes tumor excision and renal reconstruction. We present a renal-suspension traction system to place the tumor in stable optimal view during the critical steps of LPN. Thirty-three patients underwent LPN from October 2002 through December 2003. Eight had a renal sling placed intraoperatively because of difficult access to the tumor. Perioperative parameters were assessed. The renal hilum was dissected and the tumor exposed. To keep the tumor oriented perfectly toward the camera and the working ports, a 2-0 braided polyglactin (Vicryl) traction suture was passed through Gerota's fascia, catching the renal capsule; brought out through the abdominal wall; and secured to the skin with a clamp. All surgical margins were negative. For the traction and nontraction groups, the mean sizes of the tumor were 2.5 cm and 2.2 cm, respectively (P = 0.4...

Riedel's lobe of the liver is an anatomic variant, described as a caudal extension of the right lobe of the liver, that presents a challenge in laparoscopic right renal surgery. A 52-year-old woman with a Riedel's lobe of the liver and a large right renal mass underwent laparoscopic right radical nephrectomy. Transperitoneal access with the Veress needle through a right lateral port was initially unsuccessful. After a supraumbilical approach, pneumoperitoneum was eventually achieved. The right lateral liver attachments were freed, and the lobe was retracted medially to expose the right kidney and its hilum. The surgery was then performed successfully. Riedel's lobe presents two special technical concerns: intraperitoneal access and hilar exposure. For access, an initial supraumbilical approach, or possibly an open approach, decreases the risk of liver injury. For renal and hilar exposure, the right lateral liver attachments can be taken down so that the hepatic lobe can ...

We evaluated the long-term outcome, effectiveness and patient satisfaction of corporeal plication for the correction of congenital penile curvature. A total of 25 patients with congenital penile curvature were included in the study. Mean age was 39 years (range 15 to 45). Patients with Peyronie's disease, and/or chordee associated with hypospadias or evidence of erectile dysfunction were excluded from analysis. All procedures were done on an outpatient basis using local anesthesia. The technique of corporeal plication consists of placing longitudinal plication sutures of 2-zero braided polyester on the opposing side of curvature until it is corrected during artificially induced erection. A standardized questionnaire was then completed via telephone interview to assess results as well as the patient satisfaction rate. A total of 22 patients were available for evaluation. Successful results at up to 3(1/2) years (range 1 to 42 months, mean 18) of followup were achieved in 21 of th...

Introduction: Black men have a higher incidence of advanced stage at diagnosis and mortality from prostate cancer than do men in other racial groups. Given that androgen-deprivation therapy (ADT) is one of the mainstays of treatment for advanced prostate cancer, we investigated the development of biochemical failure, or recurrence of elevated prostate-specific antigen (PSA) levels, among different races in men receiving ADT.Methods: Patients with prostate cancer who received ADT in the Kaiser Permanente Southern California Cancer Registry between January 2003 and December 2006 were eligible for inclusion in our study. Patients who had prior treatment for their cancer with surgery or radiation were excluded. Treatment failure was defined as an increase in PSA of >2 ng/mL from PSA nadir, with no subsequent decrease in PSA. We compared the biochemical failure rate in white patients to those in black, Hispanic, and Asian/other patients. The Cox proportional hazards regression model w...

To evaluate the impact of the urologist's experience in selecting active surveillance (AS) versus immediate treatment (IT) for low-risk prostate cancer. Men with low-risk prostate cancer were enrolled from March 2011 to August 2013 at 13 medical centers in Kaiser Permanente Southern California. The AS cohort was defined as men who had cT1-T2a stage prostate cancer, prostate-specific antigen <10 ng/ml, a biopsy revealing Gleason grade ≤6, fewer than three biopsy cores positive, ≤50 % cancer in any core, and not undergone immediate therapy (surgery, radiation, other) within 6 months following diagnosis. The urologist's experience (age, number of years in practice, number of robotic surgeries performed, and fellowship experience in oncology and/or robotics) was then compared between AS and IT cohorts. A total of 4754 men were diagnosed with prostate cancer, and 713 men satisfied with inclusion criteria; 433 (60.7 %) and 280 (39.3 %) chose AS and IT, respectively. A total of ...

Introduction and Objective Natural language processing (NLP) software programs have been widely developed to transform complex, free text into simplified, organized data. Potential applications in the field of medicine include automated report summaries, physician alerts, patient repositories, electronic medical record (EMR) billing, and quality metric reports. Despite these prospects and the recent widespread adoption of EMR, NLP has been relatively underutilized. The objective of this study was to evaluate the performance of an internally developed NLP program in extracting select pathologic findings from radical prostatectomy specimen reports in the EMR. Methods An NLP program was generated by a software engineer to extract key variables from prostatectomy reports in the EMR within our healthcare system, which included: TNM stage, Gleason grade, presence of a tertiary Gleason pattern, histologic subtype, size of dominant tumor nodule, seminal vesicle invasion (SVI), perineural invasion (PNI), angiolymphatic invasion (ALI), extracapsular extension (ECE), and surgical margin status (SMS). The program was validated by comparing NLP results to a "gold standard" compiled by two blinded manual reviewers for 100 random pathology reports. Results: NLP demonstrated 100% accuracy for identifying Gleason grade, presence of a tertiary Gleason pattern, SVI, ALI, and ECE. It also demonstrated near-perfect accuracy for extracting histologic subtype (99.0%), PNI (98.9%), TNM stage (98.0%), SMS (97.0%), and dominant tumor size (95.7%). The overall accuracy of NLP was 98.7%. NLP generated a result in <1 second, whereas the manual reviewers averaged 3.2 minutes per report. Conclusions: This novel program demonstrated high accuracy and efficiency identifying key pathologic details from the prostatectomy report within an EMR system. NLP has the potential to assist urologists by summarizing and highlighting relevant information from verbose pathology reports. It may also facilitate future urologic research through the rapid and automated creation of large databases.

Percutaneous renal biopsy in patients with renal masses is increasing. We investigated the accuracy of percutaneous renal mass biopsy results in patients undergoing evaluation of solid renal masses. A retrospective review was performed of patients in the Kaiser Permanente Southern California Region who underwent computed tomography or ultrasound-guided percutaneous renal biopsy of a solid renal mass between January 2005 and December 2009. Patients were stratified by size of mass (≤ 4 cm vs > 4 cm). Initial biopsy results were correlated with final pathology specimens after extirpation. Medical records of 126 patients (129 renal units with 132 biopsies) were reviewed. Initial diagnostic biopsies revealed 87 (66%) malignant, 38 (29%) benign, and 7 (5%) nondiagnostic lesions. Sixty-three patients (50%) ultimately underwent extirpative surgery (23 partial and 40 radical nephrectomies). Of these patients, the diagnostic accuracy of the initial percutaneous renal mass biopsy was 76%, w...

Initiating a robotics program is complex, in regards to achieving favourable outcomes, effectively utilizing an expensive surgical tool, and granting console privileges to surgeons. We report the implementation of a community-based robotics program among minimally-invasive surgery (MIS) urologists with and without formal robotics training. From August 2008 to December 2010 at Kaiser Permanente Southern California, 2 groups of urologists performing robot-assisted radical prostatectomy (RARP) were followed since the time of robot acquisition at a single institution. The robotics group included 4 surgeons with formal robotics training and the laparoscopic group with another 4 surgeons who were robot-naïve, but skilled in laparoscopy. The laparoscopic group underwent an initial 7-day mentorship period. Surgical proficiency was measured by various operative and pathological outcome variables. Data were evaluated using comparative statistics and multivariate analysis. A total of 420 and 5...