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Canadian Urological Association Journal logoLink to Canadian Urological Association Journal
. 2016 Sep 5;10(9-10Suppl4):S158–S200.

Moderated Poster Session I: Oncology Thursday, September 29, 2016 10:15 am – 12:00 pm

PMCID: PMC5063721
Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S158.

P1: Is there a measurable association of epidural use at cystectomy and postoperative outcomes? A population-based study

R Christopher Doiron 1, Melanie Jaeger 1, Christopher M Booth 1, Xuejiao Wei 1, D Robert Siemens 1

Abstract

Background:

Thoracic epidural analgesia (TEA) is commonly used to manage postoperative pain and facilitate early mobilization after major intra-abdominal surgery. Evidence also suggests that regional anesthesia/analgesia may be associated with improved survival after cancer surgery. Here, we describe factors associated with TEA at the time of radical cystectomy (RC) for bladder cancer and its association with both short- and long-term outcomes in routine clinical practice.

Methods:

All patients undergoing RC in the province of Ontario between 2004 and 2008 were identified using the Ontario Cancer Registry (OCR). Modified Poisson regression was used to describe factors associated with epidural use, while a Cox proportional hazards model describes associations between survival and TEA use.

Results:

Over the five-year study period, 1628 patients were identified as receiving a RC, 54% (n=887) of whom received TEA. Greater anesthesiologist volume (lowest volume providers RR=0.85, 95% CI 0.75–0.96) and male sex (female sex RR 0.89, 95% CI 0.79–0.99) were independently associated with greater use of TEA. Improved short-term outcomes were not associated with TEA use. In multivariate analysis, TEA was not associated with cancer-specific survival (HR 1.02 [95% CI 0.87–1.19]; p=0.804) or overall survival (HR 0.91 [95% CI 0.80–1.03; p=0.136]).

Conclusions:

In routine clinical practice, 54% of RC patients received TEA in routine and its use was associated with anesthesiologist provider volume. After controlling for patient, disease, and provider variables, we were unable to demonstrate any effect on either short- or long-term outcomes at the time of RC.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S158.

P2: A Canadian prostate cancer electronic library for improved function post-treatment (eLIFT)

Joseph Chin 1, Garson Chan 1, Jennifer Goulart 2, Khurram Siddiqui 1, Elizabeth Wambolt 1, Hon Leong 1, Sally Hodgson 2, Nelson Leong 2, Kristin Tangen-Steffins 2

Abstract

Background:

The TrueNTH program is a Movember-funded, Canadian initiative to develop a comprehensive patient-centered online platform in English and French that will cover a full spectrum of prostate cancer survivor needs. Through the support of Prostate Cancer Canada, the TrueNTH-PCC-eLIFT resource, as part of the TrueNTH program, is being developed by a multidisciplinary team of urologists, radiation oncologists, gastroenterologists, researchers, nurses, and survivors at two Canadian pilot sites. This online portal (eLIFT) will address urinary and bowel side effects that may be experienced after curative intent treatment by external beam radiation therapy (EBRT), brachytherapy (BT), combined EBRT + BT or radical prostatectomy (RP). This comprehensive online portal will be a global resource for all patients to access.

Methods:

eLIFT includes a didactic electronic library, symptom assessment tool and content tailored to treatment or symptoms experienced. A sequential prospective cohort study is underway to evaluate the impact of the resource. A baseline cohort of eighty patients per site receiving standard of care has finished recruitment. A second cohort of eighty patients per site is open to receive the eLIFT intervention. To assess the impact of intervention, Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP), Cancer Behavior Inventory (CBI-B), EQ-5D-5L and International Prostate Symptom Score (IPSS) are used. The study will also measure patient self-efficacy, knowledge, Health Related Quality of Life (HRQoL), urinary and bowel function, health resource usage, and satisfaction.

Results:

eLIFT content, with a total of 22 video modules is complete. We have begun screening and recruitment of baseline cohort patients at both sites. Results from the first cohort of patients, receiving standard care, confirm a need for a reliable, online resource they can access. Patients note that the oral information provided by their oncologist at their preliminary consultation, while informative, is not easily retained. Information provided as print varied and was often outdated. Further, patients deem websites outside of Canada as the most reliable and helpful, which may not reflect Canadian recommendations.

Conclusions:

eLIFT will provide a unique and scalable centralized resource that will allow for expansion to an international level and increase access to a scientifically sound library of information with the goal of improving the quality of care for prostate cancer patients globally.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S158–S159.

P3: A pilot study of high-arginine nutritional supplementation prior to radical cystectomy

Timothy Lyon 1, Robert Turner 1, Dawn McBride 1, Jeffrey Gingrich 1, Benjamin Davies 1, Bruce Jacobs 1, Tatum Tarin 1

Abstract

Background:

Supplementation with high-arginine nutritional shakes prior to surgery for gastrointestinal malignancy has been shown to decrease the risk of postoperative infectious complications by improving the immunometabolic host response. The purpose of this study was to assess the feasibility of administering a high-arginine supplement to patients undergoing radical cystectomy for bladder cancer and to compare postoperative outcomes with a cohort of matched controls.

Methods:

We prospectively recruited patients to begin supplementation with a high-arginine nutritional shake (Impact: Advanced Recovery [Nestle, Vevey, Switzerland]) prior to radical cystectomy. Subjects were instructed to consume four shakes per day for five days prior to surgery and complete a log of their intake. Adverse events, tolerability, and adherence to the supplementation regimen were assessed. Additionally, postoperative outcomes (hospital length of stay and 90-day overall and infectious complications) were retrospectively compared between supplemented patients and a cohort of non-supplemented controls individually matched by surgeon and year of surgery.

Results:

A total of 20 patients were recruited and provided high-arginine nutritional shakes prior to radical cystectomy by one of three surgeons. There were no serious adverse events during supplementation. Three patients (15%) reported a minor adverse event, including nausea (n=2) and bloating (n=1). Fourteen patients (70%) consumed all prescribed shakes. Demographics and clinicopathologic characteristics, including age, gender, Charlson comorbidity index, and pathologic stage, were not significantly different between supplemented and non-supplemented patients. Hospital length of stay was similar between groups (6 days [IQR-6-8] vs. 7 days [IQR: 6–9]; p=0.33). Supplemented patients were significantly less likely to experience an infectious complication than controls (15% vs. 50%; p=0.02). There was no difference in overall complications between groups (35% vs. 65%; p=0.11).

Conclusions:

Preoperative supplementation with a high-arginine nutritional shake was well tolerated in a cohort of patients undergoing radical cystectomy. This study suggests that immunonutrient supplementation may decrease the risk of postoperative infectious complications and highlights the need for a randomized controlled study to further investigate this finding.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S159.

P4: Antibiotic prophylaxis protocol for TRUS-guided prostate biopsy based on local organism resistance patterns

Yifan Meng 1, Jimena Cubillos 1, Edward M Messing 1, Janet Kukreja 1

Abstract

Background:

Increasing microbial resistance has led to an overall increased incidence of infections following prostate transrectal ultrasound (TRUS)-guided biopsies. Based on local resistance patterns, an antibiotic protocol was instituted across all out patient offices to prevent an increase in infection incidence after TRUS-guided prostate biopsies.

Methods:

The local antibiogram resistance patterns were reviewed for common organisms causing infection after TRUS biopsies, with review every six months to monitor resistance patterns. Antibiotics chosen for prophylaxis were ciprofloxacin 500 mg by mouth and ceftriaxone 1 g intermuscular; penicillin allergic patients received gentamicin IM 2.5mg/kg. Antibiotics were administered at least 30 minutes prior to biopsy. Data were reviewed retrospectively for 2351 patients who underwent TRUS prostate biopsy between July 2012 and December 2015. In August 2014, protocol prophylaxis was implemented. Prior to this, there was no standard prophylaxis. Organisms considered resistant were those not susceptible to antibiotics used traditionally for their treatment (ex. fluoroquinolone-resistant E.coli). Univariable statistical analyses were performed with Fisher’s exact/chi-squared or Wilcoxon-Mann-Whitney where appropriate. Logistic regression was used for multivariable analyses.

Results:

There were 799 biopsies performed after protocol implementation. The protocol group had more patients with chronic kidney disease (CKD), larger prostate volume, greater number of biopsies during the procedure, and cancer in remission; other baseline demographics were similar. The rate of post-biopsy emergency department (ED) visit was low, 1.7% for non-protocol patients and 0.6% for protocol patients (p=0.027). Likewise, the overall rate of post-biopsy inpatient admissions was 1.35% for non-protocol patients and 0.4% for protocol patients (p=0.026). Organisms resistant in blood and urine decreased from 20.7% (n=23) in the non-protocol group to 7.4% (n=4) in the protocol group (p=0.030). All positive blood cultures occurred in the non-protocol group, all of which were E. coli resistant to ciprofloxacin. After adjusting for prostate volume, CKD, cancer in remission, and enema type with multivariable logistic regression, patients requiring admission were 8.8 (95% CI 1.58–49.12) times more likely to have resistant organisms cultured (p=0.004).

Conclusions:

Using local organism resistance directed prophylaxis for a TRUS-guided prostate biopsy antibiotic protocol helps keep post-procedural ED visits and inpatient admissions low.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S159.

P5: Associations between omega-3 and quality of life of patients with prostate cancer under active surveillance

Hanane Moussa 1, Molière Nguile-Makao 1, Janie Allaire 1, Karine Robitaille 1, Vincent Fradet 1

Abstract

Background:

Consumption of omega-3 fatty acids (Ω3) appears to have a protective effect against prostate cancer (PCa). We have not found data describing the relationship between the consumption of Ω3 and quality of life (QoL) of men with PCa. The objective of this study is to identify the relationship between indicators of QoL and Ω3 consumption using a transversal study design.

Methods:

We completed recruitment of 189 men with low-grade PCa who chose active surveillance to determine the effects of a dietary intervention, aiming to increase the Ω3 intake and decrease Ω6 intake, on the prostate tissue and QoL. We used the following tools to measure QoL during the preliminary visit: Inventory of Sexual Health for men (SHIM), the Expanded Prostate Cancer Index Composite EPIC-26 (hormonal, urinary, digestive, and sexual domains), and the International Prostate Symptom Score (IPSS). We measured dietary intake by a computerized food frequency questionnaire validated specifically in this population. Logistic regression was used to evaluate associations between consumption Ω3 and QoL.

Results:

The median age of patients was 63 years (IQR 11), the median body mass index (BMI) was 27.08 kg/m2 (IQR 5.20), 68% had a Gleason score ≤6 and the median prostate-specific antgen (PSA) level was 4.60 ng/mL (IQR 3.05). The median of the Ω6/Ω3 ratio was 6.52 (IQR 2.80) and the median of the Ω3 consumption was 1.68 g/day (IQR 0.90). The multivariable logistic regression models show that men categorized in the highest level of the Ω6/ Ω3 ratio had a bad QoL in the urinary irritative and incontinence domains than men categorized in the lowest level (OR 4.216; 95% CI 1.310–13.570; p=0.01; OR 2.953; 95% CI 1.190–7.329; p=0,02, respectively). Men categorized in the highest level of the Ω3 and ALA consumption had a best QoL in the urinary irritative domain than men categorized in the lowest level (OR 0.343; 95% CI 0.133–0.881; p=0.03; OR 0.339; 95% CI 0.130–0.883; p=0,03, respectively).

Conclusions:

We observed a positive association between high dietary intake of Ω3 and better QoL in the urinary domain. This suggests that Ω3 diet influences, in a beneficial way, QoL of patients with PCa. The specific effects of dietary intervention to increase Ω3 intake on QoL are still unknown, but future study is warranted.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S159.

P6: Biopsy perineural invasion in prostate cancer patients who are candidates for active surveillance by liberal and conservative criteria

Todd S Yecies 1, Robert M Turner 1, Jonathan G Yabes 1, Benjamin T Ristau 2, Benjamin J Davies 1, Bruce L Jacobs 1, Joel B Nelson 1

Abstract

Background:

Although the presence of perineural invasion (PNI) on prostate biopsy is not considered in established criteria for active surveillance (AS), it has been shown to influence selection of patients for AS in the clinical setting. The objective of this study was to evaluate the association of biopsy PNI with adverse pathological findings on radical prostatectomy in patients who would have been candidates for AS.

Methods:

Using a prospectively populated database of 3042 men who underwent open radical prostatectomy by a single surgeon between November 1999 and July 2015, candidates for AS by liberal (University of Toronto) and conservative (Johns Hopkins) criteria were identified. The presence of adverse pathologic features at radical prostatectomy was compared between those men with and without biopsy PNI.

Results:

Of 597 men who met conservative criteria for AS, 16 (2.7%) had PNI identified on prostate biopsy. In the conservative AS cohort, there were no differences in adverse pathologic features at radical prostatectomy between those with and without PNI. Of 1197 men who were candidates for AS by liberal criteria, 102 (8.5%) had PNI identified on prostate biopsy. Men with biopsy PNI in the liberal AS cohort were more likely to have extracapsular extension (23% vs. 10%; p<0.001) and pathological upgrading (63% vs. 49%; p=0.01) at prostatectomy. In addition, they had larger dominant nodules (1.5 cm vs. 1.1 cm; p<0.001), and cancer comprised a greater percentage of their prostate glands (10% vs. 5%; p<0.001). There was no difference in the proportion with positive margin between the two groups (4% vs. 3%; p=0.77).

Conclusions:

Biopsy PNI was rare in patients who met conservative criteria for AS. Among those men who met liberal criteria, PNI was associated with adverse pathologic findings upon prostatectomy. The presence of biopsy PNI may have a role in further risk stratifying patients who meet liberal criteria for AS.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S160.

P7: Development of a urine-based inflammatory test for prostate cancer

Nikunj Gevariya 1, Alain Bergeron 1, Karine Robitaille 1, Tal Ben-Zvi 1, Marc-Andre Allard 1, Yves Fradet 1, Nicolas Bisson 2, Vincent Fradet 1

Abstract

Background:

Chronic inflammation is a potential causal factor of prostate cancer (PCa). However, a non-invasive test assessing prostatic inflammation does not existent. The aim of this project is to develop a noninvasive, urine-based inflammatory test to measure prostatic inflammation and stratify risk of PCa. Specifically, we sought to identify inflammatory-related proteins particularly present in urine after prostate digital rectal examination (DRE).

Methods:

We collected urine samples before and after DRE from consenting men presenting for a prostate needle biopsy. The urine samples were analyzed using discovery label-free quantification (LFQ) mass spectrometry protocols. First, we optimized conditions in order to specifically analyze secreted prostate-specific proteins. Then, we compared global secreted protein expression of pre- and post-DRE urine samples (total 18 samples) of nine patients (three of each: Gleason (G) 8, G6, and without cancer groups) to discover cancer-specific biomarkers of inflammation. Proteins abundance were compared using the Welch t-test with p-values <0.1 declared significant.

Results:

The conditions of optimization process defined our protocol to use of 5 μg of protein for a two-hour run duration from undepleted urine samples. We identified 74 proteins greater than two-fold more abundant in post-DRE urine as compared with pre-DRE urine. We identified six proteins that were more expressed (upregulated), while 55 were down-regulated in the post-DRE urine of low-grade PCa vs. patients without cancer. We identified six upregulated proteins, while nine were down-regulated post-DRE urine of high-grade PCa vs. patients without cancer. Some of them have been already identified as candidate markers for PCa, supporting our analytical approach.

Conclusions:

Post-DRE urine is enriched with prostatic secretion proteins, indicating that it is a suitable sample type for developing a non-invasive test for PCa. We identified candidate protein signatures of low-grade and high-grade PCa. These must be validated in larger cohorts. As none of LFQ identified proteins are known as key players in inflammatory pathways, targeted proteomics assay (MRM: multiple reaction monitoring) need to be included to measure low abundant inflammatory-related cytokines.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S160.

P8: Functional status after prostate cancer treatment among Medicare advantage beneficiaries

Bruce L Jacobs 1, Samia Lopa 1, Jonathan Yabes 1, Joel B Nelson 1, Amber E Barnato 1, Howard B Degenholtz 1

Abstract

Background:

There are several effective treatments for prostate cancer. The extent to which treatment affects a patient’s functional status is under-studied. We sought to examine the relationship between treatment and subsequent functional status among older men with prostate cancer.

Methods:

Using Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) data, we identified men 65 years or older diagnosed with prostate cancer between 1998 and 2009, who were treated with conservative management, surgery, or radiation. Our primary outcome was functional status as measured by activities of daily living (ADLs). Secondary outcomes included the physical component summary (PCS) score and the mental component summary (MCS) score. We performed propensity score analyses to match cancer patients 1:5 with noncancer controls. We matched for age, race, marital status, 12 medical comorbidities, education, household income, who completed the survey, geographic region, and month and year of the survey. Generalized linear mixed effects models were used to analyze the matched data, accounting for the clustering due to medical insurance plan.

Results:

We identified 1323 prostate cancer patients who completed a survey within one year of treatment of whom 477 (36%) underwent conservative management, 229 (17%) underwent surgery, and 617 (47%) underwent radiation. Mean differences in ADL scores were not significantly different between treatment groups and matched controls (all p>0.05). Compared with matched controls, mean difference in the PCS score for conservative management, surgery, and radiation were −2.1 (95% CI −3.3, −0.9), −1.0 (95% CI −2.6, 0.5), and −2.2 (95% CI −3.2, −1.2), respectively. Mean differences in the MCS score for conservative management, surgery, and radiation were −0.7 (95% CI −1.7, 0.3), −1.0 (95% CI −2.2, 0.3), and −1.2 (95% CI −2.0, −0.3), respectively.

Conclusions:

After treatment, patients had similar ADL scores as their non-cancer peers. While surgery patients experienced no changes in any functional status measurements, radiation patients had both lower PCS and MCS scores compared with matched controls.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S160.

P9: High frequency of incidental bone lesions on prostate mpMRI in low-risk subjects

Stephanie Gleicher 1, Andrij Wojtowycz 1, Timothy Damron 1, Timothy Byler 1, Gennady Bratslavsky 1, Srinivas Vourganti 1

Abstract

Background:

Multiparametric magnetic resonance imaging (mpMRI) has been recommended for risk stratification and disease characterization in prostate cancer (PrCa) diagnosis. As the utilization of imaging increases, secondary findings may be identified which may raise suspicion for distant PrCa, prompting further workup. Differentiating benign vs. metastatic lesions and planning for an appropriate workup will be crucial in such situations. The goal of this report is to describe our institution’s experience with incidental bone lesions on prostate MRI.

Methods:

This retrospective review includes data from 187 consecutive patients who underwent a pelvic mpMRI prior to an MRI-US guided biopsy from September 2013 to August 2015 at our institution. Demographics, pre-biopsy prostate-specific antigen (PSA) levels, and PrCa status at mpMRI were captured. Images of the prostate were obtained with a 3-Tesla MRI with endorectal and surface coil capturing T1/T2W, DWI, and DCE sequences. Chi square and Fisher exact tests were used for categorical variables; t-tests were used for discrete variables.

Results:

Among 187 subjects, 8% had incidental bone lesions noted on imaging. The average bone lesion was 1.1cm, 80% were in the iliac bones, and 53% demonstrated enhancement. No significant differences in age, race, PSA, or clinical stage were found between men with bone lesions (BL+) and without (BL-). Indication of MRI was significantly associated with BL+, with lesions noted in 40%, 9%, 2%, and 0% of men with assessment of recurrence, prior negative biopsy, active surveillance, and initial biopsy, respectively (p<0.05). The number of suspicious lesions on MRI, overall MRI suspicion level, and prostate volume were not predictive of bone lesions. Workup for bone lesions included subsequent bone scan (33%), computed tomography (CT) scan (27%), and bone biopsy (13%). Non-enhancing lesions were deemed indolent based on radiologic criteria. No lesions were deemed metastatic PrCa. MR/ultrasound fusion biopsies showed 75% without PrCa in BL+.

Conclusions:

Despite the high percentage of incidental bone lesions among subjects, none were deemed to be metastatic PrCa, nor were lesions found to be correlated with the presence of PrCa. With the widespread use of MRI, clinicians must be prepared to manage similar findings with regard to subsequent testing and counselling of patients. In such settings of low likelihood of metastatic disease, our series suggest the presence of bone lesions may be highly non-specific. Moving forward, strategies to avoid unnecessary testing will be crucial.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S161.

P10: Magnetic resonance/ultrasound-guided fusion biopsy: An initial experience using the updated prostate imaging reporting and data system (PI-RADS v2)

Cameron Jones 1, Robert M Turner II 2, Alessandro Furlan 2, Bruce L Jacobs 2, Benjamin J Davies 2

Abstract

Background:

Targeted magnetic resonance (MR)/ultrasound fusion prostate biopsy has been increasingly used in the evaluation of patients with elevated prostate-specific antigen (PSA) following negative standard sextant biopsy and in those patients considering active surveillance. Single-institutional series have demonstrated an association between Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) score and the finding of clinically significant prostate cancer; however, the external validity of these studies is questioned. We report our initial experience MR/ultrasound-guided fusion biopsy and assess the predictive value of PIRADSv2 score in the detection of clinically significant cancer.

Methods:

A retrospective review of our institution’s electronic medical record was conducted to identify 69 consecutive cases between August 2015 and March 2016. Four patients with missing data and five patients with an unreported PI-RADS v2 score were excluded from the analysis. We assessed demographic and clinical characteristics of the patient population, as well as radiographic characteristics and pathologic outcomes of MR lesions targeted for biopsy. All MR imaging was performed on a 3 Tesla system, and the findings are based on the initial radiologic interpretation at the time of clinical evaluation. Among lesions with a PI-RADS v2 score of 3 or higher, the association between PI-RADS v2 and the presence of clinically significant cancer (Gleason 3+4 or higher) was evaluated using a chi square test. The positive predictive values of PI-RADS v2 scores for the detection of clinically significant cancer were also calculated.

Results:

Sixty patients underwent targeted MR/ultrasound fusion prostate biopsy for evaluation of an elevated PSA following negative standard sextant biopsy (n=51, 85%) or consideration of active surveillance of previously identified cancer (n=9, 15%). Median PSA was 9.2 ng/mL (IQR 6.9–13.9 ng/mL), and the median number of prior biopsies was one (IQR 1–2). In all, 92 lesions were targeted for fusion biopsy. Among 89 lesions with a PI-RADS v2 score of 3 or greater, there was an association between PI-RADS v2 score and the presence of clinically significant cancer (p<0.001). The positive predictive values of PI-RADS v2 scores of 3, 4, and 5 for the detection of clinically significant cancer were 13%, 22%, and 68%, respectively.

Conclusions:

In our initial experience of MR/ultrasound fusion prostate biopsy, the predictive value of PI-RADS v2 in the detection of clinically significant cancer was similar to previously published reports. These findings support the external validity of PI-RADSv2 in patients undergoing fusion biopsy.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S161.

P11: MRI-TRUS fusion biopsy in patients with atypical small acinar proliferation (ASAP): Evaluation of clinical benefit and comparison with biopsy-naive patients

Derek W Cool 1, Cesare Romagnoli 1, Jonathan I Izawa 1, Joseph Chin 1, Lori Gardi 1, David Tessier 1, Ashley Mercado 1, Jonathan Mandel 1, Aaron D Ward 1, Aaron Fenster 1

Abstract

Background:

Magnetic resonance-transrectal ultrasound (MRI-TRUS) fusion biopsy has shown improved detection of prostate adenocarcinoma over conventional systematic biopsy; however, the clinical impact of the technology on different biopsy populations requires validation. This prospective study evaluates the added clinical benefit of fusion biopsy over standard TRUS biopsy for patients with prior atypical small acinar proliferation (ASAP) histopathology as compared to first-time biopsy patients.

Methods:

One hundred patients were enrolled in a single-center prospective cohort study — 50 for repeat biopsy with prior ASAP histology, 50 for first biopsy. Inclusion criteria: prostate-specific antigen (PSA) 2–20 ng/ml; no prior MP-MRI; no history of CaP. Multiparameteric prostate MRI (MP-MRI) was performed on all patients and any suspicious MP-MRI lesion was targeted using MRI-TRUS fusion biopsy. A Prostate Imaging Reporting and Data System (PIRADS) score was assigned to all MP-MRI abnormalities. A standard 12-core TRUS biopsy was performed on all patients regardless of MP-MRI findings and was used as an internal control.

Results:

Prostate adenocarcinoma was detected in 23/50 ASAP and 26/50 first-time biopsy patients with eight and 17, respectively, having significant disease. ASAP patients had greater benefit from MRI-TRUS fusion biopsy which was significantly more likely to detect significant cancer missed on standard biopsy for ASAP patients than first-time biopsy patients (p<0.05). The MRI-TRUS biopsy identified significant cancers in 5 (10%) ASAP patients that were missed on standard biopsy. The addition of fusion biopsy to standard biopsy had a 166.7% relative risk reduction for missing Gleason ≥3+4 disease (number needed to image with MP-MRI=10 patients) compared to only 6.3% for first biopsy patients (number to image=50 patients). For ASAP patients, if biopsies were only targeted at PIRADS ≥3 lesions, then 60% (30/50) of patients would have avoided biopsy without missing any significant cancer, and insignificant disease would have only been found in three (6%) instead of 15 patients (30%). Conversely, removal of standard biopsy for first-time biopsy patients would have caused 5 (10%) of significant cancers to be missed. The negative predictive value of a normal or benign MP-MRI (PIRADS 1 or 2) was 100% for ASAP and 79% for first-time patients with a median followup of 32.1±15.5 months.

Conclusions:

MRI-TRUS fusion biopsy detected more significant cancers that were missed on standard biopsy for ASAP patients than it did for biopsy naïve patients, suggesting a greater clinical benefit of MRI-TRUS for the ASAP population.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S161–S162.

P12: Oncologic outcomes of simple enucleation partial nephrectomy in sporadic papillary type 2 renal cell carcinoma

Andres F Correa 1, Jathin Bandari 1, Ronald L Hrebinko 1, Benjamin J Davies 1, Stephen V Jackman 1

Abstract

Background:

The increase use of percutaneous biopsy in the treatment algorithm for small renal masses (SRM) has led to histology-based management. Papillary type 2 renal cell carcinoma (RCC) has been associated with poor prognosis and increased risk of local recurrence following studies in patients with hereditary familial leiomyomatosis and renal cell carcinoma (RCC). The current recommendation for patients found to have papillary type 2 features on biopsy is for radical nephrectomy or partial nephrectomy with a wide margin. Here we intend assess the margin rate along with fossa recurrence rate of patients with sporadic type 2 papillary RCC that underwent simple enucleation partial nephrectomy as compared to those with clear cell RCC.

Methods:

We performed a retrospective chart review of all patients with a small renal mass (4 cm or less in diameter) who underwent simple enucleation partial nephrectomy and were found to have papillary type 2 RCC or clear cell RCC over a 10-year period. Information regarding patient demographics, surgical technique, histological subtype, grade, margin status, recurrence rate, and development of metastatic disease was collected from the medical record. All patients with known histology prior to partial nephrectomy were excluded from the study, as were patients with mixed histology or patients who underwent laparoscopic/robotic procedures.

Results:

One hundred thirteen patients met criteria for the study. Of these, 27 (24.0%) patients were found to have papillary type 2 RCC. Patients with papillary type 2 RCC had higher rates of pT3a compared to those with clear cell RCC (13.3% vs. 4.7%, respectively; p=0.034). The margin rate for both groups was comparable with 10% of patients presenting with a positive margin in the papillary type 2 group compared to 9.3% in the clear cell RCC group (p=0.91). The recurrence was also comparable with only two (6.7%) patients developing a fossa recurrence in the papillary type 2 group compared to five (5.8%) in the clear cell RCC group (p=0.91) with a median followup of 23 months.

Conclusions:

In this retrospective trial the margin and fossa recurrence rate seen following simple enucleation partial nephrectomy was comparable between sporadic papillary type 2 and clear cell histology. These findings suggest simple enucleation can be performed with acceptable oncological outcomes in sporadic papillary type 2 RCC.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S162.

P13: Surgical treatment for stage I renal cell carcinoma: Does treatment facility or location matter?

Kyle Plante 1, Telisa Stewart 1, Dongliang Wang 1, Gennady Bratslavsky 1, Margaret Formica 1

Abstract

Background:

American Urology Association (AUA) guidelines recommend partial nephrectomy (PN) as the surgical treatment for clinical stage I renal cell carcinoma (RCC). While use of PN has increased over the last decade, it is unclear if the shift has been uniformly driven by all cancer treatment facilities. Using data from the Commission on Cancer’s (CoC) National Cancer Data Base (NCDB), this study seeks to compare the rates of PN for clinical T1 renal masses across types of cancer programs and geographic locations within the US.

Methods:

Cases of surgically treated RCC at CoC-accredited facilities were identified from the Participant User File (PUF) from 2004–2013, which was obtained from the NCDB (a joint project of the CoC of the American College of Surgeons and the American Cancer Society). Patients with clinical stage I RCC who received either PN or radical nephrectomy (RN) as the primary surgical treatment at a CoC-accredited facility were included (N=123 706). Multivariable log-binomial regression was used to estimate risk ratios for RN overall and stratified by tumor size across types of CoC-accredited cancer programs and geographic regions.

Results:

Compared to Academic Comprehensive Cancer Programs (ACAD), cases were more likely to be treated with a RN if they received care at a Community Cancer Program (CCP) (RR 1.50, 95% CI 1.47–1.52), Comprehensive Community Cancer Program (CCCP) (RR 1.38, 95% CI 1.36–1.40), or Integrated Network Cancer Program (INCP) (RR 1.23, 95% CI 1.21–1.26). Compared to patients receiving care in the Northeast, patients in the Southeast (RR 1.16, 95% CI 1.14–1.18), North Central (RR 1.13, 95% CI 1.12–1.15), South Central (RR 1.12, 95% CI 1.10–1.14), and Mountain/Pacific (RR 1.19, 95% CI 1.17–1.21) were more likely to be treated with a RN. When stratified by tumor size, the likelihood of being treated with RN was most pronounced for cT1a tumors (<4 cm) treated at CCPs (RR 1.62, 95% CI 1.57–1.67) or CCCPs (RR 1.45, 95% CI 1.43–1.49), and in the Mountain/Pacific (RR 1.25, 95% CI 1.22–1.29) or Southeast regions (RR 1.22, 95% CI 1.19–1.26).

Conclusions:

Despite having CoC accreditation there is significant variability on patterns of care for Stage I RCC patient. Patients are most likely to be treated with a PN when receiving care at an ACAD or in the Northeastern US. The variability is most pronounced for patients with cT1a masses, with community cancer centers (CCPs and CCCPs) having the greatest likelihood of performing a RN. Further research is required to explore these differences.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S162.

P14: The role of urinary cytology when diagnostic workup is suspicious for upper tract urothelial carcinoma but tumor biopsy is non-confirmatory

David Horovitz 1, Yifan Meng 1, Jean V Joseph 1, Changyong Feng 1, Guan Wu 1, Hani Rashid 1, Edward M Messing 1

Abstract

Background:

Patients with suspicious upper tract lesions may undergo an endoscopic evaluation to obtain visual and pathological evidence of upper tract urothelial carcinoma (UTUC). When tissue biopsy is negative or non-diagnostic, urinary cytology may be used to help guide treatment, although its utility has not been well-defined in this setting. Our group aims to determine the value of obtaining preoperative urinary cytology when diagnostic workup (imaging, endoscopy, presentation, clinical history) is suspicious but biopsy fails to confirm malignancy.

Methods:

Using billing code data, 239 patients were identified as having undergone RNU by 16 urologists at two hospitals from Sept. 29, 1998–July 31, 2015. Forty-three patients were initially excluded: concomitant cystectomy (25), non-functioning atrophic kidney (10), pediatric patient (4), billing code mismatch (2), RNU for extrinsic compression (1), RNU in a transplant kidney (1). Ninety-two patients had biopsies that were positive, suspicious, or suggestive of malignancy; 83 did not undergo biopsy; two had inadequate information and were also excluded. Thus, the final study population consisted of 19 patients who were divided into three groups. Group A had no urinary cytology taken (6); Group B had upper and/or lower tract cytology performed with neither positive nor atypical (7); Group C had upper and/or lower tract cytology performed with at least one positive or atypical (6).

Results:

Demographic information was similar among the groups. Diagnostic workup (including endoscopic findings) was similar, although Group A had more patients with a history of cystectomy for bladder cancer (p=0.04). One patient in Group B had benign tissue on final pathology but the other six patients in that group had discordant results. All patients in Group A and C had malignancy on final pathology and overall, the three groups had similar rates of malignancy. Tumor and histological characteristics were similar. When rearranging the 19 patients and dividing them into groups based on just their upper tract cytology status — none (n=13), negative (n=2), positive (n=4). One patient with no cytology had benign tissue on final pathology; the others all had malignant disease.

Conclusions:

When a composite of clinical findings are highly suspicious for UTUC, performing urinary cytology may not be necessary. A negative result in this setting should not be used to rule out UTUC, as this is often discordant with final pathology. A positive cytology result may help solidify the diagnosis when other findings are less clear.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S162.

P15: Utility of pre-biopsy multiparametric MRI of prostate in biopsy-naive men undergoing image fusion targeted biopsy

Joseph Mahon 1, Ahmad Essa 1, Hugh A G Fisher 1, Rebecca O’Malley 1, Ronald P Kaufman Jr 1, Badar M Mian 1

Abstract

Background:

Multiparametric magnetic resonance imaging (MP-MRI) of the prostate and image fusion targeted approach to prostate biopsy has demonstrated improved cancer detection rates. We sought to evaluate the outcomes of our newly implemented targeted biopsy program, not only as a first detection for biopsy-naïve patients, but also those with disease that have eluded the standard template biopsy.

Methods:

We reviewed the records of 361 men who underwent MP-MRI of prostate prior to their prostate biopsy. Clinical and demographic data were recorded. Men with PiRADS score 3–5 were considered to have MRI evidence of prostate cancer and were targeted for fusion MRI/US fusion biopsy, while PiRADS 1–2 were excluded as likely benign disease. The number and locations of suspicious lesion on the MRI were noted. All men underwent Uronav image fusion targeted biopsy followed by concomitant random 12-core biopsy.

Results:

Of the 361 men with pre-biopsy MP-MRI of prostate, 219 (61%) had suspicious lesion on the MRI. Mean prostate-specific antigen (PSA) at time of biopsy was 6.925 ng/ml and 70% of men had normal digital rectal exam (DRE). A single lesion on MRI was noted in 52%. Overall, cancer was noted in 198 (55%) men. Of the 257 men undergoing “first” prostate biopsy (no previous biopsies), cancer was noted in 147 (57%) of men. Of those with previous negative biopsy, 30 of 70 (43%) had a positive biopsy. Cancer detection rate per PIRADS Score for both first biopsy and repeat biopsy groups were also calculated; 19 of 39 (49%) of first biopsy patients with PIRADS 3 lesions noted on MRI exhibited positive biopsies (average Gleason 6.37), as well as 12 of 24 (50%) who had previous negative prostate biopsy (average Gleason 6.5); 44 of 57 (77%) first biopsy with PIRADS 4 (average Gleason 7.02), 19 of 30 who had previous negative prostate biopsy (average Gleason 6.53); and 40 of 45 (89%) first biopsy with PIRADS 5 (average Gleason 7.4), 10 of 17 who had previous negative prostate biopsy (average Gleason 7).

Conclusions:

A positive MP-MRI guided targeted prostate biopsy is associated with an increased rate of cancer detection in men with or without a previous negative biopsy. The majority of cancers noted are intermediate or high-grade.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S163.

P16: Validation of perioperative blood transfusion as a surgical quality indicator of radical cystectomy for urothelial bladder cancer

D Robert Siemens 1, Melanie Jaeger 1, Xuejiao Wei 1, Chris Booth 1

Abstract

Background:

Radical cystectomy (RC) is a complex surgical procedure often required for elderly patients with urothelial bladder cancer (UBC). There is a significant need to optimize outcomes and, specifically, to identify quality indicators of care. Herein, we describe factors associated with perioperative blood transfusion (PBT) at RC and evaluate its association on outcomes in order to explore its utility as a quality indicator of surgical care.

Methods:

Electronic records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients with bladder cancer who underwent RC between 2000 and 2008. Hospital discharge records were used to identify PBT. Modified Poisson regression model was used to determine the factors associated with PBT. A Cox proportional hazards regression model was used to explore the association between PBT and overall (OS) and cancer-specific (CSS) survival.

Results:

Among 2593 patients identified, 62% received an allogenic red blood cell transfusion. The frequency of PBT decreased over the study period (from 68% to 54%; p<0.001). Factors associated with receiving PBT included age, sex, greater comorbidity, T stage and surgeon volume. Use of PBT was associated with inferior early outcomes including median length of stay (11 vs. 9 days; p<0.001), 90-day readmission rate (38% vs. 29%; p<0.001), and 90-day mortality (11% vs. 4%; p<0.001). OS and CSS at five years were lower among patients with PBT and these differences persisted on multivariate analysis (OS HR 1.33, 95% CI 1.20–1.48; CSS HR 1.39, 95% CI 1.23–1.56).

Conclusions:

Although rates are decreasing, these data suggest very high utilization rate of PBT at time of RC in routine clinical practice. PBT is associated with substantially worse early outcomes and long-term survival. This association persists despite adjustment for disease-, patient- and provider-related factors, suggesting that PBT is an important and valid indicator of surgical care of UBC.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S163.

P17: Variations in preoperative use of bone scan among Medicare beneficiaries undergoing radical cystectomy

Robert M Turner II 1, Jonathan G Yabes 2, Benjamin J Davies 1, Dwight E Heron 1, Bruce L Jacobs 1

Abstract

Background:

Routine staging with bone scan prior to radical cystectomy is generally discouraged in the absence of symptoms or an elevated alkaline phosphatase level. The current use of bone scan prior to radical cystectomy in the US is unknown. We sought to examine demographic, regional, and clinicopathologic factors associated with bone scan use in patients undergoing radical cystectomy and to assess trends in preoperative use of bone scan over time.

Methods:

Using Surveillance, Epidemiology, and End Results - Medicare data, we identified 5573 patients who underwent a radical cystectomy from 2004–2011. The primary outcome was bone scan obtained within six months prior to surgery. Demographic regional, and clinicopathologic predictors of bone scan use were examined using a mixed logit model with health service area as a random effect to account for patients nested within health service areas. Covariates included age, race, comorbidity, marital status, education level and median income in ZIP code of residence, county population, region, grade, stage, measurement of an alkaline phosphatase level, and year of surgery.

Results:

Among patients undergoing radical cystectomy during the study period, 1754 (31%) completed a preoperative bone scan. Urologists ordered most of these studies (69%). The adjusted probability of a patient undergoing a bone scan decreased from 0.40 in 2004 to 0.30 in 2011 (p=0.01). Compared with patients in the northeast region, those in the south (adjusted odds ratio [aOR] 0.37 95% CI 0.24–0.58), central (aOR 0.29 95% CI 0.18–0.49) and west (aOR 0.65 95% CI 0.56–0.75) regions were less likely to have a bone scan. Compared with those with stage ≤T1, patients with T2 (aOR 1.80 95% CI 1.51–2.15), T3 (aOR 2.12 95% CI 1.76–2.56), and T4 (aOR 2.22 95% CI 1.78–2.77) disease were more likely to have a bone scan. Alkaline phosphatase assessment was not associated with bone scan use (aOR 1.03, 95% CI 0.86–1.23). Among 102 individual surgeons who performed 10 or more operations over the study period, there was significant variation in the proportion of patients who completed preoperative bone scans (p<0.001).

Conclusions:

Although bone scan use has decreased over time, they are still used frequently in the preoperative staging of bladder cancer. Future studies should investigate ways to improve patient selection and develop clinical pathways to standardize use of these studies in this setting.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S163.

P18: Young patients with T1a renal cell carcinoma and comorbidities treated at commission on cancer-accredited facilities are more likely to have radical and not partial nephrectomy

Daniel Wang 1, Kyle Plante 1, Telisa Stewart 1, Dongliang Wang 1, Margaret Formica 1, Gennady Bratslavsky 1

Abstract

Background:

Prior studies indicate that in young patients, partial nephrectomy (PN) is associated with improved overall survival at long-term followup of 10 years when compared to radical nephrectomy (RN). However, prior analyses were performed using SEER database that does not allow for analysis of comorbidities that may have influenced outcomes. Using the Charlson-Deyo Comorbidity Score (CDCS) from the Participant User File (PUF) from the National Cancer Database (NCDB), we evaluate the correlation between presence of comorbidities and the likelihood of receiving a PN at Commission on Cancer (CoC)-accredited facilities.

Methods:

Cases of surgically treated renal cell carcinoma (RCC) at CoC-accredited facilities were identified from the Participant User File (PUF) from 2004–2013 obtained from the NCDB (a joint project of the CoC of the American College of Surgeons and the American Cancer Society). Young patients aged 20–44 with tumors 4 cm or less were included in the study (N=9849). Cases were assigned a comorbidity score of 0 (CDCS=0), 1 (CDCS=1), or 2 (CDCS>1). Binary logistic regression was used to produce odds ratios (OR) for receiving RN compared to PN. Kaplan-Meier method and Cox Model were performed to estimate the overall survival curves and the hazard ratio (HR) between receiving RN and PN. The binary logistic regression and Cox models were adjusted for confounding factors.

Results:

Compared to cases with a CDCS of 0, cases were more likely to be treated with a RN if they had a CDCS of 1 (OR 1.110, 95% CI 0.931–1.322) or greater than 1 (OR 2.049, 95% CI 1.527–2.750). PN offered an overall advantage in five-year and 10-year overall survival with an adjusted HR 0.432 (from Cox model, 95% CI 0.331–0.564) when compared to RN. There were 2701 cases with a followup of five years or greater. Followup length ranged from 0–130.96 months with a mean and median of 48.40 and 45.04, respectively.

Conclusions:

NCDB PUF data analyses are consistent with prior studies demonstrating that compared with RN, PN improved overall survival in patients with small, localized RCC. Additionally, our analysis demonstrates that cases with higher CDCS are associated with an increased risk of being treated with RN.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S164.

P19: A novel technique for reconstruction of fossa navicularis and distal pendulous urethral stricture via transurethral ventral buccal mucosal inlay

Michael Daneshvar 1, Mourad Abouelleil 1, Dmitry Nikolavsky 1

Abstract

Background:

The repair of distal urethral strictures usually involves a penile skin incision to gain access to the urethra for various forms of external urethrotomy and subsequent repair with flaps or grafts. These incisions place the repair at risk for fistula formation, glans dehiscence and suboptimal cosmetic outcomes. We introduce a novel surgical technique for reconstruction of distal urethral strictures without a need for skin incision. Our approach, a modified endoscopic technique, employs a ventral internal urethrotomy and precise transurethral delivery and fixation of BMG to the surface of the urethrotomy.

Methods:

A ventral urethrotomy is performed transurethrally and a wedge of the obstructive tissue is removed to access a proximal patent lumen. An appropriate size BMG is harvested and prepared for delivery. Both arms of a double-arm 6-0 polydioxanone suture are passed through the proximal apex of the graft then through the urethra at the proximal apex of the urethrotomy and externalized through the skin. The arms of the suture are pulled externally to deliver the graft precisely into its place in the urethra. Additional 6-0 double-armed sutures are then used to quilt the graft at its mid-portion and their knots are tied externally. The distal edge of the graft is sutured to the edge of the meatotomy with absorbable sutures. We conducted a retrospective chart review of all the patients after a distal urethral stricture repair since March 2014 by a single surgeon (DN). Surgical, functional and patient reported outcomes were reviewed. Patients were assessed preoperatively and post-operatively at six weeks, four, eight, 12 months, and then yearly. Routine followup included uroflow, PVR, SHIM and IPSS scores.

Results:

This procedure was performed in a total of 10 male patients. Mean age was 46 years (26–69), mean stricture length 1.8 cm (1–4). At a mean followup of 6.5 months (2–24), there were no recurrences, fistula, penile chordee, or adverse effects on sexual function. Mean uroflow preoperatively was 4.6 (2–9), postoperatively 20 (8–32), mean preoperative PVR 77 (0–248), postoperative PVR 28 (0–78), mean preoperative SHIM score 18 (5–25), postoperative 20 (1–25) and mean preoperative IPSS 15 (5–29), postoperative 4 (2–11).

Conclusions:

We demonstrate the feasibility of an incisionless distal urethral stricture repair with ventral inlay BMG. This single-stage technique avoids urethral mobilization or skin incision and ultimately prevents glans dehiscence or fistula formation. It also circumvents the use of genital skin flaps in patients affected with LS.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S164.

P20: Buccal mucosal graft augmentation urethroplasty for bulbomembranous strictures after radiation therapy for prostate cancer

Jeffrey Spencer 1, Stephen Blakely 1, Mourad Abouelleil 1, Dmitriy Nikolavsky 1, Brian Flynn 2

Abstract

Background:

Urethral stricture disease that develops as a result of radiation therapy for prostate cancer occurs in the bulbomembranous urethra. These strictures are difficult to treat due to ischemic changes in the local tissues. Anastomatic urethroplasty has been encouraged to avoid free grafting into an ischemia graft bed. We present our series of patients undergoing buccal mucosal graft urethroplasty for post-radiation bulbomembranous urethral strictures and compare both dorsal and ventral approaches.

Methods:

We reviewed consecutive patients undergoing buccal mucosal graft augmentation urethroplasty for bulbomembranous strictures after radiation therapy for prostate cancer at two institutions. Patient factors and recurrence rates are presented.

Results:

Fifteen men underwent urethroplasty. Nine patients had a dorsal onlay buccal graft and six patients underwent urethroplasty with a ventral onlay. Eleven men had previously received external beam radiation therapy, while two were treated with brachy therapy alone and two received both. The mean age was 68 years (56–77). All patients had bulbomembranous urethral involvement and mean stricture length was 6 cm (3–17 cm). At a mean followup of 10 months (4–31months), there were two stricture recurrences, each managed with a single DVIU. Each recurrence was in a patient who underwent ventral onlay. One patient who underwent ventral onlay reported new incontinence after urethroplasty, while continence status was unchanged in the remaining patients.

Conclusions:

Urethroplasty with buccal mucosa grafting techniques has been shown to be successful in patients with radiation-induced bulbomembranous urethral stricture. Buccal mucosal grafting techniques should be considered in this setting. Larger studies are required to more accurately predict recurrence and incontinence rates

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S164–S165.

P21: Patient characteristics, morbidity, and mortality of genital and perineal burns

Yifan Meng 1, Scott Quarrier 1, Paige L Myers 1, Gareth J Warren 1, Derek E Bell 1

Abstract

Background:

Involvement of the genitalia and perineum in burn injuries can be devastating. In the literature, among all burn patients there is a reported incidence of 3–12% of patients that have genital involvement. Recent national registry data have reported that genital involvement in burns as an independent predictor of mortality. This highlights the need for more research in genital burns. This study used our institutional burn registry to report patient characteristics, morbidity, and mortality.

Methods:

A retrospective chart review was performed from our institutional burn center registry for cases of genital burns from July 2010 to January 2016. Data were gathered on patient demographics, mechanism, total body surface area (TBSA), length of stay, burn location, mortality, and presence of bacteriuria and bacteremia. Univariate statistical analysis was performed with t-test and chi-square.

Results:

One hundred and twelve cases of burns to the genital region were identified from 1595 total admissions to our burn center. Genital burns affected males more than females (65.2%), although this percentage is similar to non-genital burn controls. The TBSA was higher for genital burns compared to non-genital burns (12.7% vs. 4.8%; p<0.0001). The most common mechanism for genital burns was scald, and the most commonly involved genital region was the perineum. Significantly more patients with genital burns had bacteriuria compared to those without genital burns (9.7% vs. 0.9%; p<0.0001). Mortality was significantly worse for patients with genital burns (8% vs. 0.9%; p<0.0001).

Conclusions:

Burn injury to the genitals and perineum are rare but associated with higher mortality rates than burns not involving the genital region. The etiology of the higher mortality rates among genital burn patients has not yet been elucidated. Among our patient population, patients with genital burn have significantly higher bacteriuria rates, although the trend to higher bacteremia rates did not reach statistical significance. More research is needed to identify the factors that impact higher rates of mortality in this patient population.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S165.

P22: Bulbospongiosus muscle dissection and ejaculatory function outcomes in urethroplasty

Laura B Cornwell 1, Stephen Blakely 1, Dmitry Nikolavsky 1

Abstract

Background:

It has been speculated that bulbospongiosus muscle (BSM) bisection may negatively affect ejaculatory function. New dissection techniques were proposed with the intent of minimizing neuromuscular damage. We hypothesized that muscle sparing techniques may have better ejaculatory outcomes as compared to bisection techniques.

Methods:

Our institution’s urethral stricture database was used to retrospectively analyze all male patients undergoing anterior urethroplasty. Excluded patients were those who underwent multi-staged procedures, had previous BSM dissections, had poor ejaculatory function unrelated to their stricture, and those who did not complete surveys. The patients were divided into four groups based on the type of BSM dissection: 1) traditional midline muscle bisection, 2) unilateral bisection (Kulkarni-type), 3) muscle-sparing (Barbagli-type), and 4) distal urethroplasty patients with no muscle manipulation. To evaluate outcomes, patients were given pre- and postoperative Men’s Sexual Health Questionaires (MSHQ). Ejaculatory function and bother scores (best possible 35 and 5, respectively) from the MSHQ surveys were compared between groups.

Results:

A total of 173 patients were included in the database between August 2012 and March 2016. Of those, 48 men met inclusion criteria. Twelve, eight, 18, and 10 patients were included in Groups 1–4 (Table 1). The groups were compared and found to differ significantly in preoperative ejaculatory function scoring (p=0.019). Postoperative ejaculatory function was found to be improved when all patients were evaluated together (p=0.026). No single group achieved statistical significance in exhibiting a change between pre- and postoperative function. No statistically significant difference was identified comparing ejaculatory bother either between groups or in relation to the procedure.

Conclusions:

Urethroplasties involving any type of muscle dissection may result in improved ejaculatory function possibly by simply un-obstructing the urethral lumen. Randomized prospective studies assessing subjective and objective outcomes are needed to determine whether different techniques of muscle dissection have an effect on ejaculatory function.

Table 1.

All (n=48) Group 1 (n=12) Group 2 (n=8) Group 3 (n=18) P value
Preoperative function 24.1 ± 7.6 21.5 ± 11.0 19.5 ± 6.3 24.9 ± 5.1 29.4 ± 3.7 0.019
Postoperative function 26.8 ± 8.7 28.0 ± 6.4 24.4 ± 11.3 25.4 ±10.6 29.8 ± 3.4 0.419
P value 0.026 0.062 0.103 0.763 0.764
Preoperative bother 3.8 ± 1.2 3.5 ± 1.5 3.3 ± 1.2 4.0 ± 1.1 4.3 ± 1.1 0.234
Postoperative bother 4.2 ± 1.2 4.3 ±1.1 4.1 ± 1.1 4.1 ± 1.4 4.3 ± 1.3 0.958
P value 0.074 0.096 0.087 0.726 1.000
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S165.

P23: Changes in nocturnal bladder diary parameters in men after urethroplasty for anterior urethral strictures

Jyoti D Chouhan 1, Frank Copeli 1, Jeffrey P Weiss 1, Rajveer S Purohit 1

Abstract

Background:

We evaluated changes in nocturnal voiding patterns of men (M) before and after anterior urethroplasty for urethral stricture disease using a 24-hour bladder diary.

Methods:

This was a retrospective study of M undergoing anterior urethroplasty for urethral stricture between June 2011 and August 2015 and who had a preoperative and postoperative 24-hour bladder diary. Diaries done any time prior to surgery and only those done at least one month after surgery were included. On the 24-hour diary, patients were asked to record the volume and time of each urination. Paired t-tests were performed on nocturnal voiding variables.

Results:

One hundred and four anterior urethroplasties were performed during the study period, of which 17 had bladder diaries. Mean age was 45.4 years (range 26–70). The majority had bulbar urethral strictures (n=10, 58.8%) followed by pendulous-bulbar strictures (n=4, 23.5%), bulbomembranous (n=2, 11.8%), and penile (n=1, 5.9%). Means of correction were buccal mucosa onlay graft (n=8, 50%), end-to-end repair (n=6, 37.5%), urethroplasty (n=1, 6.3%), and augmented excision and primary anastomosis with buccal graft (n=1, 6.3%). Mean days from surgery to first postoperative 24-hour bladder diary was 287.5 days (median 109, range 32–1116). Preoperative and postoperative changes in nocturnal bladder diary parameters are listed in Table 1.

Conclusions:

Anterior urethral reconstruction improves nocturnal voiding parameters. The most striking change was decreased nocturia severity postoperatively, which appears to be attributable to a combination of increased bladder capacity and decreased nocturnal urine production. This is the first study evaluating changes in nocturnal voiding function after urethroplasty.

Table 1.

Bladder diary parameters

Bladder diary parameter Pre-urethroplasy Post-urethroplasy P value
24-hour voided volume (mL) Mean: 1818.0 Mean: 2100.7
Median: 1500.0 Median: 1882.0 0.35
Range: 439–6225 Range: 746–4543
Maximum voided volume (mL) Mean: 338.1 Mean: 416.4
Median: 350.0 Median: 400.0 0.07
Range: 80–700 Range: 130–740
Actual number of night voids Mean: 1.6 Mean: 0.8 0.06
Median: 1.0 Median: 1.0
Nocturnal urine volume (mL) Mean: 443.4 Mean: 378.2
Median: 371.8 Median: 347 0.44
Range: 74–1650 Range: 10.4–977.2
Nocturnal polyuria index Mean: 0.2 Mean: 0.2 0.09
Median: 0.2 Median: 0.2
Nocturnal bladder capacity index Mean: 1.5 Mean: 1.0 0.15
Median: 1.6 Median: 1.0
Nocturnal index Mean: 1.1 Mean: 0.9 0.07
Median: 1.0 Median: 0.8
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S165–S166.

P24: Early ambulation decreases hospital stay in renal trauma: A randomized, prospective sudy

Ilija Aleksic 1, Igor Sorokin 1, Himanshu Aggarwal 2, Adam Walker 3, Paul Feustel 1, Ronald Kaufman 1

Abstract

Background:

Non-operative management (NOM) is the standard of care for blunt renal trauma. Observation for blunt renal trauma has been widely adopted with practitioner dependent duration of bed rest. A paucity of data exists regarding the effect of bed rest on outcomes and on hospital length of stay (LOS). Urologists commonly offer either bed rest for four to five days or until the resolution of gross hematuria. Given the system-wide emphasis on reducing LOS, we sought to prospectively determine if early ambulation leads to shorter hospital stays and its safety for patients with Grade 2–4 blunt renal trauma.

Methods:

After obtaining IRB approval and consent from patients with Grade 2–4 renal laceration, patients were randomized to either four days of strict bed rest or strict bed rest until resolution of hematuria. Primary endpoint was hospital LOS while intervention performed, complications, and rate of re-bleed was also collected. The study was closed due to failure to accrue.

Results:

From August 2012 to September 2015, 12 patients were randomized into one of the two groups. The bed rest group consisted of four patients while the early ambulation group consisted of eight. Median age overall was 23.5, with 22.99 in the bed rest and 25.61 in the early ambulation group (p=0.8). Overall, three were female (25%) and nine were male (75%). The cohort consisted of one Grade 2 (8.3%), eight Grade 3 (66.7%), and three Grade 4 (25.0%) renal lacerations. Median time to ambulation was two days, with five and 1.5 days for bed rest and early groups, respectively (p<0.01). Median LOS was four days with six days and three days for the bed rest and early groups, respectively (p<0.05).No re-bleeds were documented in either group and no interventions were required for the early ambulation group. Two patients in the bed rest arm required angiography without other intervention and one required a blood transfusion. One patient acquired a catheter associated urinary tract infection.

Conclusions:

Strict bed rest protocols are associated with higher morbidity due to prolonged immobilization and the subsequent increase in LOS exposure iatrogenic morbidity and cost. Albiet a small sample size, our data illustrate Level 1 evidence that early ambulation yields decreased hospital LOS without causing adverse side effects.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S166.

P25: Outcomes following urethral reconstruction in the geriatric population

Jillian Egan 1, Jeffrey Spencer 1, Dmitry Nikolavsky 1

Abstract

Background:

Urethral reconstruction has evolved as gold standard treatment for urethral strictures. As the population of the US gets older, increasing numbers of geriatric patients are undergoing urethral reconstruction. This patient population tends to have different baseline characteristics that have the potential to affect surgical outcomes. We investigated patient reported and surgeon reported outcomes in urethroplasty patients over 65 years of age to define the determinants of success and potential morbidities in this age group.

Methods:

This was a retrospective chart review of post-urethroplasty patients from August 2012 to February 2016. The cohort was divided based on age; those 65 years and older were considered “geriatric.” Patients under 18 years old, prisoners, and those with out-of-state followup were excluded. At presentation, baseline demographics, maximum urine flow (Qmax), measured by uroflowmetry, and International Prostate Symptom Score (IPSS) were collected. These were related to postoperative measures of urine flow, patient-reported satisfaction, complications, and need for subsequent procedures.

Results:

One hundred and fifteen patients met inclusion criteria. Twenty-six patients were age 65 or older. The geriatric population had a higher prevalence of diabetes and a lower rate of smoking and prior urethroplasty than the under 65 population. The prevalence of prior endoscopic procedures was similar in both groups. Pre and postoperative Qmax and IPSS showed statistically significant improvement in the geriatric age group (mean Qmax, in ml/second, improved from 4.7 [range 2–11] to 19.5 [3–56]; p<0.001; mean IPSS 19–11; p=0.001). These results were similar to what was observed in patients under the age of 65 (mean Qmax improved from 7.2 [0–24] to 23.5 [2–61]; p<0.001; mean IPSS from 20 [0–35] to 5 [0–29]; p<0.001). Average length of hospital stay was one day for geriatric patients and 0.97 days for the younger population, which was not significant (p=0.557).

Conclusions:

Surgical outcomes and patient satisfaction following urethral reconstruction in geriatric patients seems to be similar to that observed in the general population. Furthermore, these patients do not require increased hospital stays.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S166–S167.

P26: Surgical management of adult acquired buried penis: Escutcheonectomy, scrotoplasty, and penile split thickness skin graft

Thomas W Fuller 1, Katherine Theisen 1, Paul Rusilko 1

Abstract

Background:

Adult acquired buried penis as a result of obesity is a morbid condition with increasing incidence. Affected patients have poor sexual function, urine dribbling and skin breakdown, mood disturbance, and poor quality of life (QoL). Lichen sclerosis develops causing subsequent stricture disease. Weight loss is ineffective due to chronic skin changes and suprapubic fat pad (termed the escutcheon) lymphedema. Previous efforts have described limited repairs including isolated resection of the escutcheon, which unfortunately often leads to reburying. We present a more extensive surgical repair including escutcheonectomy, scrotoplasty, and penile degloving with split-thickness skin graft (STSG) to provide definitive repair and halt the progression of the disease process.

Methods:

A retrospective chart review was conducted of patients managed surgically for adult acquired buried penis in 2015–2016. Nine patients were identified who underwent escutcheonectomy, scrotoplasty, penile degloving, and STSG repair. All patients had morbid obesity as a sole etiology or significant contributing factor. Outcomes evaluated were surgical complications, reburying of the penis, graft take rate, and urinary symptoms.

Results:

Nine patients underwent repair of adult acquired buried penis. All patients had good cosmetic results and durable unburying at intermediate term followup. Etiology of buried penis was due to morbid obesity in all cases. Mean patient body mass index (BMI) was 45.4±3.7. Sixty seven percent of the patients in the series were diabetics and 56% had hypertension and hyperlipidemia (Table 1). Mean operative time, length of stay (LOS), and estimated blood loss (EBL) were 305±21 min, 5.6±1.1 days, and 321±147 cc respectively. STSG take rate was 80–100% (mean 91%) (Table 2).

Conclusions:

Adult acquired buried penis is a challenging condition to treat. Limited surgical repairs can lead to reburying of the penis, need for further procedures, and the progression of urethral disease with voiding dysfunction. Escutcheonectomy, scrotoplasty, and STSG have encouraging intermediate-term outcomes with durable unburying of the penis and good STSG take rates. Further followup in larger series is needed, but results are thus far encouraging.

Table 1.

Demographics (n=9)

Age 45.4 ± 13.8
Weight (kg) 143.0 ± 14.0
Body mass index 45.4 ± 3.7
Comorbidities
  Diabetes 6/9 (67%)
  Hypertension 5/9 (56%)
  Hyperlipidemia 5/9 (56%)
  Lichen sclerosus 9/9 (100%)
  Depression 2/9 (22%)
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Table 2.

Surgical details and outcomes (n=9)

Mean followup (months) 3.5
Would dehisence 1
Split-thickness skin graft take rate 80–100% (mean: 91%)
Readmission 3
Estimated blood loss (mL) 321 ± 147
Operative time (minutes) 305 ± 21
Length of stay (days) 5.6 ± 1.1
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S167.

P27: Practice patterns among genital burn patients: Surgical interventions and urologic service involvement

Scott Quarrier 1, Yifan Meng 1, Paige L Myers 1, Gareth J Warren 1, Derek E Bell 1

Abstract

Background:

Plastic surgeons, general surgeons, and urologists all play in a role in the management of this specific burn patient population. The distribution of genital burn cases managed by urologists has not been previously described. This study assessed the role of urology in managing genital burns and identified characteristics of patients whose cases required urologic involvement.

Methods:

A retrospective chart review was performed from our institutional burn center registry for cases of genital burns from July 2010 to January 2016. Data were gathered on patient demographics, mechanism, total body surface area (TBSA), length of stay, mortality, burn degree, burn location, surgical intervention, urologic service involvement, reason for consultation, and urologic intervention.

Results:

Out of 112 cases of genital burns, eight (7.1%) required surgical intervention to the genital region by excision and grafting. All eight patients had third- or fourth-degree burns. Six of the patients suffered scald burns, while the other two suffered burns from fire or flames. All surgical interventions were performed by a plastic surgery trained burn surgeon. Among patients with genital burns, 10 (8.9%) had consultation by a urologic service. Most common reason for consultation was Foley management including placement and assessment for removal. Urology was also consulted to evaluate need for urologic procedures, assess extent of genital involvement and manage artificial urinary sphincter. No patients required surgical intervention from a urologic service. One patient had an intraoperative consultation due to concern for urethral involvement. Despite the level of urologic service involvement, no salvage procedures were performed by urology for burn injury complications.

Conclusions:

Management of genital burns involves many subspecialties. Most burns are treated with local wound care only, but acute surgical intervention is indicated in severe cases. In our practice pattern, urologists are rarely involved in the care of genital burn patients. When urology is consulted, the consult question seldom involves burn management. Despite the rarity of consultations for genital burn patients, no salvage procedures for urologic complications were identified.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S167–S168.

P28: Safety and surgical outcomes of same-day anterior urethroplasty

Katherine M Theisen 1, Thomas Will Fuller 1, Jeremy Reese 1, Utsav K Bansal 2, Paul Rusilko 1

Abstract

Background:

Urethroplasty is underused for the management of urethral stricture disease; patients routinely undergo several failed endoscopic interventions before urethroplasty referral. One of the barriers to referral may be that anterior urethroplasty is routinely managed with a 2.5-day average hospitalization so patients/providers may elect repeated endoscopic intervention due to fear of longer convalescence following urethroplasty. This is despite recent literature demonstrating the safety of same-day urethroplasties. More studies showing the safety of same-day urethroplasty with comparable outcomes may dispel such fears. At our tertiary care center, we routinely perform same-day substitution and anastomotic urethroplasty. We assess the safety and short/intermediate-term outcomes of outpatient urethroplasty.

Methods:

We performed a retrospective chart review of 122 consecutive anterior urethroplasty patients (15 anastomotic, 107 substitution) performed by two surgeons from 2012 through 2016. We analyzed relationships between patients who were admitted and variables of age, stricture length, stricture etiology, number and type of prior stricture procedures, and stricture recurrence rates. Multivariate analysis was used to determine which factors were predictive of admission and stricture recurrence.

Results:

Ninety-two of 122 (75%) patients were discharged home same-day. Sixteen of 30 patients (53%) were admitted for anesthesia issues, late OR finish, or planned admissions for medical comorbidities. Six (20%) were admitted for pain control, and only five (17%) were admitted for unanticipated extended operative times. There was no difference between same-day and admitted groups for age (49.7 years vs. 49.3 years), stricture length (4 cm vs. 5 cm), stricture etiology, or the types or numbers of prior stricture procedures. Only the number of prior interventions predicted admission in a multivariable model (>3 prior surgeries had 5.3x odds of admission). There were no unplanned readmissions in same-day group. There was no association between stricture recurrence and same-day surgery (15% same-day, 23% admitted).

Conclusions:

We describe the largest series of outpatient anterior urethroplasty to date. The only factor that predicted the need for postoperative admission was an increased number of prior endoscopic stricture surgeries. Success rates between same-day and admitted groups were similar. These findings highlight the feasibility and safety of same-day urethroplasty without compromising success. A timely referral for urethroplasty may improve ability to perform outpatient surgery.

Table 1.

Urethroplasty failure (recurrence) and prior procedures in admitted vs. same-day urethroplasty

No. prior procedures Same-day (%) Admitted (%)
  ≤3 37 (88) 5 (22)
  >3 52 (68) 25 (32)
Failure
  Yes 14 (15) 7 (23)
  No 78 (85) 23 (77)
Total patients 92 (75) 30 (25)
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S168.

P29: The PRIVATES study: Pain rates in vasectomy and testing to ensure sterility — A contemporary series

William D Ulmer 1, Anand Brahmamdam 2, Michael Kottwitz 2, Benjamin M Bova 2, Bradley Holland 2, Georgia Mueller 2, Danuta Dynda 2, Tobias S Kohler 2, Charles Welliver 1

Abstract

Background:

Literature on post-vasectomy pain rates and vasectomy related complications is extremely disparate. We review a contemporary, single-surgeon series of vasectomies. In particular, we assess post vasectomy pain (PVP) of any kind, post procedure clinic contact, and examine time to sterility using contemporary AUA guidelines.

Methods:

A retrospective chart review of the first four years of the senior author’s experience were identified and reviewed. Data for 303 men were obtained including surgical and demographic data, semen analyses (SA), and patient post-procedure clinic contact. Our technique uses local lidocaine (with or without valium), includes two high incisions, vas resection, clipping, cautery, interposition, interrupted chromic skin closure and a prescription for 20 Narcotic based pain pills. Incisional complaints were typically treated empirically with a short course of antibiotics, whereas PVP was treated with two weeks of non-steroidal anti-inflammatory drugs (NSAIDS) and a quinolone with or without scrotal ultrasound.

Results:

Our 303 subject cohort’s average age was 38 years (range 22–62) and had had a mean of 2.6 children (0–8) and a mean followup of 1140 days (500–1865). Patient-initiated phone contact occurred from 8% patients with roughly equal complaints of incision concerns and pain. Post procedure visits occurred in 9% of cases with the most common complaints being incisional concerns (3%), scrotal pain (3%), epididymal complaints (1%) and infection (1%). Only 2% of patients required a second visit and only one patient (0.3%) required a third visit for post-procedural pain. Patients receiving prophylactic antibiotics at vasectomy had a higher (12%) but comparable rate of later receiving antibiotics than those who did not receive prophylaxis (5%).

Only 1.7% of patients required narcotics other than the initial prescription. NSAIDs were prescribed to another 4.3% of patients for PVP. No patients had PVP refractory to NSAIDs.

Only 62% of men provided any required post-vasectomy SA (when two completely azoospermic samples were required for clearance) and of these men, 10% required a third SA and 1% required a fourth SA to ensure sterility. A phone call to the office for any reason increased the likelihood that a man would provide the required SA (p<0.001). Using the new guidelines, 94% would have been cleared after the first sample, 99% after the second sample and 100% after the third sample.

Conclusions:

Our contemporary vasectomy series reveals men can safely be told they are at a very low risk for refractory PVP, the need for narcotic refills, and secondary procedures of any kind.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S168.

P30: Rates of hypogonadism in a nationwide sample: Results from NHANES

Michael Daugherty 1, Michael Daneshvar 1, Dmitriy Nikolavsky 1, Timothy Byler 1

Abstract

Background:

Testosterone deficiency has become increasingly recognized in US males with an estimated rate of hypogonadism in approximately 25–30% of aging men. Men typically present with fatigue and or loss of libido as cardinal symptoms of hypogonadism. This has been predominantly studied in middle-aged men and is believed to be related to andropause. There is minimal literature describing testosterone levels in healthy younger men. We sought to identify rates of hypogonadism in the younger population using information from a national sample.

Methods:

The NHANES database was queried for all men that had total testosterone levels drawn for the years 2011–2012. Men were stratified into groups according to age. Hypogonadism was defined as those patients with a T level <300 ng/dl. Patient demographics and patient-reported fatigue was collected for all patients. Univariate and multivariable logistic regression was performed to identify variables associated with hypogonadism.

Results:

A total of 2571 patients were analyzed. There were 730 men between the ages of 16 and 29 with an 18.6% rate of hypogonadism, and of these hypogonadal men, 54.3% reported fatigue. There were 446 men between the ages of 30 and 39 with a 25.2% rate of hypogonadism, and 45% of these hypogonadal men reported fatigue. The rate of hypogonadism was higher in older populations (Table 1). On univariate analysis, age (p=0.002), body mass index (BMI) (p<0.0001) and diabetes (p<0.0001) were associated with an increased risk of hypogonadism. Whereas, HDL level (p<0.0001) and smoking (p<0.0001) were found to have a decreased risk of hypogonadism. On multivariable analysis, BMI, HDL level, and smoking status remained significantly associated.

Conclusions:

In this nationwide sample, a surprising level of biochemical and symptomatic hypogonadism was seen in men under 40. A growing body of literature suggests a connection between metabolic syndrome and hypogonadism, which is consistent with our data as well. Young men who report symptoms of hypogonadism, especially with metabolic syndrome characteristics, should be screened for low testosterone and counseled appropriately.

Table 1.

Hypogonadism rates among age groups

Age Number of subjects % hypogonadism % fatigue
16–29 730 18.6 54.3
30–39 446 25.2 45.0
40–49 397 35.7 56.2
50–59 389 30.6 49.0
60–69 407 28.1 54.6
70–79 206 33.6 27.0
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S168–S169.

P31: The efficacy of tadalafil daily vs. on-demand in the treatment of erectile dysfunction: A systematic review and meta-analysis

Utsav K Bansal 1, Cameron Jones 1, William Fuller 2, Charles Wessel 1, Stephen Jackman 2

Abstract

Background:

Erectile dysfunction (ED) is a morbid condition for both patients and their partners. Over 40% of men over the age of 40 experience some degree of ED. Phosphodiesterase-5 (PDE-5) inhibitors are the mainstay of initial treatment but little is known about the optimal dosing frequency for patient satisfaction. We present a systematic review comparing patient satisfaction with the use of tadalafil daily vs. on-demand (PRN) dosing.

Methods:

A comprehensive database search including the Cochrane Database, PROSPERO, PubMed, EMBASE, Google Scholar, and clinicaltrials.gov was conducted to identify studies that examined varying frequencies of tadalafil therapy for the treatment of ED. The primary author then extracted the data from studies that met the following inclusion criteria: (1) randomized controlled trials that examined the use of tadalafil 5–10 mg daily vs. 20 mg PRN in adult men who had erectile dysfunction for at least three months or post-prostatectomy; (2) primary or secondary endpoint of International Index for Erectile Dysfunction-Erectile Function domain (IIEF-EF); and (3) at least 12 weeks of followup. The number of patients, mean, and standard deviation was extracted for each intervention group. Meta-analysis was performed using Stata® 14.0.

Results:

A total of 886 articles were reviewed for inclusion in the systematic review. Sixteen studies were identified that examined the desired dosing regimens with IIEF-EF as an outcome. However, only four of these randomized controlled trials included a common endpoint of 12 weeks. The mean IIEF-EF scores for tadalafil PRN and daily were 10.75 and 10.8 at baseline and 19.22 and 21.26 after 12 weeks, respectively. At 12 weeks, those patients taking tadalafil daily scored on average 1.86 points higher in IIEF-EF score compared to those taking tadalafil PRN (WMD 1.86, 95% CI 0.66–3.05; p=0.002, I2 38.5%; p=0.18) (Fig. 1).

Conclusions:

Tadalafil continues to be an effective treatment for ED. Those patients taking tadalafil daily for three months have a significant increase in satisfaction compared to an on demand regimen based on IIEF-EF scores. Further studies are necessary to examine other scoring systems and to perform a sensitivity analysis on patients with ED due to prostatectomy or diabetes.

Fig. 1.

Fig. 1.

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Forest plot of the effect of tadalafill PRN vs. daily dosing regimens on patient satisfaction.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S169.

P32: Analysis of semen parameters during two weeks of daily ejaculation: A first in humans study

Joseph Mahon 1, Aaron D Benson 4, Luke Frederick 5, Benjamin Leader 6, Edna Tirado 6, Paul Feustel 7, Mary McAsey 8, Tobias S Köhler 5, Charles Welliver 1,2,3

Abstract

Background:

Timed and frequent intercourse around the time of female ovulation is recommended to improve conception, but is debated due to insufficient evidence. Although both short and protracted periods of abstinence have been shown to have a negative effect on semen quality, the effects of increased frequency of ejaculation have not been rigorously studied.

Methods:

Twenty normal men were recruited for daily ejaculation over 14 consecutive days, after a 3–5 day abstinence period. Semen samples were collected at the beginning of the study (Day 1) and then on Days 3, 7, and 14. In addition to the standard semen analysis, markers of sperm DNA quality were assessed.

Results:

The mean age of men completing the study was 25 years (range 23–33). Significant decreases were observed in mean semen volume, total motile count (TMC), and sperm concentration during the study period without significant changes in motility or morphology. A large initial change in ejaculate volume, TMC, and sperm concentration provided the primary difference in these values over the study period, with a plateau in values after this initial decrease. Metrics of DNA integrity did not change in a statistically meaningful way during the study period.

Conclusions:

While a small study, this represents the most extensive examination of sperm quality with daily ejaculation. In normal men, these observed changes may not have a significant effect. However, oligospermic men in particular may benefit from less frequent ejaculation around the time of female partner ovulation or providing samples for assisted conception.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S169.

P33: Stuttering priapism: Can’t keep a good man down

JC Trussell 1

Abstract

Background:

Stuttering priapism is a recurrent form of ischemic priapism whereby unwanted painful erections occur repeatedly with intervening periods of detumescence. While each recurrent episode should be treated emergently, the ultimate goal is to manage such patients with additional interventions aimed at preventing future episodes. For instance, consider a trial of anti-androgens or gonadotropin-releasing hormone (GnRH) agonists. In the meantime, intracavernosal self-injection using phenylephrine should be considered in patients who either fail or reject systemic (hormonal) treatment. Finally, once systemic therapy controls stuttering priapism reset the erectogenic pathway using a daily phosphodiesterase type-5 inhibitor. This study reviews both the treatment outcomes and insurance-based limitations to treating stuttering priapism.

Methods:

From 2/15 through 3/16, treatment outcomes for a cohort of four patients with stuttering priapism were retrospectively reviewed. A telephone survey allowed for post-treatment feedback.

Results:

Please see Tables below.

Conclusions:

Although rare, stuttering priapism is a challenge to treat, taxing the patient, physicians, and hospital resources. All four patients responded to bedside treatments — avoiding surgical shunting. Lupron was well-tolerated and resulted in normalized erections within 10–21 days. During this time interval, no patients were able to obtain phenylephrine self-injections. Four to six weeks after Lupron wore off, two of three patients had recurrence of priapism. Based on this review of stuttering priapism, consider early hormonal ablation concurrent with a hospital policy allowing phenylephrine self-injections.

Table 1.

Patient information 1

Patient 1 2 3 4
Race White African-American Middle-Eastern White
Risk factors No Cocaine Thalesemia No
ABG: pH 6.7 6.8 6.7 6.6
Sono/Doppler No No No No
Emergency room visits 15 13 3 15
No. of irrigations 3/15 8/13 2/3 8/15
No. of injections 15/15 11/13 3/3 12/15
Phenylephrine (dose in mcg) (800–2000) (600–4000) (1500–6000) (500–2000)
Pelvic angiogram Yes: negative Yes: 2 coils No Yes: negative
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Table 2.

Patient information 2

Patient 1 2 3 4
Casodex 11/12/15 3/13/15 No 8/28/15
Lupron (1 month) 11/6/15
12/5/15		 3/13/15
6/29/15
9/5/15		 No 8/28/15
9/25/15
10/30/15
1/4/16
2/26/16
3/25/16
After Lupron priapism stopped 10 days 14 days N/A 10 days
21 days
Lurpon ran out, priapism returned 4 weeks (single occurrence) 6 weeks N/A 6 weeks
Complications No Penile pain, pan management No No
Lost job
Libido on Lupron Slight decline Lost to followup N/A Normal
Erections on Lupron Present Lost to followup N/A Present
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Table 3.

Insurance coverage

Patient 1 2 3 4
Phenylephrine self-injections No No No No
Daily Cialis No Yes No No
Lupron Yes Yes N/A No
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S169–S170.

P34: Histopathologic characterization of urethral strictures: A comparison of various types

Morgan Prince 1, Tiffany Caza 1, Steve Landas 1, Dmitriy Nikolavsky 1

Abstract

Background:

Urethral stricture is a relatively common urologic problem, with an incidence of approximately one in 200 men. Stricture disease can result in several comorbidities that can affect a patient’s quality of life, including acute urinary retention, hydronephrosis, recurrent urinary tract infections, hematuria, and formation of bladder stones. Lichen sclerosus, a chronic inflammatory disease thought to possible be autoimmune in etiology, is a known cause of urethral strictures when involving the urethra. Men with repair of urethral stricture over a 3.5-year time period were reviewed with histologic characterization of the urethral stricture. Our objective was to look at the location of urethral stricture and incidence of lichen sclerosus associated with location.

Methods:

One hundred seventy-three male urethral strictures were reported in a prospective registry over a 3.5-year time period between 2012 and 2015. Of the 173 urethral strictures, 77 specimen were available for analysis. Histological examination of each specimen was performed by a surgical pathologist at the time of specimen collection. Additionally, the specimens were retrospectively studied for tissue types present (including the presence or absence of urothelium, urethral tissue, skeletal muscle, and nerve), and processes associated with repair (chronic inflammation, acute inflammation, necrosis, granulation tissue formation, multinucleated giant cell reaction, and ectopic calcifications). The density and organization of collagen was assessed to examine the degree of fibrosis. The presence or absence of lichen sclerosus was also noted, using basal cell vacuolation, epidermal atrophy, dermal edema, homogenization of collagen, and focal perivascular infiltrate of the papillary dermis as defining features.

Results:

Out of the 77 urethral strictures repairs with available specimen, 15 (19.5%) involved the fossa navicularis, five (6.5%) were pendulous urethral strictures, 13 (16.9%) were panurethral strictures, 19 (24.7%) involved the bulbar urethra, 23 (29.8%) were bulbomembranous in location, and two (2.6%) were anastomotic strictures in patients status post-prostatectomy and radiation therapy for prostate cancer. Sixteen of the 77 (20.7%) examined specimen were consistent with lichen sclerosus after histologic characterization. Eight of the 16 (50%) specimen with lichen sclerosus were noted to have clinical examination findings suspicious for lichen sclerosus prior to urethroplasty. Lichen sclerosus was found in 9/15 (60%) of fossa navicularis, 2/5 (40%) of pendulous urethra specimen, 3/13 (23%) of panurethral stricture specimen, 2/19 (10.5%) of bulbar stricture specimen, 0/23 (0%) of bulbomembranous stricture specimen, and 0/2 (0%) of the anastomotic stricture specimen. In all stricture groups, there was a high prevalence of chronic inflammation (40–100%). Skeletal muscle and nerve tissue was more prevalent in bulbomembranous strictures (60–80%) than other types.

Conclusions:

While a majority of urethral strictures showed collagen fibrosis and mild-to-moderate chronic inflammation, lichen sclerosus was present in an overwhelming percentage of distal urethral strictures. Of the specimen that were consistent with lichen sclerosus, half were not suspected clinically. A high index of suspicion for this premalignant lesion should be maintained with urethral strictures, especially distal strictures, given it is not always clinically apparent.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S171.

P35: Blood product utilization pattern in pediatric renal transplantation: A single-institution analysis

Rakan I Odeh 1, Frank J Penna 1, Naimet K Naoum 1, Teresa Skelton 1, Armando J Lorenzo 1, Walid A Farhat 1, Martin A Koyle 1

Abstract

Background:

In renal transplantation (RT), there is an inherent lack of evidence-based guidelines to direct the amount and need of cross-matching blood products for surgery. Due to the inherent added costs, limited availability of blood products and potential waste if not used, we aimed to evaluate our practice to identify factors that can lead to standardized policy for blood product utilization in RT.

Methods:

Retrospective chart review of patients who underwent pediatric RT over a 10-year period at our institution was performed. Variables analyzed included: patient age, weight, pre- and postoperative hemoglobin (Hb), donor source (deceased- or living-donor), estimated allograft size by ultrasound, mean intra-operative blood loss (EBL), erythropoietin, number of units transfused per case, cross-matched/transfusion (C:T) ratio, overall transfusion rate, type of dialysis and the total cost of unused cross matched units.

Results:

RT was performed in 188 patients during the study period. Males represented 59.5% (n=112) and females, 40.5% (n=76). Of these, 54% (103/188) received blood transfusions. The total number of units cross-matched was 455 (2.3 units/patient). Average EBL was 212 mL, and C:T ratio was 2.6:1. Univariate analysis of factors predictive of the need for intra-operative blood transfusion demonstrated the following statistically significant parameters:preoperative Hb, age, weight, and EBL. Multivariate analysis showed EBL as the only factor predictive of the need for intra-operative blood transfusion. Total estimated cost of unused cross-matched units was $22 282 CAD.

Conclusions:

At our center, the number of unused cross matched units in pediatric renal transplantation represents a considerable waste of limited resources. EBL is the only factor predictive of intra-operative transfusion. More efficient institutional policies with regard to blood cross-matching in RT are in progress.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S171.

P36: Cost-effectiveness of a multidisciplinary stone clinic in a tertiary care children’s hospital

Jessica M Ming 1, Elizabeth Harvey 1, Darius J Bagli 1, Roberto I Lopes 1, Megan A Saunders 1, Walid A Farhat 1, Joana Dos Santos 1

Abstract

Background:

Here, we assess the cost-effectiveness of a multidisciplinary clinic for children with urinary stones. With rising healthcare costs, the primary goals of the clinic were to decrease unnecessary visits, duplicate imaging and costs, while optimizing quality of care.

Methods:

Since October 2012, children with complex stone disease, previously treated in urology and/or nephrology clinics, were seen at a triannual pediatric combined stone clinic. Patients attended one appointment in which they were seen by both nephrology and urology teams, allowing for both medical and surgical needs to be assessed simultaneously. A total of 79 patients have been evaluated since the clinic began. We compared the number and cost of imaging studies, emergency room visits and stone surgeries performed before and after the initial evaluation of each patient. All patients also received satisfaction surveys in clinic or the mail.

Results:

Median age at diagnosis of all clinic patients was 72 months (range 5–185). Of the 79 patients, 32 were seen at least twice in the combined clinic. Prior to the combined clinic, 27 of these patients were followed multiple times in either a urology or nephrology clinic and numbers and costs of the above interventions in this subgroup were compared. Underlying metabolic disease was identified in 17 (63%) patients, including idiopathic hypercalciuria (25.9%), cystinuria (18.6%), nephrocalcinosis (11.1%), and primary hyperoxaluria (7.4%). There was no significant difference in the number per year (1.97 vs. 1.6; p 0.13) or cost (591.2 vs. 496.2; p=0.16) of the ultrasounds performed before and after the clinic intervention. The number per year (0.29 vs. 0.1; p<0.001) and cost (59.2 vs. 8.9; p<0.001) of emergency room visits significantly decreased after being evaluated in clinic. There was also a significant difference in the number per year (0.38 vs. 0.20; p=0.016), and cost (482.4 vs. 89.3; p=0.003) of surgeries related to stone disease. After correction for followup time of two years, the results remained significant. Twenty four survey responses were returned. Seventy five percent of families believed the clinic was time saving and 79% agreed that the information given was consistent between the teams and they had a better understanding of their child’s condition.

Conclusions:

We believe this combined clinic may be beneficial for those patients requiring long term management of nephrolithiasis to decrease overall healthcare costs. Although a small sample size, the number of emergency room visits and stone related operations were significantly decreased after the initial combined clinic intervention. Longer-term data will need to be collected to see if the positive findings continue.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S171–S172.

P37: Feasibility and efficiency of pediatric outpatient cystoscopy: A step out of the operating room

Frank J Penna 1, Abby Varghese 1, Katharine Williams 1, Hissan Butt 1, Martin A Koyle 1, Armando J Lorenzo 1

Abstract

Background:

Awake cystoscopy is routinely performed in the adult ambulatory setting, while pediatric cystoscopy is most commonly performed in the operating room (OR), particularly in younger children. Cystoscopy in the OR necessitates additional anesthetic risk to the child, is time-consuming, and expensive. We hypothesized that selective cystoscopy in the ambulatory setting is feasible and results in higher satisfaction and lower costs.

Methods:

All older children and adolescents requiring cystoscopy at our institution within a one-year period (2014–2015) were offered the option of in-clinic vs. OR cystoscopy for diagnosis, stent removal or intravesical botulinum toxin injection. Parameters such as age, gender, procedure time, and total clinic time, were reviewed. The patients were administered a survey assessing their level of satisfaction with the experience and their preference for scheduling future outpatient procedures, if indicated.

Results:

Thirty children underwent cystoscopy in the outpatient setting. The mean age was 12 years, with 18 male and 12 female patients. Anxiolytic medication was requested by 87% of the patients. The mean procedure time was 22 minutes and mean total clinic time was 131 minutes, as compared to 240 minutes (the mean in-hospital time for cystoscopy in the OR). The mean cost was $217 (CAD), compared to the estimated cost of cystoscopy in the OR ($1016 CAD). Over 95% of patients either strongly preferred or preferred the procedure in the ambulatory setting.

Conclusions:

Outpatient cystoscopy in children is safe and feasible and translates to improvements in patient satisfaction and overall efficiency and availability, while minimizing costs. This option should be considered and offered to older children and adolescents.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S172.

P38: Impact of email and media communication on emergency room visits post-hypospadias repair

Michael Chua 1, Megan Saunders 1, Paul Bowlin 2, Jessica Ming 1, Roberto Iglesias Lopes 1, Walid Farhat 1, Joana Dos Santos 1

Abstract

Background:

Advances in communication technology are shaping our medical practice; herein, we aim to evaluate the effect of email communication with application of smart phone photography on emergency room (ER) visits post-hypospadias repair.

Methods:

This prospective cohort study included patients who underwent hypospadias repair performed by a single surgeon from October 2014 to November 2015. Patients were categorized into two groups: Group A consented to email communication with smart phone photography and Group B declined. Reason for ER visits within 30 days postoperatively was assessed by another physician for an objective evaluation. The reason was categorized as: unnecessary ER visits (defined as postoperative wound check with no intervention needed); indicated ER visits (defined as ER visits that required intervention or visits unrelated to hypospadias surgery). Chi square test and T test were used for statistical analysis. Relative risk and corresponding 95% confidence interval were also calculated. Statistical significance set at p<0.05.

Results:

Over a 14-month period, 96 patients underwent hypospadias repair (Group A 81, Group B 15). Patients in Group A were significantly younger than patients in Group B (Group A median 11 months [IQR 9–17] vs. Group B median 15 months [IQR 9–23, respectively], p<0.001). The number of ER visits for wound check not requiring intervention was significantly lower in Group A than in Group B (3 [4%] vs. 4 [27%], respectively [RR 0.14; p=0.005; 95% CI 0.035–0.56). A higher number of ER visits requiring intervention was noted in Group A compared with Group B.

Conclusions:

Email communication with the use of smartphone photography significantly reduced the number of unnecessary ER visits for postoperative wound.

Table 1.

Summary of baseline characteristics of study groups

Consented Declined P value
Number 81 15
Average pictures sent 6.8 (5%) 0
  ≥2 60 (74%)
  ≥6 46 (57%)
  ≥10 34 (42%)
Age in months, mean (standard deviation) 16.3 (15.4) 32 (46.4) <0.001
  Median (interquartile range) 11 (9–17) 15 (9–23)
Comorbidities
  None 76 (93.8%) 13 (86.7%) 0.33
  Yes 5 (6.2%) 2 (13.3%)
Concomitant inguinal surgery
  None 78 (96.3%) 14 (93.3%) 0.6
  Yes 3 (3.7%) 1 (6.7%)
Hypospadias classification
  Distal 47 (58%) 13 (86.7%) 0.09
  Midshaft 13 (16%) 0 (0%)
  Proximal 21 (26%) 2 (13.3%)
Hypospadias repair type
  Single stage 62 (76.5%) 14 (93.3%) 0.26
  First stage 12 (14.8%) 0 (0%)
  Second stage 7 (8.6%) 1 (6.7%)
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Table 2.

Emergency room (ER) return analysis of study groups

Consented Declined P value Relative risk (95% confidence interval)
ER return for consult 15 (18.5%) 6 (40%) 0.05 0.46 (0.21–1.0)
ER return reason
  Wound check 3 (4%) 4 (27%) 0.005 0.14 (0.035–0.56)
  Non-related/medical reason 3 (4%) 2(13%) 0.14 0.28 (0.05–1.52)
  Indicated (excessive bleeding/catheter issues) 9 (11%) 0 (0%) 0.36 3.7 (0.23–60.54)
  Postoperative day return 3.4 (4.8%) 8.17 (7%) 0.14
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S173.

P39: Withdrawn

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S173.

P40: Improving the management of bladder and bowel dysfunction in children

Joana Dos Santos 1, Rebecca Rockman 1, Niraj Mistry 1, Roberto I Lopes 1, Walid A Farhat 1, Martin A Koyle 1

Abstract

Background:

Bladder and bowel dysfunction (BBD) is very common, but underdiagnosed in children, resulting in significant complications and family distress. The majority of BBD cases improve with basic bladder retraining and constipation treatment. We are seeing increasing numbers of children with BBD in urology practice. As a result, the excessive number of referrals to the surgical specialist led to delays in care. We aim to decrease the number of BBD urology visits and wait times by 50% over six months, by optimizing strategies to empower pediatricians to manage BBD in the community. Objectives: 1) Identify which barriers pediatricians may have in preventing care of such conditions via online questionnaires; 2) assess the impact on care from a pediatric elimination network in which children with BBD who are referred to urology in a single quaternary center are re-referred to a network of community pediatricians (closer to home) with support of the urology division (Fig. 1).

Methods:

After quality management approval, an online survey was distributed; 54 community pediatricians have answered to date. In the elimination network, the Dysfunctional Voiding Score System and Bristol stool chart are being completed at zero, three, and six months, and an anonymous satisfaction survey is offered to families at every visit. Results from multiple community pediatric offices and a urology clinic in a single quaternary center will be compared.

Results:

83% (45/54) of respondents were primarily office-based or combined office-hospital practice. BBD was diagnosed at least five times per month by 42.5% (23/54) of pediatricians; 55.5% (30/54) refer up to four patients per month to urology or gastroenterology. BBD management with polyethylene glycol 3350 and dietary changes was recommended by at least 89.1%; however, the use of a voiding diary was only done by 45.6%. Increased fluid intake was recommended by 60%, and bladder retraining strategies was recommended by 73.9%. 50.9% of pediatricians considered treatment failure to be the lack of improvement before six months of adequate management. Most pediatricians requested additional educational initiatives for healthcare practitioners and parents.

Conclusions:

Our preliminary data suggests that constipation is adequately managed by community pediatricians, however, improvement in strategies surrounding bladder retraining is needed. Once data from the elimination network is analyzed, we will be able to compare outcomes from community pediatricians and urology. Educational initiatives are recommended for improvement of the management of BBD in children.

Fig. 1.

Fig. 1.

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Elimination (Bowel Bladder Dysfunction) Network.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S173–S174.

P41: Operating room utilization in a tertiary care, free-standing pediatric hospital: Current practices and improvements

Jessica M Ming 1, Michael E Chua 1, Megan A Saunders 1, Melyssa Stoute 1, Vannessa Chin 1, Martin A Koyle 1

Abstract

Background:

Operating room (OR) hours are a valuable resource for hospitals and can be very limited due to a variety of factors, including: appropriate scheduling and allocation of case times, efficiency of turnover, and the preset culture of each individual facility. Multiple attempts have been made to identify optimal utilization in the OR with variable success and mostly in the adult setting. Here, we characterize the operating room efficiency and utilization of four pediatric urologists in a free standing children’s hospital with the aim to identify points of potential improvement for increased throughput and team satisfaction.

Methods:

We prospectively, after QI committee approval, collected data over a six-week time period of the four pediatric urologists operating collectively for 10 full OR days per week. This included: scheduled time per OR case, time in and out of the room, turnover, induction to incision start, surgery time, incision end to extubation, and extubation to time out of room. For any delays or alterations to the schedule, we identified cause for delay or change and recorded the reason. OR efficiency ([sum of operative time/sum of case time including turnover] x100) and utilization ([sum of time OR occupied by patient/ sum of block time] x 100) was calculated per day.

Results:

Overall, times were recorded for 129 patients. For the four surgeons, overall mean OR efficiency ranged from 38–44%. The overall mean OR utilization for each surgeon ranged from 63–75%. There were 45 late starts (35%) identified with the majority of cases being due to the prior case going over time scheduled. This subsequently created an expected domino effect for the remaining cases in the day. All first start cases were on time (in the room within five minutes of 8:00 am start). The second most common reason was due to a delay in receiving a PACU bed, requiring time waiting in the operating room (46% of cases). The mean wait time was five minutes overall with range of 2–15 minutes. Patient factors such as NPO violations did not have a major impact on schedule delays, but did lead to cancellations.

Conclusions:

We have identified the overall utilization and efficiency of OR time among pediatric urologists operating in a free-standing academic children’s hospital. Important factors contributing to our late starts was appropriate booking times and delay of transporting the patient to the PACU. Current efforts to improve the flow of patient care in the operating room are in effect.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S174.

P42: Optimal length of followup for the detection of an unsuccessful pediatric pyeloplasty: A single-center experience

Utsav K Bansal 1, Pankaj Dangle 1, Heidi Stephany 1, Asad Durrani 1, Glenn Cannon 1, Francis Schneck 1, Michael Ost 1

Abstract

Background:

There are no standard guidelines on ideal followup and imaging post-pediatric pyeloplasty. Our goal was to assess the optimal length of followup for patients undergoing both open and minimally invasive pyeloplasties to ensure detection of a recurrent obstruction in timely manner.

Methods:

A retrospective chart review identified 279 patients (<18 years old) who underwent pyeloplasty for ureteropelvic junction obstruction between April 2002 and December 2014. Ultrasound was obtained every 3–4 months for the first year following pyeloplasty and thereafter at the discretion of the treating physician. Patient characteristics including symptoms and imaging were reviewed.

Results:

Of the 279 patients, 71% were male (mean age of 52 months) and mean followup of 27.4 months. Of these 279 patients, 73% were followed up to three years. Fifteen patients (5.4%) had a recurrent obstruction. Among the failures, 80% were diagnosed and underwent successful redo-pyeloplasty within three years. The six infants with recurrence (40% of all unsuccessful surgeries) were detected and diagnosed within three years of the initial surgery. Patients undergoing a minimally invasive procedure were less likely to be followed for more than three years compared to an open procedure (p<0.001). Patients with severe hydronephrosis preoperatively were followed longer and this was statistically significant in a univariate analysis (p=0.036). Age at time of surgery and type of surgical approach (p<0.01) were significant predictors of length of followup in a negative binomial regression, which accounts for maximal length of followup.

Conclusions:

Based on the results, a minimum of three years of followup is necessary to detect the majority of recurrent obstructions. Among those who require a secondary pyeloplasty, younger patients with severe hydronephrosis are at an increased risk of recurrence.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S174.

P43: Prognostic factors of chronic kidney disease in patients with posterior urethral valves

Monica Salgado 1, Yann Chaussy 1, Pierre-Alain Hueber 1, Anne-Marie Houle 1, Diego Barrieras 1, Julie Franc-Guimond 1

Abstract

Background:

Posterior urethral valves (PUV) is the most common cause of congenital bladder outlet obstruction and chronic kidney disease (CKD) in the male pediatric population. The aim of this study is to determine the prognostic value of nadir creatinine during the first year of life and all other potential factors that might increase the likelihood of developing CKD in patients with this condition.

Methods:

Hospital records of all patients with PUV were reviewed from 1980–2010. Abnormal kidney function was defined as CKD Stage 2 or higher (National Kidney Foundation). Patients were divided in two groups based on GFR at latest followup. Receiver operating characteristic (ROC) curve, univariate and multivariate analysis were conducted in order to identify independent prognostic factors for CKD. Statistical significance was defined as a p<0.05.

Results:

A total of 114 PUV patients satisfied our inclusion criteria. At diagnosis, the mean age was three years. Among them, 32.5% were diagnosed antenatally, 23.7% before one year of life and 43.9% after. The mean followup period was eight years (SD ±4.6). An abnormal kidney function was found in 18.4% patients, among them 4.38% reached end-stage renal disease (ESRD). Mean of Nadir creatinine at first year of life in patients who developed CKD was 54.75 μmol/l vs. 27.95 μmol/l for patients with normal renal function. Levels of nadir creatinine during the first year of life >30 μmol/L were found to be a cutoff point for determine future prognosis (ROC curve, AUC=0.94; p<0.001) with a sensibility of 95%, specificity of 32%. Diagnosis before one year of age, elevated nadir creatinine at first year of life, bilateral hydronephrosis, recurrent UTIs, and loss of corticomedullary differentiation were significant predictors of renal outcome on univariate analysis.

Conclusions:

PUV disease can lead to deleterious effects on renal function. Nadir creatinine during the first year of life was the only independent predictor of CKD on multivariate analysis. As a predictive factor for future CDK, we found a much lower threshold than previously reported in the literature. In addition, age at diagnosis, presence of urinary tract infection, and radiological findings on ultrasound represent important prognostic factors that should be taken into consideration in order to optimize patient management.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S174–S175.

P44: Radiation exposure in children with posterior urethral valvesduring the first year of life: A necessity or an avoidable oversight?

Frank J Penna 1, Rakan I Odeh 1, Hissan Butt 1, Armando J Lorenzo 1, Walid A Farhat 1, Darius J Bägli 1, Martin A Koyle 1

Abstract

Background:

Although the long-term risks of radiation exposure remain unknown, it has been estimated that cumulative exposure increases the long-term risk of malignancy. Posterior urethral valves (PUV) is one of the most common causes of chronic kidney disease in children. While certain imaging studies are necessary to adequately diagnose and treat the critically ill child, we hypothesized that some of these studies, which carry radiation exposure, may be avoidable, particularly in the critical first year of life.

Methods:

A retrospective, single-institution review of all children born with a diagnosis of PUV over a 10-year period (2003–2013) was performed. Patients were stratified into three groups at two different time periods (one month and one year of age) based on creatinine (Cr) range and mean total radiation exposure from all imaging studies performed during the first year of life was estimated for each group: Group I (20–50 umol/L), Group II (50–100 umol/L), and Group III (>100 umol/L).

Results:

Fifty-three children were included in the study. The mean gestational age was 36.6±1.9 weeks and the mean birth weight was 3.0±0.3 kg. All of the children except for three had a documented history of antenatal hydronephrosis, with seven having a history of oligohydramnios. The majority of the children were treated with endoscopic valve ablation; only three had vesicostomy creation. Table 1 summarizes the mean Cr and radiation exposure/patient by Group. Fig. 1 demonstrates the significant shift in Groups based on Cr at one month vs. one year.

Conclusions:

There was greater total radiation exposure during the first year of life in the category of patients with higher Cr (Group III) at one month as compared to those with initial lower values (Groups I and II), albeit not statistically significant. Cr at one month was not a predictive indicator of Cr at one year, as the majority of patients at one year migrated to Group I. Cr at one month may not be the best parameter to base imaging studies on. Long-term risks of radiation exposure to children from imaging studies is unknown, and therefore should be minimized.

Table 1.

Patient radiation exposure parameters during the first year of life

Group % patients (at 1 month) Mean Cr at 1 month (µmol/L) % patients (at 1 year) Mean no. studies/patient Mean total radiation/patient (mSv) P value
I 9.5% 35.4 ± 8.6 81.8% 2.4 0.30 ± 0.08 0.42
II 39.6% 71.8 ± 13.8 4.5% 5.2 0.32 ± 0.34 0.08
III 50.9% 189.7 ±75.6 13.7% 14.3 0.47 ± 0.36 0.14
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S175.

P45: Short-stay pediatric pyeloplasty: A pilot project

Martin A Koyle 1, Armando Lorenzo 1, Darius Bagli 1, Walid Farhat 1

Abstract

Background:

Healthcare costs continue to escalate, and this has incentivized hospitals and healthcare workers to increase value by maintaining and/or increasing quality and safety, while reducing wastes and costs. A surgical short stay (SSS) unit was introduced to our facility, where cases were identified by each surgical service, where potentially, length of stay (LOS) could be reduced to <24 hours. Pyeloplasty was the procedure chosen as the pilot case for analysis in this unit by pediatric urology. The primary objective was to assess adverse outcomes (AOs) associated with reduced LOS by examining readmissions and emergency room (ER) visits.

Methods:

During the inaugural period of this pilot project, September 23–November 15, 2014, 149 total patients passed through the SSS. The records of these patients were reviewed to document those who underwent pyeloplasty and measure LOS compared to historic controls and report any adverse events.

Results:

Pyeloplasty represented the fourth most common indication for SSS admission, 7/149 (9%) of patients, equal to that of appendectomy. In 2013–2014, 54 pyeloplasties were performed with mean LOS of 1.61±1.69 days compared to 0.89±0.41 days in the SSS group. No patients in the SSS were readmitted. However, a single child was evaluated and treated in the ER for a febrile urinary tract infection, >48 hours after discharge. All eight services who used SSS felt that the pilot was of benefit, although other than pyeloplasty, in the majority of other procedures, LOS did not demonstrate a trend to decrease. Of 44% (n=60) of families who completed feedback by returning a survey, satisfaction with the SSS unit surpassed that of pre-pilot patients in eight categories.

Conclusions:

Pediatric pyeloplasty patients can be discharged safely with LOS <24 hours, from a unit where the culture is focused on SSS. Based on our early experience, there is the potential for reducing costs because of reduced LOS. We have agreed to expand our inclusion criteria to include other common surgical procedures involving the ureter and bladder (e.g., reimplants). It has been our observation that if cases selected for SSS unit are performed as the first case of the day, particularly in infants, they invariably are ready to be discharged that evening with the proper nursing support and family/patient education. Family and surgeon acceptance is superb. Selection bias likely influences LOS, as all patients chosen had open pyeloplasty performed and were <2 years.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S175.

P46: The fate of postoperative perinephric fluid collections within one month of pediatric renal transplantation: Etiology and therapeutic interventions

Frank J Penna 1, Armando J Lorenzo 1, Walid A Farhat 1, Martin A Koyle 1

Abstract

Background:

Postoperative perinephric fluid collections are common after pediatric renal transplantation (RT), and may be caused by clinical entities such as urinoma, hematoma, and lymphocele. These collections are usually monitored with serial ultrasounds. Size, etiology, extrinsic ureteral obstruction, and/or the presence of symptoms dictate management. We hypothesized that these fluid collections rarely require intervention and gain little benefit from close followup with imaging in the presence of stable clinical status (asymptomatic with stable renal function) and absence of hydronephrosis.

Methods:

Retrospective review was performed of all children who underwent pediatric RT at our institution within the last five years (2010–2014) and monitored at least one month postoperatively. Perinephric fluid collections on postoperative renal ultrasounds were measured in three axes and correlated with clinical parameters and symptomatology. Indicated interventions including image-guided drainage and surgery were captured.

Results:

One hundred three children underwent RT (59 deceased and 44 living-related donor) over this period, at a mean age of 10.6±5.4 years. Only 37 patients (36%) had no perinephric collections on ultrasound at two weeks postoperatively. Sixty-six patients (64%) had fluid collections, 14 of which underwent intervention: nine lymphoceles (8.7%), three infected hematomas (2.9%), and two urinomas (1.9%). Four patients with lymphoceles underwent laparoscopic marsupialization after failed drainage and/or sclerotherapy. The average fluid collection volume was 169 cm3; 618 cm3 in the intervention group compared to 46 cm3 in those observed.

Conclusions:

Perinephric fluid collections are common after pediatric renal transplantation, the majority of which do not require intervention. Larger volume fluid collections were associated with intervention and are usually secondary to lymphoceles.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S175–S176.

P47: Trends in renal extirpative surgery: A single-institution experience over 10 years

Rakan I Odeh 1, Frank J Penna 1, Naimet K Naoum 1, Ibraheem Abu Azzawayed 1, Walid A Farhat 1, Armando J Lorenzo 1, Darius J Bägli 1, Martin A Koyle 1

Abstract

Background:

Renal extirpative surgery (RES) for benign and malignant conditions may be performed as total or partial nephrectomy, accomplished in an open (O) or laparoscopic (L) fashion. We set out to trend RES at a large, free-standing children’s hospital and hypothesized that the trend of surgical intervention for benign conditions would demonstrate a decrease over the course of the study, primarily due to a paradigm shift in the management of benign congenital urological conditions, particularly duplex systems.

Methods:

A retrospective chart review was performed on all patients who underwent RES at a large pediatric referral center over a 10-year period (2005–2014). Parameters evaluated included: diagnosis, surgical approach (O vs. L, total vs. partial), mean age, operative time, estimated blood loss (EBL), and complications.

Results:

Of the 292 patients evaluated, 30 patients were excluded who either underwent transplant nephrectomy or were lost to followup. Of the 262 patients included, 60.7% had benign conditions, with over half (52.4%) being approached laparoscopically. Over the time course of the study, the trend of surgical intervention for benign conditions decreased significantly (15.7–6.3%; p=0.0003). Partial nephrectomy for benign conditions, particularly duplex systems also decreased significantly (28.6–4.76%; p=0.009). Conversely, malignant conditions represented 39.3% of patients, with 22.3% of these patients being treated laparoscopically. The trend of surgical intervention for malignant conditions demonstrated a steady increase over the time course of the study (3.9–18.4%; p=0.06).

Conclusions:

Over the period of the study, the trend of extirapative surgery for benign disease has decreased significantly, particularly duplex systems and multicystic dysplastic kidneys. Conversely, the trend for malignant conditions increased steadily over the same time period. Despite initial enthusiasm, the trend for laparoscopic approaches for all conditions has remained flat.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S176.

P48: Consistent and durable improvements in quality of life with long-term onabotulinum toxin A treatment in patients with overactive bladder

Benjamin Brucker 1, Victor Nitti 2, Sidney Radomski 3, Angelo Gousse 4, Marcus Drake 5, Albert Kaufmann 6, Andrew Magyar 7, JP Nicandro 8, David Ginsberg 9

Abstract

Background:

Overactive bladder (OAB) is a chronic condition that can cause significant burden and have a negative effect on patients’ daily lives. There is a need to offer patients with OAB who are inadequately managed by an anticholingergic alternative therapies that are effective and improve quality of life (QOL) over the long-term. A long-term extension study involving patients with OAB and urinary incontinence (UI) who were inadequately managed by an anticholinergic (ACH) demonstrated that onabotulinum toxin A 100U provides consistent, long-term improvement of OAB symptoms. Here we evaluated the long-term effects of onabotulinum toxin A 100U on QOL in this extension study.

Methods:

Eligible patients who completed either of two phase 3 trials could enter a three-year extension study to receive onabotulinum toxin A treatment “as needed” for control of symptoms. Results are reported for up to six treatments. Assessments included change from baseline in Incontinence-QOL (I-QOL) total score and proportions of patients who achieved/exceeded the minimally important difference (MID) in I-QOL score (+10 points) after each treatment. Consistency of response over repeat treatments was evaluated by determining whether patients achieved ≥MID after the first treatment, and then analyzing the proportion who achieved ≥MID for all subsequent treatments.

Results:

Of 829 patients enrolled, discontinuations due to lack of efficacy/adverse events were 5.7%/5.1%. After onabotulinum toxin A treatments 1–6, QOL improvements were consistently maintained at 2–3X MID across treatment cycles, with most patients achieving ≥MID (range 65.2–76.1%). 72.9% of patients who achieved ≥MID after treatment 1 maintained I-QOL improvements ≥MID in all subsequent treatments. Over one-third (38.3%) of patients not achieving ≥MID after treatment 1 achieved improvements ≥MID in all subsequent treatments. No new safety signals were observed.

Conclusions:

Consistent improvements in OAB symptoms after long-term treatment with onabotulinum toxin A corresponded with durable QOL improvements, with no new safety signals. Patients with clinically meaningful QOL improvements after treatment 1 had similar improvements in subsequent treatments, while lack of response to treatment 1 did not preclude positive response(s) in subsequent treatments. These results help set treatment expectations of patients and clinicians for onabotulinum toxin A and support persistence of its use over the long-term. Additional analyses may further characterize the long-term effects of treatment with onabotulinum toxin A in patients with OAB inadequately managed by an ACH.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S176.

P49: Do postoperative urinary retention and urinary tract infections predict complications of mid-urethral slings?

Nahid Punjani 1, Jennifer Wince-Ng 2, Blayne Welk 1

Abstract

Background:

Mid-urethral slings (MUS) are the gold standard for treatment of stress urinary incontinence. Limited data exists regarding predictive factors for future mesh complications. Our study examines if postoperative urinary retention and urinary tract infection were predictors of future mesh complications requiring surgical intervention.

Methods:

Administrative data in Ontario, Canada between 2002 and 2013, was used to identify all women who underwent a mesh-based MUS. The primary outcome was future transvaginal mesh complications including erosion, fistula, removal, or urethrolysis. The primary exposure was postoperative urinary retention (within 30 days of procedure) and secondary exposure was the number of postoperative serious urinary tract infections (requiring emergency room visit or hospital admission).

Results:

A total of 59 556 women had a MUS, of which 1598 (2.7%) required reoperation for mesh complications. Of the 2025 women who presented to the emergency room or were admitted for postoperative urinary retention, 212 (10.5%) developed mesh complications. Of the 11 747 patients who had at least one postoperative urinary tract infection, 366 (3.1%) patients developed mesh complications. Postoperative urinary retention was predictive of future reoperation (HR 3.33, 95% CI 2.86–3.87). Postoperative urinary tract infections were also associated with an increased risk for future complications (HR 1.15, 95% CI 1.13–1.17).

Conclusions:

Postoperative urinary retention and frequent urinary tract infections are associated with an increased risk of reoperation for MUS complications. These patients should be closely followed and appropriately investigated.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S176–S177.

P50: Increasing screening for overactive bladder and incontinence in at-risk patient population

Diane K Newman 1, Ruth Cohen Cooper 2, Vandana Iyer 2

Abstract

Background:

Overactive bladder (OAB) and urinary incontinence (UI) remain underdiagnosed and undertreated, despite evidence-based guidelines on assessment and treatment. Most patients are embarrassed to initiate conversations about UI and, since the prevalence of OAB increases with age, patients and clinicians often accept OAB as an inevitable part of aging. Diabetic and obese women are particularly at risk. Increasing numbers of these patients are being seen by advanced practice providers (APPs), nurse practitioners (NPs), and physician assistants (Pas). They have the opportunity to improve outcomes by consistently screening patients and increasing the use of strategies that promote patient adherence to treatment. To this end, the aim of this practice building activity was to increase APP communication techniques and use of guideline-based screening tools to improve diagnosis, treatment adherence, and long-term monitoring of OAB and UI within their practice.

Methods:

In the initial (baseline) phase, APPs (NPs=39, PAs=15; total n=54) who see patients with OAB and UI were asked to review medical records of four patients with either type 2 diabetes (T2DM) and/or obesity and answer seven questions about their care in an online questionnaire. The APPs then received four educational email briefs reinforcing important aspects of optimal care for patients with OAB and UI, and were then asked to complete an action plan. In the final phase, APPs reviewed charts of four new patients with T2DM and/or obesity and answered the same questions to determine whether a change in performance occurred regarding practices involved in screening and management.

Results:

Outcomes reported are based on a change from baseline to final phase (Table 1). There was a 141% increase over baseline in percentage of clinicians asking their four patients all main main questions (p<0.01), and a 125% increase over baseline in the percentage of clinicians offering all four patients a voiding diary (Table 1). Results between NPs and PAs were minor.

Conclusions:

Clinical performance can be improved when clinicians participate in an educational format that requires them to assess their own practice patterns before and after an educational intervention. This activity led to significant improvements in practices related to OAB and UI screening, symptom evaluation, and long-term monitoring by targeting patients at increased risk for OAB and UI.

Table 1.

Summary of performance change for each of the 5 main patient questions

Questions % asking all 4 patients at initial phase % asking all 4 patients at final phase % increase P value
Ask patient about concerns about bladder control problems? 57% 83% 45% <0.01
Document patient’s bladder complaints at every visit? 48% 72% 50% <0.01
Offer the patient a voiding diary? 24% 54% 125% <0.01
Discuss bladder symptoms at each subsequent visit? 44% 78% 77% <0.01
Provide patient with material on behavioral and pharmacotherapeutic options? 33% 61% 85% <0.01
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S177.

P51: Network meta-analysis to assess the treatment effect of onabotulinum toxin A, mirabegron, and anticholinergics vs. placebo for overactive bladder

Benjamin Brucker 1, Marcus Drake 2, David A Ginsberg 3, Christopher Chapple 4, Rachael McCool 5, Julie Glanville 5, Kelly Fleetwood 6, Daniel James 6, Kristin Khalaf 7, Victor W Nitti 8

Abstract

Background:

Pharmacotherapy is the second-line treatment for overactive bladder (OAB) after behavioral therapy, but there is a high discontinuation rate due to inadequate efficacy and/or intolerable side effects. Onabotulinum toxin A provides an additional treatment option for OAB in patients who are inadequately managed by an anticholinergic. This is the first comparison of the efficacy of all licensed doses of anticholinergics, mirabegron, and onabotulinum toxin A vs. placebo in adults with idiopathic overactive bladder using network meta-analysis (NMA) and meta-regression (NMR).

Methods:

Electronic databases, review documents, guidelines, and web-sites were searched for randomized blinded trials of ≥2 weeks duration comparing any dose of onabotulinum toxin A, mirabegron, or oral/ transdermal anticholinergics with each other or placebo. Networks were developed for outcomes of interest based on studies of similar quality of study methods, confounding factors, common treatment arms, and outcomes measured. Bayesian random effects NMA (for the outcome of 100% reduction in urinary incontinence episodes [UIE]) and NMR (for outcomes on changes from baseline in UIE, urgency episodes, and micturition frequency) models were used to synthesize results at Week 12. Safety outcomes were not compared due to differences in adverse event profiles.

Results:

One hundred two trials were assessed. NMRs indicated that, after adjusting for differences in baseline severity between trials, all treatments were more efficacious than placebo. Patients who received onabotulinum toxin A (100U) had the greatest mean reductions in UIE (1.55 episodes/ day more than placebo [95% credible interval (CrI) 1.10, 2.01]), urgency (2.01 episodes/day more than placebo [CrI 1.48, 2.54]) and micturition frequency (1.37 episodes/day more than placebo [CrI 1.03, 1.70]). Onabotulinum toxin A patients also had the highest likelihood of achieving 100% UIE reduction (OR 4.30 vs. placebo [CrI: 3.03, 6.23]).

Conclusions:

This analysis suggests that onabotulinum toxin A 100U provides the greatest reduction in OAB symptoms and higher likelihood of being dry, relative to placebo, than all licensed doses of anticholinergics and mirabegron in the network. Additional studies should also evaluate the cost-effectiveness of onabotulinum toxin A vs. other OAB treatments.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S177.

P52: The use of urodynamics in followup of neurogenic bladders treated with onabotulinum toxin A

Michelle Bergeron 1

Abstract

Background:

Patients with neurologic disorders may suffer from detrusor overactivity (NDO) or low bladder compliance, which can damage the upper urinary tract. Intradetrusor injections of onabotulinum toxin A (BoNTA) have recently emerged as a treatment for NDO. Urodynamics (UDS) are currently used at initial diagnosis and at regular intervals during followup to ascertain that the intravesical pressure remains within safe limits. However, with regards to the discomfort and risks associated with UDS, our objective was to assess if UDS done at regular intervals in the followup of neurogenic bladders treated with BoNTA had an impact on management.

Methods:

We analyzed retrospectively the medical records of adult patients with neurologic disorders treated with intradetrusor injections of BoNTA for either detrusor overactivity or low bladder compliance at the Institut de réadaptation en déficience physique du Québec (IRDPQ). In our center, UDS were routinely done at baseline and then after every fifth set of injections.

Results:

We identified 57 patients with a diagnosis of neurologic disorder. Each patient had between one and 19 sets of injections, with a mean number of 5.61 injections, and 1–6 followup UDS representing a mean number of 2.09 UDS. Of the 119 followup UDS reviewed in our center, urologists took the decision to interrupt treatment in five cases (4.2%), which was eventually resumed, while three patients (2.5%), due to persistence of symptoms or high intravesical pressure, had their management changed to bladder augmentation. Two regimens were suspended and one was ended due to patient’s preference.

Conclusions:

Our study showed that UDS at pre-set intervals for followup of patients receiving BoNTA injections were rarely associated with modifications in the treatment course. Therefore, UDS should only be performed in cases where there is a change in the patient’s symptoms or if the urologist suspects that the treatment response is suboptimal.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S178.

P53: Voiding symptoms, age, and BMI are driving factors in AUASS

Ilija Aleksic 1, Charles Welliver 1, Randy Sulaver 2, Adam Whittington 3, Brian Helfand 3, Ömer Onur çakır 4, James Griffith 5, Kevin McVary 2

Abstract

Background:

The AUA Symptom Score (AUASS) includes voiding (straining, incomplete emptying, intermittency, weak stream) and storage symptoms (nocturia, urgency, frequency). To date, no comorbidity has been shown to have predictive value and no chief lower urinary tract symptoms (LUTS) complaint (CLC) has been implicated as a driving factor in AUASS. Our objective is to determine influence of comorbidities, CLC, and treatment on AUASS.

Methods:

Prospective evaluation of men with LUTS, completing AUASS and CLC survey at two consecutive visits. Collected comorbidities included: age, body mass index (BMI), hypogonadism, diabetes, hyperlipidemia, hypertension, and smoking. Treatments included: anticholinergics, alpha blockers, 5-alpha-reductase inhibitors, and phosphodiesterase type 5 inhibitors.

Results:

Predictors of AUASS are BMI and age (adjusted R2 7.5%) with each BMI and year of age yielding a score increase of 0.16 (SE 0.03; p<0.001) and 0.18 (SE 0.08; p<0.05), on stepwise regression. Straining as the CLC yielded the highest AUASS (ANOVA; Table 1A) of 17.0 (95% CI, 13.8–20.1), significant vs. frequency, nocturia, multiple and no complaints (Tukey’s test; p<0.05). No CLC yielded the lowest score, 6.76 (95% CI 5.68–7.27), significant against all except intermittency (Table 1B).Oneway ANOVA for AUASS change to CLC, the worst change was seen in patients with straining 3.5 (95% CI 1.06–5.99) and incomplete emptying by 2.1 (95% CI 0.750–3.416). Comparing AUASS change to treatment initiated, only anticholinergics demonstrated significant decrease in score (p<0.001) by 4.44 (95% CI 2.3–6.6). Initiating finasteride or alpha-blocker yielded a decrease of 0.70 and 0.75. No new medication led to a decrease of 0.47 (95% CI 0.14–0.80).

Conclusions:

Age and BMI are driving factors for AUASS. Four of the top five CLC are voiding symptoms, with straining as the largest driving factor at presentation and between visits. Anticholinergics are the only initiated therapy yielding a clinically and statistically significant improvement in AUASS.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S179–S180.

P54: An analysis of industry effects on prescriber behavior: Degarelix and denosumab

Jathin Bandari 1, Robert M Turner II 1, Bruce L Jacobs 1, Benjamin J Davies 1

Abstract

Background:

The influence of financial ties to pharmaceutical companies remains controversial. We aimed to assess a potential relationship between pharmaceutical payments and prescription patterns for degarelix and denosumab.

Methods:

Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (Medicare B) data containing 2012 claims compared to OpenPayments (Sunshine Act) data for the second half of 2013. Urologists and medical oncologists who billed Medicare for degarelix or denosumab were cross-referenced in both databases and payments were aggregated into a consolidated dataset. Adjusted beneficiary count and total Medicare reimbursement were compared according to receipt of Sunshine payment, and an association between Sunshine payment amount and total Medicare reimbursement was also assessed.

Results:

Of the 160 prescribers of degarelix and 1507 prescribers of denosumab, 91 (57%) and 854 (57%) received Sunshine payment, respectively. Degarelix prescribers who received Sunshine payment had higher median total Medicare reimbursement ($13 257 vs. $9554; p=0.01). Denosumab prescribers who received Sunshine payment had both higher median adjusted beneficiary count (55 vs. 50, p & lt; 0.001) and median total Medicare reimbursement ($69 620 vs. $60 732, p & lt; 0.001). On multivariable analysis, both receipt of Sunshine payment (adjusted median difference $5844, 95% CI $937–$10 749) and oncology specialty (adjusted median difference $34 380, 95% CI $26 715–$42 045) were independently associated with total Medicare reimbursement for denosumab.

Conclusions:

In the case of degarelix and denosumab, there is a weak association between pharmaceutical company payments on prescribers’ prescription behavior patterns.

Fig. 1.

Fig. 1.

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Relationship between total Sunshine payment amont and total Medicare reimbursement for degarelix and denosumab.

Table 1.

Characteristics of the study population stratified by receipt of Sunshine payment for degarelix and denosumab

Degarelix Denosumab
Characteristics No Sunshine payment (n=69) Sunshine payment (n=91) P value* No Sunshine payment (n=653) Sunshine payment (n=854) P value
Specialty (%)
  Urology 62 (90) 91 (100) -- 93 (14) 78 (9) 0.002
  Oncology 7 (10) 0 (0) 560 (86) 776 (89)
Adjusted beneficiary count, median (IQR) 36 (23–62) 52 (29–79) 0.051 50 (31–74) 55 (38–79) <0.001
Total Medicare reimbursement, USD, median (IQR) 9554 (7507–14 291) 13 257 (9398–17 772) 0.01 60 732 (37 182–92 577) 69 620 (44 281–99 272) <0.001
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IQR: interquartile range; USD: United States dollars.

*

P values determined using Chi-square test for categorical variables and Wilcoxan rank-sum tests for continuous variables.

Table 2.

Median regression analysis examining predictors of total Medicare payment

Univariable analysis Multivariable analysis*
Variable Predicted median difference (95% CI) P value* Adjusted median difference (95% CI) P value
Sunshine 0.001 0.02
  No Reference Reference
  Yes 8912 (3702–14 121) 5844 (937–10 749)
Specialty <0.001 <0.001
  Urologist Reference Reference
  Oncologist 36 649 (29 131–44 167) 34 380 (26 715–42 045)
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*

P values are computed using the Wald test. The multivariable model included receipt of Sunshine payment and prescriber specialty.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S180.

P55: The light at the end of the scope: The history of Electro Surgical Instruments Co and the mignon lamp

Scott Quarrier 1, Ronald Rabinowitz 1

Abstract

Background:

Prior to the development of the mignon small light bulb, endoscopes struggled to gain traction in the medical field. The first endoscopes were expensive, cumbersome due to the extensive and complicated water cooling systems of early models, and provided poor visualization. The mignon lightbulb was a small inexpensive interchangeable lightbulb that screwed in to the end of the endoscope allowing significant improvement in visualization.

Methods:

Literature review was performed on topics related to the development and impact of the mignon lamp within urology. This included review of textbook chapters, original product catalogues, and peer-reviewed articles on Pubmed.

Results:

Thomas Alva Edison introduced the light bulb in 1879. He is also responsible for introducing the screw cap for easy changes of light bulbs. At this time, cystoscopy commonly used open platinum incandescent filaments requiring extensive cooling mechanisms to make medical use safe. The rapid spread of Edison’s light bulb technology did not spare the medical field. Within a few months of its introduction, Dr. Henry Koch, a urologist and Charles Preston, an electrician, from Rochester, NY, modified the Edison bulb to a smaller size and amperage suitable for medical devices and the mignon lamp was born. The first urologic use of the mignon lamp came in 1883, when David Newman of Glasgow attached a mignon bulb to the end of a cystoscope. Three years later, German urologist Maximillian Nitze and Austrian instrument manufacturer Josef Leiter, introduced the cystoscopes incorporating the new technology. Electro Surgical Instruments Co., founded in 1896 by Koch, Preston, and Maier, marketed the mignon bulb as a “cold” lamp allowing contact with body tissue without the potential for burns and ulcerations when the switch was made from carbon to metal filaments in 1905. Electro Surgical Instruments Co. although founded by a urologist, also produced light bulbs for vaginal speculums, rectal speculums, esophagoscopes, bronchoscopes, and rhinoscopes.

Conclusions:

The mignon lamp, developed by a urologist and Electro Surgical Instruments Co, revolutionized endoscopy not only for urology, but for many surgical disciplines. For the first time, endoscopic visualization of the bladder became accessible to the average urologist. Endoscopic illumination using mignon light bulbs was not improved upon until the advent of the rod lens system in the second half of the twentieth century.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S180.

P56: Clinical phenotyping does not differentiate Hunner’s lesion subtype of interstitial cystitis/bladder pain syndrome (IC/BPS): A relook at the role of cystoscopy

R Christopher Doiron 1, Victoria Tolls 1, Karen Irvine-Bird 1, Kerri-Lynn Kelly 1, J Curtis Nickel 1

Abstract

Background:

Identification of Hunner’s lesions in interstitial cystitis/bladder pain syndrome (IC/BPS) patients presents an opportunity for objective classification into those with Hunner’s lesion IC/BPS (classic IC) and those with non-Hunner’s lesion BPS. While currently a diagnosis of Hunner’s lesion IC/BPS requires cystoscopy, limited data exists suggesting that these subtypes can be distinguished without endoscopic examination based on the degree of bladder-focused centricity and infrequent association with generalized pain conditions.

Methods:

Patients from a prospective, single-center database of IC/BPS patients who had documented cystoscopic findings were categorized as those with Hunner’s lesion IC/BPS and non-Hunner’s lesion BPS. Their demographics, pain and symptom scores, voiding symptoms, presence of IBS, and clinical UPOINT scoring were comparatively analyzed.

Results:

A total of 469 patients were reviewed. Of those, 359 had documented local anesthetic cystoscopic findings; 44 (12.3%) with Hunner’s lesion IC/BPS and 315 (87.7%) with non-Hunner’s BPS. Patients with Hunner’s lesions were older (p=0.004), had greater urinary frequency (p=0.013), more nocturia (p=0.0004) and higher ICSI scores (p=0.017). Prevalence of Hunner’s lesions was significantly higher in those <50 years old (7.8%) compared to those aged 50 and older (14.9%; p=0.0095). There was no difference in number of UPOINT phenotype domains reported, overall UPOINT scores or prevalence of IBS between the groups.

Conclusions:

A subtype of IC with Hunner’s lesions has worse bladder-centric symptoms, but did not have a distinct bladder-centric phenotype. Given the management implications of distinguishing classic IC from non-Hunner’s lesion BPS, we recommend cystoscopy with local anesthesia for patients diagnosed with IC/BPS.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S180–S181.

P57: A rectal swab-guided prophylaxis program on the incidence of infectious complications following transrectal ultrasound-guided prostate biopsy and fiducial marker placement

Alexander Van Hoof 1, Dylan Stoy 1, Sarah Faisal 1, Bashar Omarbasha 1, Christopher Pieczonka 1, Yi Yang 1, David Albala 1

Abstract

Background:

Transrectal ultrasound-guided prostate biopsy (TRUSBX) and fiducial marker placement (TRUSFM) are noted sources of infectious complications. While data describing the risk of post-TRUSFM infection are lacking, there is an abundance of evidence describing the increasing rate of post-TRUSBX infectious complications. Particularly significant is the rising incidence of more serious infections such as sepsis and urinary tract infections (UTIs), which are associated with a high degree of morbidity and cost. Recent evidence links this to a concomitant rise in prevalence of flouroquinolone resistant (FQR) organisms and suggests that use of empirical prophylaxis needs reevaluation. This study aims to make a case for adopting a rectal swab (RS) guided prophylaxis by showcasing the effectiveness and feasibility of implementing such a protocol in a large private practice with multiple locations. Additionally, we will be able to better describe the risk of infection associated with TRUSFM.

Methods:

From January 1, 2011 through May 30, 2015, we observed the difference in rates of infectious sequelae post-TRUSBX and post-TRUSFM in men who received RS-guided prophylaxis vs. empirical prophylaxis with fluoroquinolones per AUA guidelines. RS specimens were collected from patients using a BBL culture swab and plated on selective media containing ciprofloxacin to identify FQR. Standard FQ prophylaxis was prescribed to patients showing FQ sensitivity and patients with cultures positive for FQR organisms received targeted prophylaxis based on further susceptibility testing.

Results:

5084 men underwent 1106 TRUSFM and 5843 TRUSBX. The prophylactic regimen was prescribed empirically for 2296 TRUSBXs and 404 TRUSFMs; of these 83 (3.61%) and 21 (5.20%) resulted in infectious complications respectively. A RS-guided prophylactic regimen was used for 3547 TRUSBXs and 707 TRUSFMs; of these 27 (0.76%) and 7 (1.00%) resulted in infection. 4248 RS were performed and cultured on 3294 men. Of these, 472 (11.2%) of the rectal swabs were positive, and 393 men (11.9%) were found to have at least one FQR organism. Of the FQR organisms identified (96.27% being E. coli) 83.7% were multidrug resistant and 37.5% possessed co-resistances to at least five other antimicrobials. Co-resistance rates for specific antimicrobials were as high as 70% (ampicillin).

Conclusions:

The considerably lower infection rates observed in men receiving RS-guided prophylaxis along with the significant prevalence of FQR displays the advantage of adopting the practice of a rectal swab program. Additionally, the high prevalence of multidrug resistance suggests that alternative methods such as augmented or multidrug prophylaxis regimens that are commonly empirically prescribed would likely have limited success.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S181.

P58: Randomized, controlled trial of laser vs. bipolar plasma vaporization treatment of benign prostatic hyperplasia

Thomas A A Skinner 1, Robert J Leslie 1, Stephen S Steele 1, J Curtis Nickel 1

Abstract

Background:

It remains unknown how vaporization surgery for benign prostatic hyperplasia (BPH) fits into the North American medical system. Evolution of competing systems makes it difficult for centers to adopt a single transurethral vaporization system. We compare two technologies to help guide urologists and hospitals in selecting new prostate treatment technologies.

Methods:

Patients meeting standardized BPH symptom criteria are randomized into a single-blinded, controlled trial comparing Biolitec Evolve Laser Vaporization to Olympus TURis Plasma Button Vaporization. Primary outcome is cost-effectiveness with secondary outcomes of clinical efficacy, resection time, surgical team satisfaction, and safety. Sixty patients will be randomized to achieve analysis of primary outcome.

Results:

Fifty-six patients have been randomized and treated by April 14, 2015 with three-month followup available for 47. Mean age was 71 (68.1–73.7) years, mean preoperative International Prostate Symptom Score (IPSS) 24/35 (22.2–26.8), with mean bother 4.7/6 (4.3–5.2). Mean six- and 12-week IPSS was 12 (9.5–14.8) and 10 (7.1–12.2), respectively. Mean surgeon satisfaction was 22/25 (20.4–23.1). Mean nursing satisfaction was 22/25 (21.3–23.6). Mean surgical time 28 min (24.3–32.8). Two patients were converted to transurethral resection of the prostate (TURP), four patients sought medical care for hematuria, three patients required dilation for urethral or bladder neck stricture, one developed deep vein thrombosis, one a urinary tract infection, and one suffered a thermal bladder injury. All 60 patients have been screened and the last four will be randomized in April 2016 with completion of three-month followup by July 2016 and unblinded analysis completed by August 2016.

Conclusion:

Analysis of blinded data with three-month data suggests that while these technologies may achieve a cost savings and appear to provide significant amelioration of lower urinary tract symptoms, there is a definite learning curve in terms of safety considerations. Analysis of the unblinded comparative data in early August will provide insight into the optimal adoption of vaporization technology in North American urologic practice.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S181.

P59: Re-examining the role of prophylactic ciprofloxacin prior to transrectal ultrasound-guided prostate biopsies at a tertiary academic teaching hospital

Nathan C Wong 1, Aalok Shah 1, Camilla Tajzler 1, Anil Kapoor 1

Abstract

Background:

Transrectal ultrasound guided prostate (TRUS) biopsies are not standardized, particularly with regard to antibiotic prophylaxis. Recently, there has been an increase in resistance to fluoroquinolones, and thus fluoroquinolone-sparing prophylaxis has been encouraged. We performed a retrospective chart analysis of patients who underwent a TRUS biopsy at our tertiary academic teaching hospital to examine infection rates comparing ciprofloxacin to other antibiotic therapies.

Methods:

A retrospective chart review was performed between January 2013 and December 2015 of men who underwent TRUS biopsy. A total of 382 charts were reviewed and 311 met inclusion criteria (71 were excluded due to insufficient information). Demographic data, prostate-specific antigen (PSA), prostate sizes on TRUS, and complications, particularly post-TRUS infections (particularly sepsis) within 30 days were ascertained from electronic records.

Results:

A total of 311 patients were included. The average age was 64.5±5.4 years. Mean PSA was 7.2±3.4ng/mL and average prostate volume was 42.3±7.1 cc. Approximately 84.9% of patients (264/311) were given ciprofloxacin only prior to TRUS biopsy. The rest of the patients (47/311) were given other prophylactic antibiotics including tobramycin, gentamycin, septra, ampicillin, vancomycin with or without concurrent ciprofloxacin. Overall rate of sepsis within 30 days was 3.22%. The rates of sepsis for ciprofloxacin only and other antibiotic therapies were 3.79 and 0% respectively (p<0.05). The majority of those treated with ciprofloxacin who developed bacteremia grew organisms resistant to ciprofloxacin. There were no other serious post-biopsy complications.

Conclusions:

At our center, rates of post-TRUS biopsy sepsis in patients receiving ciprofloxacin only compared to other antibiotic regimen with or without concurrent ciprofloxacin was higher. Consideration should be given to using alternative antibiotic regimens, examine local patterns of antibiotic resistant organisms, or perform rectal swabs to identify at risk individuals.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S181–S182.

P60: AUA annual census: Assessing urologists’ participation in quality reporting measures

Jamie Uy 1, Timothy Averch 1

Abstract

Background:

Over the last several years, reimbursement has been increasingly tied to use of quality performance measures due to new initiatives by both the federal government and private insurers to improve care while curbing excess spending. The AUA has been especially active in this area, contributing to the creation of many urology-specific quality measures. Despite this, the number of urologists who are participating in the new quality reporting programs is unclear. This study aims to determine whether urologists are participating in quality reporting programs, and if so, are they altering the scope of their practice based on these measures.

Methods:

Participants in the 2015 AUA annual census, collected between May and September 2015, made up of practicing urologists in the US, were asked to complete a series of questions relating to quality measure participation. If they had submitted data to a quality reporting program over the past year, they would answer subsequent questions to determine which quality programs they had participated in and how it had affected their practice.

Results:

The overall response rate was 4.7%, with 566 of 11 990 urologists participating in the census. Of the responders, 52.2% had participated in a quality reporting program over the past 12 months, 14.6% did not participate and 33.3% were not aware if they had. Among those who participated in a quality reporting program, many participated in more than one, with 77.1 % submitting to Meaningful Use, 58.1% to CMS PQRS, 15.9% to ACS NSQIP, 14.6% to Accountable Care Organization, 7.7% to AUA AQUA registry and 24.6% to homegrown measures. About half of participants also used the quality reporting programs to enhance the quality of their practice, with changes to patient care work flow (27.5%), practice patterns (26.0%), performance assessment (25.3%), or changes to financial incentives (18.1%). Only 21.5% of participants in quality reporting measures had not changed any aspect of their practice, with 28.4% unsure if their practice had changed.

Conclusions:

Despite increasing emphasis by the government and insurers on quality reporting measures, many urologists are still not participating in these programs. Among the urologists who are participating, most are reporting to more than one program, with half using quality measures to improve their practices. While the specifics of each program and their effect on reimbursement will continue to evolve, the use of quality reporting as a means of improving care in a cost efficient manner is here to stay. As new initiatives are promoted, better ways of promotion and promulgation will need to be addressed.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S182.

P61: An update on fluoroquinolones: The emergence of a multisystem toxicity syndrome

Lauren E Tennyson 1, Timothy D Averch 1

Abstract

Background:

The FDA recently convened a committee meeting to review the risks/benefits of oral fluoroquinolones (FQ). The meeting was prompted by a growing number of cases involving patients suffering from a constellation of symptoms now termed “fluoroquinolone-associated disability” (FQAD). Thirty-five patients testified to a panel of committee members, narrating their accounts of serious and disabling health issues after being prescribed oral FQ. FQAD is defined as previously healthy patients who experienced prolonged and disabling adverse effects in two or more organ systems after being prescribed an oral FQ. This newly recognized syndrome has generated concern and prompted patients and researchers to advocate for stronger quinolone drug labels.

Methods:

A literature search was performed to identify previous reports of quinolone-induced multisystem toxicity syndromes. Four primary sources emerged: the recent FDA review, a 45 patient case series from 2001 by a physician who dedicated the majority of his career to FQ toxicity awareness, a more recent case series of four patients, and social media platforms. All sources share a reliance on patient self-reporting, and those cases submitted to the FDA adverse event reporting system (FAERS) are estimated to comprise less than 10% of the total. Patients are more comfortable voicing issues on social media platforms, which provide a real-time barometer, but do not filter out cases with questionable validity. The FDA applied a particularly narrow definition in order exclude uncertain cases.

Results:

The FDA identified 1122 FQ disability reports from November 1, 1997 to May 30, 2015; 178 cases qualified as FQAD after applying inclusion and exclusion criteria. Another author estimates there are as many as 45 000 cases of FQ toxicity syndrome in the US. All sources agree the affected population is generally young (mean age 40s–50s), previously healthy and predominantly female. The FDA’s analysis revealed average duration of symptoms was 14 months, and the longest duration nine years at the time of the review. Notably, there has been an increase in FQAD reports over the past five years even though FQ prescribing patterns have remained unchanged (see graph).

Conclusions:

FQAD has generated concern and prompted patients and researchers to advocate for stronger quinolone drug labels. It does not affect the majority of patients exposed to FQ, but is likely underappreciated and underreported. As providers seeking to heal and avoid harm in our patients, proper education, and diligent prescribing practices are paramount.

Fig. 1.

Fig. 1.

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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S182.

P62: Giving underactive bladders a second chance: Holep for management of lower urinary tract symptoms in patients with detrusor underactivity

Jessica Paonessa 1, Garrett Smith 1, Portia Thurmond 1

Abstract

Background:

Lower urinary tract symptoms (LUTS) are a common complaint among aging men. Although non-specific, LUTS in men are classically attributed to bladder outlet obstruction (BOO). However, LUTS can also exist in the presence of detrusor underactivity (DU). Evaluation of the voiding phase in patients with BOO demonstrates high bladder pressures with low flow rates. In contrast, low bladder pressures and low flow rates characterize the voiding phase in patients with DU. Holmium laser enucleation of the prostate (HoLEP) has been shown to be a safe, durable, and effective surgical treatment for BOO secondary to benign prostatic enlargement (BPE) in prostates of any size. Catheterization is the standard treatment for patients with DU and incomplete bladder emptying (ICBE). In our early experience, we have identified a population of patients with DU who have benefited from HoLEP. We compared patients with BOO to those with DU to determine if outcomes post-HoLEP are comparable.

Methods:

Our HoLEP database was retrospectively reviewed, identifying 55 patients with preoperative urodynamic studies (UDS) who underwent HoLEP with or without bladder neck incision (BNI). Of these patients, 34 had UDS consistent with DU; defined as a bladder contractility index (BCI) <100. The remaining 21 patients were categorized as having BOO (BCI ≥100). All patients were operated on by a single surgeon, supervising residents from December 2014 to March 2016.

Results:

There were no differences in patient demographics, enucleation time, morcellation time, or tissue volume removed between the two groups. Patients without DU were more likely to be on alpha-blockers preoperatively (p=0.03). Patients with DU had higher preoperative PVRs (p=0.01) and were more likely to perform CIC preoperatively (p=0.03). There were no differences in preoperative International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM), or maximum flow rate (Qmax) between groups. There were also no differences in postoperative IPSS, SHIM, Qmax or post-void residual (PVR). All patients with DU were able to void after HoLEP. A single patient with DU was still requiring CIC at six months.

Conclusions:

Historically, men with DU and ICBE were not offered surgery. Primary treatment options included intermittent catheterization or chronic indwelling catheter. For patients who can Valsalva and stand to void, HoLEP with or without BNI may improve quality of life by allowing them to live catheter free. These findings may also support expanding the indications for HoLEP.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S183.

P63: Outcomes after holmium laser enucleation of the prostate in patients 75 years and older

Garrett Smith 1, Portia Thurmond 1, Jessica Paonessa 1

Abstract

Background:

Increased morbidity and mortality have been observed in elderly patients undergoing major surgery compared to younger patients. Significantly higher postoperative complication rates have been reported in patients over 80 years of age who underwent transurethral resection of the prostate. GreenLight photoselective vaporization prostatectomy was reported to be equally safe and efficacious in patients older or younger than 70. Higher complication and mortality rates have been reported in older patients undergoing radical prostatectomy, with the greatest risk occurring over 75 years. Advances in medical management of benign prostatic enlargement (BPE) have delayed the age at which many patients present for surgical consultation, with an increase in attendant comorbidities and often very large prostates. Few studies elucidate outcomes based on age for the treatment of BPE using holmium laser enucleation of the prostate (HoLEP). We compared patients treated with HoLEP who were younger than 75 years and those 75 years and older to determine if outcomes were different.

Methods:

Our HoLEP database was retrospectively reviewed, identifying 87 patients who underwent HoLEP with or without bladder neck incision. Of these patients, 38 were 75 years of age or older and 47 were younger than 75. All patients were operated on by a single surgeon, supervising residents from December 2014 to March 2016. Patients completed International Prostate Symptom Score (IPSS), Quality of Life (QoL) and Sexual Health Inventory for Men (SHIM) questionnaires before surgery and at six weeks (6wk) and six months (6mo) postoperatively.

Results:

Preoperative comorbidities, use of medications for BPE and catheter dependence did not differ between groups. Preoperative prostate volume, IPSS, QoL, SHIM, bladder capacity, maximum flow rate (Qmax), detrusor pressure and post-void residual (PVR) were comparable in both groups. Enucleation time, morcellation time, volume of tissue removed, and length of stay were similar. Postoperative IPSS, QoL, SHIM, and PVR did not differ between groups at 6wk and 6mo followup. Mean Qmax at 6mo followup was lower in the older group (age<75: 22.29 ml/sec; age≥75: 8.55 ml/sec). Pre- and postoperative incontinence were similar between groups. There was no difference in the incidence of significant complications (Clavien Grade≥III) at 30 days, which were low.

Conclusions:

Traditionally, there has been concern about risks of performing surgery in elderly patients, particularly cardiovascular complications. Our study showed no difference in outcomes between older and younger patients. HoLEP is a safe and effective surgical treatment for BPE in men 75 years and older.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S183.

P64: The relationship of physician payments from drug manufacturers to Medicare claims for abiraterone and enzalutamide

Omar M Ayyash 1, Jathin Bandari 1, Robert M Turner II 1, Bruce L Jacobs 1, Benjamin J Davies 1

Abstract

Background:

Abiraterone and enzalutamide are both FDA-approved treatments that have been increasingly used for metastatic castration resistant prostate cancer. At the same time, the pharmaceutical companies that developed these oral chemotherapeutic agents have pursued aggressive marketing campaigns that target physicians. We sought to investigate if there is an association between pharmaceutical industry payments to physicians and prescriptions for abiraterone and enzalutamide.

Methods:

Using the Open Payments Database from 2014, we determined the number and total dollar amount of payments from industry to each urologist or oncologist who prescribed abiraterone and enzalutamide. These data were merged with the 2013 Medicare Part D Provider and Utilization Data to identify the total claim count (i.e., prescriptions) ascribed to each physician, as well as the total drug cost per prescribing physician. Claim counts and drug costs were compared between prescribers who did and did not receive industry payment using Wilcoxan rank-sum tests. Spearman Rank correlation was used to assess the relationship between industry payments and total claim count for each drug.

Results:

Of 1812 physicians who prescribed abiraterone, 615 (34%) received a payment from industry. The median payment amount to prescribers was $0 (IQR $0–$28.26). The number of abiraterone claims and total drug costs were similar between prescribers who did and did not receive industry payment (18 vs. 18; $118 362 vs. $118 246; p=0.94). There was a weak association between industry payment amount and total Medicare claims among abiraterone prescribers (ρ=0.05; p<0.001). Of 701 physicians who prescribed enzalutamide, 289 (41%) received a payment from industry. The median payment amount to prescribers was $0 (IQR $0–$41.83). The number of enzalutamide claims and total drug costs were similar between prescribers who did and did not receive industry payment (15 vs. 16; p=0.41; $119 097 vs. $122 760; p=0.94). There was a weak association between industry payment amount and total claims among enzalutamide prescribers (ρ=0.09; p=0.0145).

Conclusions:

Industry payments to prescribers of abiraterone and enzalutamide were common, but of low amount. While this suggests little association between industry payments and physician prescribing behavior for these drugs, continued public reporting of industry payments to physicians will allow for further investigation of this relationship.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S183.

P65: Pulsed fluoroscopy safely reduces radiation exposure during ureteroscopy

Lorraine Liang 1, Yifan Meng 1, Oleg Mironov 2, Kevin Tsai 1, Janet Kukreja 1, David Dever 1, Ahmed Ghazi 1

Abstract

Background:

Fluoroscopy is a standard procedural component of endourology. Occupational radiation exposure increases the risk of carcinogenesis, cataract formation and harmful genetic effects in a dose-dependent manner. We evaluated the average radiation exposure and complication rate with continuous or pulsed fluoroscopy in ureteroscopy cases for urolithiasis.

Methods:

We retrospectively reviewed the operative details of 66 patients who underwent ureteroscopy for urolithiasis performed by two PGY-5 urology residents under the supervision of a single attending at an academic affiliate institution from June 1, 2014 to May 30, 2015. Residents A and B performed ureteroscopy using continuous fluoroscopy (30 frames per second) for 17 and 30 cases, respectively. Resident A then performed 19 consecutive cases using pulsed fluoroscopy (three frames per second). Fluoroscopy time (FT), stone size, stone location, number of procedural components (access sheath placement, stent placement, basketing, lasering, and ureteral dilation), and procedure-related complications were included in our analysis. Differences in FT between Resident A and B were compared using t-test. Correlations between FT and stone size, stone location and number of procedural components were assessed with Spearman rho test. Complication rates were compared using chi-square analysis.

Results:

Prior to intervention, there was no difference between average FT per case between Resident A and Resident B (p=0.993). Following intervention, Resident A reduced average fluoroscopy exposure per case compared to pre-intervention (45±33s to 24±20s; p=0.028) and compared to Resident B (p=0.04). Resident B did not show a significant reduction in FT over the course of the study (p=0.309). FT was positively correlated with the number of procedural components (p=0.0001; Spearman coefficient 0.453) and more difficult stone position (p=0.001; Spearman coefficient 0.423). FT was not correlated with stone size or patient gender. There was no statistically significant difference in procedure complexity and complication rate between cases performed by Residents A and B post-intervention or between cases performed by Resident A pre- and post-intervention. The control and intervention groups had four and three complications, respectively, including bleeding and ureteral injury. There was one instance of stent malposition into the ureter in each group.

Conclusions:

Ureteroscopy cases using pulsed fluoroscopy had a 47% reduction in FT with a similar complication rate compared to cases using continuous fluoroscopy. Our results suggest that pulsed fluoroscopy may be safely used in place of continuous fluoroscopy to reduce occupational radiation exposure.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S184.

P66: Changing lithogenic trends in patients with neurological derived musculoskeletal deficiencies

Ilan Kafka 1, Thomas Fuller 1, Sarah Sprauer 1, Hassan Taan 1, Timothy Averch 1, Michelle Semins 1

Abstract

Background:

Patients with neurologically derived musculoskeletal deficiencies (NDMD) (e.g., spinal cord injury, spina bifida, etc.) have higher risk for chronic complicated urolithiasis and when compared to the general population show higher rates of recurrence. Recent studies suggest that stone etiology in this population may have shifted from infectious to metabolic. We asses a cohort of NDMD patients attending our stone clinic to identify specific lithogenic risk factors.

Methods:

Patients seen in our stone clinic with any type of NDMD and urolithiasis from 2000–2015 who had available 24-hour urine collections were retrospectively reviewed. Demographics, neurological deficiency, bladder management, urine cultures, 24-hour urine and stone parameters were reviewed.

Results:

Seventy-eight patients with NDMD and nephrolithiasis were identified. Of these, 26 had both 24-hour urine and stone analysis available. Most common stone type was apatite (53.8%) followed by mixed apatite/oxalate (19.2%) (Table. 1). Urinary citrate was significantly lower in patients with apatite stones. Metabolic abnormalities were gender specific. Females were found to have hypocitraturia and low volumes, while males more commonly had hyperoxaluria and hypernatriuria. Positive urine cultures prior to treatment were present in 77%. 85% were urea splitting organisms, most commonly pseudomonas. There were no statistically significant differences in 24-hour urine parameters when analyzed by neurological deficiency or bladder management strategy. However, there were trends toward positive urea-splitting cultures and apatite stones in catheterized patients.

Conclusions:

NDMD patients have both metabolic and infectious stones. A high incidence of apatite stones were seen and can possibly be attributed to bacteriuria and elevated pH. Obesity, low volumes, and higher oxalate suggest a metabolic etiology as well. Identifying metabolic risk factors in NDMD patients is important but challenging, mainly due to poor followup and difficult specimen collections.

Table 1.

Cohort demographics

Sex
  Male, n (%) 14 (53.8)
  Female, n (%) 12 (46.2)
Age, years (range) 44 (21–74)
Weight, kg (range) 77.6 (37.5–127)
Body mass index (range) 27.9 (11.9–53.8)
Bladder management, n (%)
  Spontaneous voiding 6 (23)
  Clean intermittent catheterization 8 (30.8)
  Suprapubic tube or indwelling Foley 11(42.3)
  Ileal conduit 1 (3.9)
Positive repeat urine cultures, n (%) 20 (77)
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Table 2.

24-hour urine analysis by main stone composition

Stone composition
Apatite Oxalate
n % n % P value
Volume/24 hours Low 11 64.7 7 87.5 0.16
Normal 6 35.3 1 12.5
Ca 24-hour Normal 15 88.2 6 75.0 0.631
High 2 11.8 2 25.0
Ox 24-hour Normal 14 82.4 6 75.0 0.804
High 3 17.6 2 25.0
Cit 24-hour Normal 1 5.9 4 50.0 0.029
Low 16 94.1 4 50.0
pH Normal 1 5.9 1 12.5 0.81
High 16 94.1 7 87.5
UA 24-hour Normal 16 94.1 8 100.0 0.759
High 1 5.9 0 0.0
Na 24-hour Normal 13 76.5 6 75.0 0.853
High 4 23.5 2 25.0
K 24-hour Low 2 11.8 1 12.5 0.963
Normal 14 82.4 6 75.0
High 1 5.9 1 12.5
P 24-hour Normal 2 11.8 4 50.0 0.213
Low 12 70.6 4 50.0
High 3 17.6 0 0.0
Ca 24/kg Low 11 64.7 7 87.5 0.47
Normal 5 29.4 1 12.5
High 1 5.9 0 0.0
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S185.

P67: Treatment of forniceal rupture: A single-institution experience with conservative management

Tara N Nikonow 1, Jathin Bandari 1, Timothy Averch 1

Abstract

Background:

Forniceal rupture is a condition of perirenal urinary extravasation often associated with ureteral obstruction. Treatment considerations for this condition have not been standardized, and there is very limited information in the literature regarding clinical practice.

Methods:

We retrospectively searched all radiographic records for patients treated at our institution between January 2009 and January 2016 using the terms “forniceal rupture,” “fornix rupture,” “calyx rupture,” or “caliceal rupture,” and identified 111 patients. Each patient was followed for two months from presentation. Three patients were excluded for age <18 and five were excluded for incomplete records or a failure to find a history of forniceal rupture in their profiles. We compiled demographic data, etiology, clinical factors at presentation, treatments and outcomes.

Results:

One hundred three patients were included for analysis. The median age at presentation was 64 years (IQR 52–73); 47 were male and 56 were female. The etiology of forniceal rupture was most commonly urolithiasis (73%), with cancer being the next most common cause (11%). Regarding specific stone data, most cases were caused by small (1–5 mm) stones in the distal ureter (Table 1). Thirty-two patients (31%) were treated surgically with ureteral stent placement upfront; 27 of those patients were stone patients and most had some clinical factors making them higher risk (Table 2). There was only one operative complication during the study period. Only one patient developed an abscess. Forty-three patients were sent home from the emergency room. Of the patients who were admitted, the average hospital stay was three days (IQR 2–6). For the entire cohort, there were six related readmissions in the study period.

Conclusions:

There are very limited data in the literature regarding clinical practice in the treatment of forniceal rupture. There are studies showing favorable outcomes of this condition in institutions with operative intervention rates from 59–99%. Clinical practice at our institution is conservative treatment of forniceal rupture in the absence of infection, kidney failure, or other risk factors with few complications or readmissions.

Table 1.

Gender
  Male 47
  Female 56
Age (median) 64 (interquartile range 52–73)
Laterality
  Left 47
  Right 50
  Bilateral 6
Etiology
  Bladder outlet obstruction 7
  Trauma 1
  Idiopathic 5
  Cancer/extrinsic compression 11
  Iatrogenic 2
  Ureteropelvic junction obstruction 4
Stone 75
  Proximal 16
  Mid 9
  Distal 50
  Size 1–5 mm 46
  Size 5–10 mm 21
  Size >10 mm 8
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Table 2.

Clinical factors, treatment, and outcomes

Outcomes
  Discharged from emergency department 43
  Related readmission 6
  Hospital stay (median days) 3 (interquartile range 2–6)
  Complications 1
  Abscess 1
Intervention
  Stent 32
  Stone + stent 27
Clinical factors
  Fever >38.3 4
  Leukocytosis >12 12
  Positive urinalysis 8
  Cr>1.5 12
  Emesis 13
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S185–S186.

P68: Single pulse-per-second setting significantly reduces fluoroscopy time during ureteroscopy

Todd S Yecies 1, Anisleidy Fombona 1, Michelle Semins 1

Abstract

Background:

Both patients and surgeons are exposed to ionizing radiation during endourologic procedures. Modern C-arms have settings that can be modified to lower radiation exposure, including “low-dose” and pulsed fluoroscopy. The pulsed fluoroscopy rates range from a standard rate of 30 to a single pulse-per-second (pps). We present here the only known series evaluating the effect of 1 pps on fluoroscopy time and surgeon radiation exposure.

Methods:

A retrospective review of a single endourologist’s operative records was performed over a 12-month period. Adult patients undergoing ureteroscopy were included. At the six-month point, the switch from continuous “low-dose” to 1 pps “low-dose” fluoroscopy was made. Collected data included patient age, gender, body mass index (BMI), aggregate stone burden, stone multiplicity, laterality, laser and ureteral access sheath usage, operative time, fluoroscopy time, rates of failed or staged ureteroscopy and complication rates. Surgeon radiation exposure was measured using 1 dosimeter placed at the torso under the lead apron and 1 dosimeter overlying the chest outside the lead apron. Deep Dose Equivalent (DDE), Lens Dose Equivalent (LDE), and Shallow Dose Equivalent (SDE) were calculated using the EDE1 formula.

Results:

A total of 84 and 70 patients underwent ureteroscopy using continuous and 1 pps fluoroscopy, respectively. No significant differences were identified between the two groups with regards to patient age (p=0.96), sex (p=0.26), BMI (p=0.95), stone multiplicity (p=0.31), bilateral ureteroscopy (p=0.07), pre-stenting (p=0.99), staged (p=0.84) or failed ureteroscopy (p=0.99), ureteral access sheath use (p=0.10), or case duration (p=0.54). Patients in the 1 pps cohort had a larger median stone burden (1.3 cm, IQR 0.8–2.0 cm vs.1.8 cm, IQR 0.9–2.8 cm; p=0.04). Median fluoroscopy time was reduced from 77 (IQR 54–115) to 16 seconds (IQR 13–24) using 1 pps (p<0.001). Monthly surgeon radiation exposure was reduced by an average of 64%, from 6.8±8.3 to 1.8±2.7 mRad DDE (p=0.11), 120.6±101.4 to 49.2±66.6 mRad LDE (p=0.10), and 116.2±97.8 to 47.6±64.0 mRad SDE (p=0.11). Complications were rare, without significant difference between the two groups. Image quality was acceptable in all cases using 1 pps fluoroscopy despite a maximal patient BMI of 82.2. The only technical compromise noted was increased motion artifact, which was easily avoided by allowing the C-arm to complete motion prior to image acquisition.

Conclusions:

Use of single pulse-per-second fluoroscopy significantly reduces fluoroscopy time and lowers surgeon radiation exposure by 64%.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S186.

P69: Does the timing of magnesium supplementation affect urinary oxalate levels in patients with nephrolithiasis

Omar Ayyash 1, Timothy Averch 1, Julie Riley 1, Michelle Semins 1

Abstract

Background:

Urinary magnesium has been shown previously to inhibit kidney stone formation in chemical models; however, when applied to in vivo human models, the results have been conflicting. The purpose of this study is to investigate the timing of magnesium supplementation on the inhibitory effect on nephrolithiasis. We hypothesize that if magnesium is taken with meals, more will be absorbed in the small intestine and excreted in the kidney to allow for better inhibitory effect, specifically by reducing oxalate excretion.

Methods:

We prospectively enrolled known calcium oxalate stone formers with isolated hyperoxaluria identified on 24-hour stone risk testing. Patients were then randomized to take magnesium supplementation either fasting or with food. An initial 24-hour urine collection was obtained on enrollment and then repeated after seven days of magnesium supplementation to determine the effect on urinary excretion of oxalate. Participants were given a controlled diet during the seven days of intervention which included adequate fluid intake, low oxalate, low salt, moderate animal protein, and normal calcium intake — the standard dietary treatment for hyperoxaluric kidney stone patients.

Results:

Seven patients were enrolled with three patients randomized to each arm of magnesium supplementation and one individual excluded due to inability to complete the control diet. Those taking it with food experienced a 25.2 mg/d decrease in their urinary oxalate over the course of seven days as compared to a 13.7 mg/d decrease for those taking magnesium while fasting. There were only modest decreases in calcium oxalate supersaturation and calcium but profound increases in stone protective factors like citrate (Table 1). Secondary endpoints including sodium (decrease 53 mg/d with food vs. 84 mg/d fasting) also showed improvement with little difference between groups.

Conclusions:

Those taking magnesium supplementation with food experienced twice the reduction in urinary oxalate as those who took it while fasting. Additionally, secondary endpoints like citrate and sodium showed improvement with modest differences between groups. Our pilot study supports the need for further investigation with a larger sample to establish the significance of these trends. Funded by Northeastern Section Young Investigator Grant.

Table 1.

Magnesium supplementation with food Magnesium supplementation while fasting
Mean initial Mean final Mean change Standard deviation Range Mean initial Mean final Mean change Standard deviation Range
Volume 1.92 2.77 0.85 0.35 0.15–1.20 3.10 3.56 0.46 0.39 −0.01–1.24
Calcium oxalate supersaturation 9.29 3.26 −6.03 1.15 −8.09– −4.09 3.40 2.39 −1.01 1.04 −2.62–0.96
Calcium 194.70 189.75 −4.95 40.49 −84.83–46.48 170.04 158.21 −11.83 49.39 −79.42–84.36
Oxalate 53.85 28.63 −25.23 9.74 −41.55– −7.84 43.15 29.36 −13.78 17.99 −47.53–13.92
Citrate 839.34 1036.86 197.51 188.89 −31.50–572.21 967.82 1094.18 126.36 168.05 −204.70–342.10
Calcium phosphate supersaturation 0.62 0.83 0.21 0.21 0.00–0.63 0.66 0.76 0.10 0.06 −0.02–0.20
pH 5.79 6.41 0.62 0.22 0.22–0.98 6.41 6.84 0.43 0.12 0.22–0.65
Uric acid supersaturation 1.61 0.31 −1.29 0.70 −2.57– −0.15 0.37 0.11 −0.26 0.19 −0.65– −0.03
Uric acid 0.71 0.67 −0.04 0.03 −0.07–0.03 0.68 0.60 −0.09 0.03 −0.13– −0.03
Sodium 141.69 88.25 −53.45 31.53 −113.95– −7.78 159.88 75.41 −84.48 13.67 −106.54– −59.46
Potassium 54.83 77.87 23.04 6.69 9.67–30.00 78.33 106.85 28.52 2.61 23.67–32.59
Magnesium 90.63 131.83 41.20 13.22 22.61–66.79 105.38 118.86 13.48 14.25 −8.88–39.95
Phosphorus 0.94 0.82 −0.12 0.22 −0.54–0.18 0.87 0.71 −0.17 0.17 −0.46–0.12
Ammonium 40.36 30.25 −10.12 2.88 −14.85– −4.90 43.44 29.88 −13.57 3.87 −21.28– −9.11
Chloride 141.69 91.95 −49.74 43.00 −127.42–21.05 166.23 93.68 −72.55 18.22 −102.75– −39.80
Sulfur 40.30 44.33 4.04 4.69 −2.48–13.14 36.76 32.89 −3.87 7.37 −14.50–10.30
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S186–S187.

P70: External lower abdominal pressure to aid semirigid ureteroscopy in the proximal ureter: Opinion of modern-era endourologists: Is it safe and effective?

Monica A Farcas 1, Daniela Ghiculete 2, Keith Barrett 1, Robert J Sowerby 1, Kenneth T Pace 2, R John D’A Honey 2

Abstract

Background:

In 2005, we described a technique of applying external lower abdominal pressure to allow semirigid ureteroscopy (SURS) above the iliac vessels for treatment of upper ureteral calculi. This has led to attempted treatment of all upper and mid ureteric calculi at our center with SURS. In this study, we surveyed modern-era endourologists about their use of this technique four and eight years following its initial description. Furthermore, we performed a retrospective review of our experience to document the technique’s safety and efficacy.

Methods:

In 2009, an email survey was circulated to Endourological Society members inquiring about their use of abdominal pressure to aid SURS. Survey results and the reference to the published technique were circulated. In 2013, the survey was re-circulated to those unfamiliar with the technique in 2009. Retrospective chart review included all upper- and midureteric calculi treated with SURS at our center from 2012–2014 with radiologic followup of at least three months postoperatively in order to evaluate stricture formation. Records were reviewed for access difficulties, intraoperative complications, stone clearance, and ureteral strictures.

Results:

Two hundred eight-two endourologists responded to the 2009 survey. Fifty-one (18%) regularly used abdominal pressure for SURS. In 2013, re-survey of the 231 urologists who had not used this technique yielded a 43% response rate, with 23 having attempted it and 16 planning to continue to use it. Five hundred nineteen URSs were performed at our center from 2012–2014; 75 were SURSs meeting our criteria. Abdominal pressure to aid access was used in all cases as deemed necessary. In 91% of cases the mid- or upper-ureter was accessed without difficulty. Five (6.7%) conversions to flexible URS were required due to a tortuous or narrow ureter. Two patients (2.7%) were stented due to narrow ureter, and SURS was performed at a later date. One patient (1.3%) suffered ureteric perforation at an impacted stone site. There were no ureteric injuries due to SURS over the iliac vessels or psoas muscle. No patients developed ureteric strictures requiring intervention. Two patients (2.7%) had persistent hydronephrosis at three months, but did not require intervention. The stone clearance rate was 94%.

Conclusions:

Eight years after publication of a new technique for using abdominal pressure to aid access to the upper ureter for SURS, only a minority of endourologists have adopted it. At our center this technique continues to be the standard of practice, with excellent success rates and minimal complications.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S187.

P71: Evaluation of student athlete kidney stone risk via 24-hour urine collection

Katherine M Theisen 1, Omar Ayyash 1, Matthew Ferroni 1, Kevin Rycyna 1, Julie Riley 2, Timothy D Averch 1, Michelle J Semins 1

Abstract

Background:

Dehydration is a known risk factor for kidney stone formation. High-caliber athletes who undoubtedly experience prolonged states of dehydration during competition and training do not have an apparent increased risk of stone events. We aimed to determine why athletes do not experience an increased incidence of nephrolithiasis. To do this, we performed a prospective study evaluating urinary risk factors for kidney stone formation in Division I student-athletes versus non-athletes using 24-hour urine collections.

Methods:

After IRB and NCAA compliance office approval, 74 student-athletes and 20 non-student-athletes enrolled in the study. Demographics, body mass index, medical and surgical history, medications, and individual sport were recorded. Participants were asked to collect at least one 24-hour urine specimen, with athletes asked to collect more than one at varying time points throughout the athletic season. Athletes were also asked to provide diet and activity logs at the time of collection. Standard stone risk parameters were assessed and compared between athletes and non-athletes.

Results:

A total of 34 student-athletes (ages 19–22) and 10 non-student-athletes (age 21) completed the study. Summary of results can be seen in Table 1. The median age of athletes was higher than non-athletes (20 vs. 19 years old). Athletes had significantly lower urinary pH than non-athletes. In addition, athletes excreted significantly higher amounts of urinary magnesium, ammonium, phosphorus, and creatinine. The urine supersaturation of uric acid was significantly higher in athletes than non-athletes. Female athletes excreted more calcium and more creatinine/ kg/24hrs than female non-athletes.

Conclusions:

Student athletes had a lower urine pH, higher supersaturation of uric acid, and a higher calcium excretion (specifically in female athletes). These risk factors for stone formation in athletes may be offset by higher levels of stone protective factors such as magnesium, which was significantly higher in athletes than non-athletes. Lastly, high muscle mass as seen in athletes may be protective against stone formation or a marker of decreased risk. These findings may potentially explain the lack of increased incidence of nephrolithiasis in athletes. Further study is needed.

Table 1.

Subset of differences in 24-hour urine parameters between athletes and non-athletes

Variable Litholink normal Athletes Non-athletes P value
Volume >2 1.46 1.33 0.52
pH>2 5.8–6.2 6.32 6.55 0.01
Calcium (F) <200 219 107 0.04
SSUA 0–1 0.6 0.2 0.02
Phosphorus <1.2 1.04 0.59 0.02
Ammonium <60 43 29 0.02
Magnesium <120 126 87 0.02
Cr/kg/24 hour (F) 15–20 28.5 23 <0.01
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S188.

P72: Investigating tumor dissemination during robot-assisted radical cystectomy

Ahmed Hussein 1, Yingyu Ma 1, Gissou Azabdaftari 1, Wei Luo 1, Victoria N Cranwell 1, Brittany L Bunch 1, Justen D Kozlowski 1, Nobuyuki Hinata 2, Sean T Glenn 1, Song Liu 1, Candace S Johnson 1, Khurshid A Guru 1

Abstract

Background:

Local recurrence remains a major cause of cancer-specific mortality following radical cystectomy. We sought to investigate tumor dissemination in the operative field and contribution of pneumoperitoneum during robot-assisted radical cystectomy (RARC).

Methods:

Six RARCs were included. Four pelvic irrigations with 0.9% normal saline were performed: Sample I: before RARC; Sample II: after RARC; Sample III: after pelvic lymph node dissection (PLND), and leftover irrigation fluid at end of procedure (Sample IV). CO2 used for pneumoperitoneum was filtered using surgical smoke plume evacuation device. Filter was then removed, washed with 0.9% saline, centrifuged and sediment was analyzed. Intravesical bladder irrigations were performed for three patients. Methodology: pelvic irrigations (SI-IV) were examined for cytology using thin preparation and cell block by a genito-urinary pathologist/cytopathologist. Meanwhile, intravesical wash, pelvic irrigation, and filter sediment were analyzed for mRNA expression of bladder cancer related genes. mRNA expression was examined by qRT-PCR, with human bladder cancer cell line 253J and GAPDH (controls). Epithelial cell markers EpCAM, cytokeratins 8, 18, and 19 were also assessed. Bladder cancer gene panels used in the Cxbladder Detect urinary test were also examined (CDK1, MDK, IGFBP5, HOXA13 and CXCR2).

Results:

Four patients received neoadjuvant chemotherapy. The mean operative time was 300 minutes. Four patients had pT1 disease, two had pT2 disease. All patients had negative soft tissue surgical margins and mean LNY was 31. One patient had positive lymph nodes. No spillage of tumor cells or inadvertent entry into the bladder was observed. All lymph nodes were removed in specimen bags. Cytology: Pelvic Irrigation showed mostly blood, inflammatory, mesothelial cells and macrophages. All specimens were negative for malignant cells. mRNA expression: Bladder cancer-related mRNA was detected in the intravesical wash and 253J bladder cancer cells (control). In contrast, all pelvic irrigations and filter sediment had very low or undetectable mRNA levels. However, in patient with node positive disease, SI irrigation showed many epithelial markers (KRT8, 18, 19, IGFBP5).

Conclusions:

Our preliminary analysis showed that bladder cancer cells, bladder cancer-related genes and epithelial markers were not present in pelvic irrigation but in intravesical wash. These cells were detected in the pelvis in one patient with advanced disease. Active enrollment in this study continues, which will allow better understanding of local spread of bladder cancer. Funding by Roswell Park Alliance Foundation

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S188.

P73: A comparison of open vs. robot-assisted prostatectomy postoperative oncological outcomes in high-risk prostate cancer patients between 2003 and 2013: Analysis of a single-center

Arash Samiei 1, Jeffrey Cohen 1, Ralph Miller 1

Abstract

Background:

Prostate cancer (PCa) is the most commonly diagnosed solid-organ tumor in the U.S. and robot-assisted radical prostatectomy (RARP) is currently the most common approach for localized PCa treatment. Comparative studies with respect to long-term biochemical recurrence rates associated with open radical prostatectomy (ORP) and RARP in the treatment of high-risk PCa patients are still lacking. The aim of our study was to compare the oncological outcomes and biochemical cancer recurrence in RARP and ORP in high-risk PCa patients.

Methods:

This was a retrospective observational study of high-risk PCa prostatectomies, which were performed by two practiced surgeons in a single center from 2003–2013, with a record of 36-month followup time. Preoperative and postoperative data (Preoperative prostate-specific antigen [PSA], Nadir PSA, Gleason scores, pathologic stage, biochemical recurrence time) were compared with oncological results. Patients were categorized in different groups according to time to biochemical failure (six, 12, 24, 36months). High-risk PCa was defined as pathological stage ≥T3a, or biopsy Gleason score 8–10, or PSA>20 ng/ml, and biochemical failure was defined as two consecutive PSA≥0.2 ng/ml postoperatively.

Results:

A total of 211 high-risk PCa patients (73 [34.59%] ORP and 138 [65.40%] RARP) were included in the study who had a record of 36 months of followup. Mean (median) age at the time of diagnosis was 60 (61) for PARP and 59 (60) for ORP. In high-risk patients, pathologic stage ≥T3a in RARP vs. ORP was 81.88% vs 75.34% (p=0.26] and Gleason score ≥8 in RARP was 39.85% and 36.98% in ORP (p=0.68). Patients who progressed to biochemical failure in 36-month followup were (42 [57.53%] ORP and 60 [43.47%] RARP) (OR 1.76; p=0.051). Patients who progressed to biochemical failure <6 months (16 [21.91%] ORP and 12 [8.69%] RARP) (OR 2.94; p=0.007); and <12 months (25 [34.24%] ORP and 30 [21.73%] RARP) (OR 1.87; p=0.048]; and <24 months (33 [45.20%] ORP and 47 [34.05%] RARP) (OR 1.63; p=0.112].

Conclusions:

High-risk PCa patients who underwent ORP had a higher probability of a biochemical failure in the first six months and 12 months of followup than RARP. Our data displayed a trend toward more frequency and earlier biochemical failure in patients who underwent ORP than RARP. Despite early concerns regarding margin status in RARP patients, our data would suspect a trend toward a superior biochemical control in RARP group.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S189.

P74: Outcomes of robot-assisted radical cystectomy in patients over 80 years

Ahmed Hussein 1, Nobuyuki Hinata 2, Sana Raheem 1, Khurshid Guru 1

Abstract

Background:

Despite being the gold standard for treatment of non-metastatic muscle invasive bladder cancer, radical cystectomy remains a morbid procedure, especially for a high-risk population such as elderly. We sought to explore the safety, efficacy, and oncological outcomes of robot-assisted radical cystectomy (RARC) in patients older than 80 years.

Methods:

We retrospectively reviewed our database of 425 RARCs. Patients were divided into two groups based on cutoff age of 80 years. Both groups were compared in terms of preoperative characteristics, perioperative outcomes including pathologic outcomes, complications, and survival rates.

Results:

Sixty-two patients (14%) were 80 years or older. Although older patients received neoadjuvant chemotherapy less frequently (10% vs. 23% vs. 23%; p<0.01), they showed similar perioperative, pathological outcomes, and complications. Younger patients demonstrated better cancer specific and overall survival but not recurrence free survival rates (Fig. 1).

Conclusions:

A minimally invasive approach to radical cystectomy does not seem to pose additional perioperative risks or compromise oncological outcomes in older patients.

Fig. 1.

Fig. 1.

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(A) Recurrence-free survival; (B) cancer-specific survival; and (C) overall survival of patients ≥80 years (blue) compared to those aged <80 years (red).

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S189.

P75: Should robot-assisted radical cystectomy be the gold standard? A surgeon perspective

Ahmed Hussein 1, Nobuyuki Hinata 2, James Peabody 1, Alex Mottrie 1, Douglas Scherr 1, Koon-Ho Rha 1, Mani Menon 1, Peter Wiklund 1, Prokar Dasgupta 1, Lee Richstone 1, Shamim Khan 1, Carl Wijburg 1, Matthias Saar 1, Abdullah Canda 1, Jihad Kaouk 1, Andrew Wagner 1, Bertram Yuh 1, Vassilis Poulakis 1, Juan Palou Redorta 1, Manish Vira 1, M Derya Balbay 1, Abolfazl Hosseini 1, Thomas Maatman 1, Geert Smits 1, Khurshid Guru 1

Abstract

Background:

Robot-assisted radical cystectomy (RARC) has been associated with similar oncological outcomes to the conventional open approach and superior in terms of perioperative outcomes. We sought to investigate the surgeon perspective of RARC after more than a decade of the first case.

Methods:

Survey included questions about the demographics, training, surgical experience (open, laparoscopic and robot-assisted surgery), cystectomy experience, institution characteristics (volume of cases, robotic cases, cystectomy volume). We fitted a logistic regression model to evaluate surgeon and institution characteristics factors associated with considering RARC as the gold standard.

Results:

Thirty-eight surgeons from 21 institutions participated in the study. Only one-third of the surgeons considered RARC as the new gold standard treatment. Twenty-six surgeons (68%) had experience of more than 10 years, and 22 surgeons (61%) received formal minimally invasive-robotic training, 18 surgeons (47%) performed >100 cases. Twenty surgeons (52%) performed more than 1000 robotic cases, 18 (47%) performed >100 RARC. Twenty-five institutions perform ≥500 inpatient urological procedures/year, and 26 had a dedicated cystectomy program. Considering RARC as the gold standard, surgeon age >55 years (p=0.04), urologic experience >10 years (p=0.04), and robot-assisted experience >1000 cases (p=0.02) were positive predictors of considering RARC as the current gold standard. In terms of institutions characteristics, performing >500 procedures a year (p<0.01) was a predictor of considering it as gold standard.

Conclusions:

Higher institution and surgeon volume, based on surveying of bladder surgeons, were associated with considering RARC as the gold standard.

Footnotes

Funding by Roswell Park Alliance Foundation

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S189–S190.

P76: Robot-assisted laparoscopic ureterolysis and omental wrapping for management of idiopathic retroperitoneal fibrosis

Matthew Truong 1, Yifan Meng 1, Guan Wu 1

Abstract

Background:

Retroperitoneal fibrosis (RF) is a rare cause of ureteral obstruction. We report our experience of managing unilateral and bilateral idiopathic retroperitoneal fibrosis (RF) with robot-assisted laparoscopic ureterolysis (UL) and omental wrapping (OW).

Methods:

Robot-assisted laparoscopic UL and OW were performed on four patients with idiopathic RF between March 2012 and January 2015. Our operative procedure included a cystoscopy with retrograde pyelogram to confirm the area of obstruction. Unilateral UL was performed in lateral decubitus position, while bilateral UL was performed in supine position. We introduced trocars using the da Vinci robotic system. The bowel was medialized and the retroperitoneum was entered, exposing the fibrotic ureter. The excised fibrotic tissue was sent for pathology to rule out malignancy. Following UL, an OW of the exposed ureter was performed via a window in the mesentery. The patient was then closed. Patient charts retrospectively reviewed.

Results:

Three male and one female received clinical diagnosis of RF and underwent surgical treatment. The age range was 21–65 years. All patients presented with hydronephrosis, two of which were bilateral. Two patients had baseline chronic kidney disease. None received rheumatologic workup or preoperative steroid treatment. Two patients underwent bilateral UL and OW, and two patients underwent unilateral UL and OW. Mean estimated blood loss range was 75–180 cc. There were no intraoperative or postoperative complications. Total length of stay was one postoperative day for three patients and two for one patient. The final pathology was consistent with retroperitoneal fibrosis in all four patients. The mean postoperative followup period was 31 months. All patients had complete resolution of symptoms and had either stable or improved renal function at followup.

Conclusions:

Our surgical approach is unique in that we perform our OW through a mesenteric window rather than lateral to the colon as described by other groups, thereby eliminating the lateral movement and tension on ureter as the colon is reflected back to its usual anatomic position. Our experience with robotic-assisted laparoscopic UL and OW has resulted in no perioperative or long term complications, with excellent outcomes at midterm followup.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S190.

P77: Is robot-assisted radical cystectomy acceptable for locally advanced bladder cancer

Ahmed Hussein 1, Basel Ahmad 1, Justen Kozlowski 1, Justen Kozlowski 1, John Binkowski 1, Amir Khan 1, Khurshid Guru 1

Abstract

Background:

Although cystectomy in the setting of locally advanced bladder cancer may be associated with higher morbidity and worse outcomes, it may be necessary to alleviate local symptoms. We aim to investigate if robot-assisted radical cystectomy (RARC) offers benefit in terms of perioperative outcomes and oncological control.

Methods:

We reviewed our database of 425 RARCs. Patients with locally advanced disease (≥pT3) were subdivided based on the pathologic T and the N stages. Kaplan-Meier method and survival tables were used to compute recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) rates. Cox proportional hazards model were fit to evaluate predictors of survival.

Results:

One hundred ninety-one patients (45%) had locally advanced disease; one-third of them had pT4 disease. No open radical cystectomy was performed in 10 years. Both groups had comparable perioperative outcomes. Patients with pT3N− disease demonstrated the best survival outcomes, while those with pT4N+ demonstrated the worst survival (Table 1, Fig. 1). On multivariable analysis, positive soft tissue surgical margins and pT4 were significant predictors of RFS, CSS, and OS.

Conclusions:

RARC may offer survival benefit in patients with locally advanced disease, especially for patients with pT3 node negative disease.

Fig. 1.

Fig. 1.

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(A) Overall survival; (B) disease-specific survival; and (C) recurrence-free survival of patients with locally advanced bladder cancer classified by pT and pN stages.

Table 1.

RFS, DSS, and OS of patients with locally advanced bladder cancer classified by pT and pN stages

Overall survival (%) Disease-specific survival (%) Recurrence-free survival (%)
1 year 3 years 5 years 1 year 3 years 5 years 1 year 3 years 5 years
pT3N−ve 78 56 50 82 64 58 73 57 57
pT3N+ve 66 32 32 68 47 47 60 49 49
pT4N−ve 79 37 12 79 43 14 46 15 0
pT4N+ve 62 28 0 62 33 0 72 56 0
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S190.

P78: Withdrawn

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S190–S191.

P79: Spinal segmental contribution to pudendal and tibial inhibition of bladder overactivity in cats

Utsav K Bansal 1, Jathin Bandari 1, Bing Shen 1, Zhaocun Zhang 1, Jicheng Wang 1, James Roppolo 1, William de Groat 1, Changfeng Tai 1

Abstract

Background:

As the etiology of overactive bladder (OAB) has largely remained unknown, treating OAB has been a major challenge. Alternative treatments have involved the use of sacral neuromodulation in alleviating OAB symptoms. Both tibial and pudendal nerve neuromodulation have been shown clinically to increase bladder capacity. The purpose of this study was to delineate the spinal segmental contribution of tibial and pudendal nerves, enabling inhibition.

Methods:

Our experiment was conducted using a cat model in which we isolated the tibial and pudendal nerves and exposed the lumbar and sacral roots L5-S3 by performing a laminectomy. Initial bladder capacity was determined based on repeated cystometrograms (CMGs) with saline. An OAB model was created by infusing 0.50% acetic acid. Once a stable bladder capacity was achieved, both tibial and pudendal nerves were stimulated consecutively. The stimulation threshold was defined as the minimal intensity for inducing external anal sphincter or toe twitch and was performed at the beginning of the experiment. After stimulation and control CMGs, spinal dorsal roots from L5 to S3 were transected sequentially. After transection, stimulation was then tested to determine spinal dorsal root contribution to tibial and pudendal nerve inhibition.

Results:

During acetic acid irritation, tibial nerve stimulation (TNS) significantly inhibited bladder overactivity and increased bladder capacity from 100.5±0.4% to 139.4±7.2%; p=0.001 (n=10 cats). Only after tran-section of L7 dorsal root was TNS inhibition eliminated (Fig. 1). Pudendal nerve stimulation (PNS) also significantly increased bladder capacity from 100.5±0.4% to 179.2±14.5%; p=0.002. Transection of the S1 dorsal root partially reduced PNS inhibition (177.1±12.8% to 158.5±15.0%; p=0.002). The inhibition was completely removed following S2 dorsal root transection (Fig. 1).

Conclusions:

Tibial afferents in L7 dorsal root has a major role in the inhibitory effect of TNS on bladder overactivity. In contrast, pudendal afferents in S1 and S2 dorsal roots modulate PNS inhibition on bladder overactivity. As a result, the pudendal afferents rather than tibial afferents might play a role in sacral neuromodulation in overactive bladder.

Fig. 1.

Fig. 1.

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Effect of tibial and pudendal stimulation on bladder capacity pre- and post-transection.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S191.

P80: Role of connective tissue growth factor in epithelial maladaptive repair in renal fibrosis

Alex M Arnouk 1, Rohan Samarakoon 1, Paul Higgins 1

Abstract

Background:

Chronic kidney disease (CKD) affects approximately 14% of U.S. population. Almost all etiologies are associated with renal fibrosis, and the severity of fibrosis correlates with degree of decline in renal function. Effective treatment to halt progression of CKD is largely lacking. Renal tubular expression of connective tissue growth factor (CTGF) is upregulated in various nephropathies. For example, in a mouse model of unilateral ureteral obstruction, increased CTGF expression and renal fibrosis is noted in the obstructed kidney, and pre-treating mice with a CTGF antibody reduces the degree of renal fibrosis. Thus, CTGF is an attractive target for drug therapy since it is considered a causative factor in kidney fibrosis. Precise mechanism of CTGF contribution to the maladaptive phenotype, however, is largely unknown.

Methods:

Human kidney tubular epithelial cells (HK-2) were stably transduced with either control or CTGF expression lentiviral particles to mimic CTGF induction in renal injury. Immunoblot analysis was used to confirm CTGF overexpression and to investigate the effects of CTGF overexpression on various fibrotic factors and de-differentiation markers. Studies on epithelial cell-cell cross-talk were conducted by transfer of conditioned media from control or CTGF expression cells to similarly seeded HK-2 cells. Microscopy was used in evaluation of cell morphologic changes.

Results:

Prolonged epithelial cell CTGF overexpression results in upregulation of pro-fibrotic factors including fibronectin and PAI-1, upregulation of dedifferentiation maker, vimentin, and downregulation of expression of epithelial cell adhesion molecule, E-cadherin, compared to vector transduced controls. Changes in epithelial morphology and suppression of cell count are also accompanied by CTGF overexpression relative to the control cultures. CTGF-derived paracrine factors promote grown inhibition in normal epithelial cells.

Conclusions:

CTGF contributes to the maladaptive fibrotic phenotype via upregulation of various fibrotic factors, induction of epithelial dedifferentiation, suppression of cell growth, and epithelial cell-cell cross-talk. CTGF may be a good drug target in prevention or reduction in renal fibrosis.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S191–S192.

P81: Effects of dietary omega-3 fatty acids on prostate tumor in immunocompetent mouse models

Nikunj Gevariya 1, Alain Bergeron 1, Marjorie Besançon 1, Valérie Picard 1, Karine Robitaille 1, Yves Fradet 1, Vincent Fradet 1

Abstract

Background:

Prostate cancer (PCa) is second most diagnosed cancer in the world. Chronic inflammation is one of the contributing factors to PCa. The potential anti-inflammatory effects of omega (Ω)-3 fatty acids (FA) on PCa tumor microenvironment still remain to be explored. Our objective was to measure the effects of dietary Ω3 vs Ω6 FAs on prostate tumor growth and immune response in androgen-dependent and androgen-independent immunocompetent murine models.

Methods:

C57BL/6 mice were fed with Ω3 or Ω6-enriched diets. After four weeks of diets, androgen-dependent murine prostate tumor cells, 2×10E6 TRAMP-C2 cells were injected sub-cutaneously in all mice. Tumor growth was measured every following day. Mice were sacrificed when the tumor volume reached 2 cm3. Plasma, red blood cells (RBC) and tumors were collected from each mouse at sacrifice. RBCs and tumors FA profiles were determined by capillary gas-liquid chromatography. Plasma and tumor lysate cytokine profiles were determined using Luminex assays. Tumors were dissociated and analyzed for immune cell infiltration by multicolor flow cytometry. To study the effect of Ω3 vs Ω6 on androgen-independent PCa tumor, we repeated a similar experiment in surgically castrated mice.

Results:

Tumor growth was slower in Ω3-fed mice than Ω 6-fed mice in both models. Fatty acid profiles show that dietary FAs get incorporated into RBCs and tumors. Cytokine profile of plasma was not modulated by Ω3-nor Ω6-enriched diet. However, the intra-tumoral immune response was modulated by Ω3-enriched diet as compared to Ω6 in both models. In non-castrated mice, GM-CSF, eotaxin, IL1b, IL13, and MIP-1b were more expressed in Ω3-fed mouse tumors. In castrated mice, eotaxin, IL6, and IL9 were absent, while IL4, IL5, IL10, IL12(p70), MCP-1, MIP-1b, and TNF-α were expressed higher in tumors of Ω3-fed mice. In addition, infiltrating lymphocytes CD4+ and CD8+ were abundant in noncastrated Ω6-fed mice, but none of the CD4+ subtypes were different, indicating that functional status of these cells may be compromised. In castrated mice, CD4+ and CD8+ cells were not differentially infiltrated into tumors of Ω3-fed mice. However, CD4+ cell subtypes CD4+IL10+ and CD4+IL4+ cells were more abundant, indicating that Ω3 help to build a better immune response via Th2 cells in androgen-independent PCa.

Conclusions:

As compared to dietary Ω6, Ω3 could favor a more effective immune response to slow down tumor growth in both, androgen-dependent and -independent PCa.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S192.

P82: A novel live cell diagnostic platform using phenotypic biomarkers for risk-stratifying prostate cancer

David M Albala 1, Kevin B Knopf 2, KImberly M Rieger-Christ 3, Travis B Sullivan 3, Naveen Kella 4, Hani H Rashid 5, Vladimir Mouraviev 6, Michael S Manak 7, Brad J Hogan 7, Gauri Dixit 7, Wendell R Su 7, Delaney Berger 7, Matthew J Whitfield 7, Jonathan S Varsanik 7, Mani Foroohar 7, Stephen Zappala 8, Ashok C Chander 7, Grannum Sant 9

Abstract

Background:

Current prostate cancer (PCa) diagnostics do not risk stratify patients well, leading to overdiagnosis and overtreatment of the disease. A novel risk stratification test using a live cell phenotypic biomarker suite was developed to objectively assess disease aggressiveness and invasive potential of PCa. The risk stratification diagnostic test incorporates matrix biology, phenotypic biomarkers, microfluidics, image analysis, and predictive statistical algorithms that are designed to improve understanding of disease progression and metastatic spread. This technology was developed to stably harvest single cell suspensions from suspect tumor sites and automate biomarker measurements of those cells via image analysis algorithms to generate predictive metrics on adverse pathologies. Data are presented towards clinical validation, the ability to risk stratify, and prediction of local aggressiveness and metastasis.

Methods:

Cancer cells were stably maintained under in vitro optimized conditions that simulate in vivo conditions by using a specialized extracellular matrix (ECM) formulation. Live automated microscopy imaging of the phenotypic biomarkers was established by placing tumor samples in an ex vivo standardized environment using an ECM treated microfluidic device.

Results:

This IRB approved clinical validation study was performed in 300 consecutive PCa radical prostatectomy (RP) derived specimens collected between 03/2014 and 04/2016. Statistical analysis of the data was analyzed with receiver operating characteristics (ROC) generated area under the curve (AUC). The data include capsular penetration, seminal vesicle invasion, as well as margin-positive disease-predictive analysis. The study further demonstrated that a suite of phenotypic biomarkers can be used to produce predictive scores termed local adverse pathology potential (LAPP) and metastatic adverse pathology potential (MAPP). Concordance correlation analysis supports that LAPP and MAPP are integral for distinguishing between cancer cells and non-cancer cells, which sample-wide analysis predicts both stage and adverse pathology such as extra-prostatic extension (EPE) and lympho-vascular invasion (LVI). The study results demonstrate AUCs greater than 0.80 in predicting EPE and LVI.

Conclusions:

Using RP samples with established adverse pathology reports the clinical validation of a novel live-cell phenotypic in vitro tumor diagnostic test was established. This test has the potential to predict adverse pathologies for PCa and may have extended clinical applications to optimize staging and risk stratification.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S192.

P83: Fibrotic response to synthetic midurethral sling mesh in women with complications

Lauren E Tennyson 1, Stacy Palcsey 1, Steve Abramowitch 1, Pamela Moalli 1

Abstract

Background:

The mechanisms of the host-tissue response as it relates to mesh complications have not been well-delineated. The host response to midurethral slings (MUS) has been even less studied. TGF-β is a dominant mediator of fibrotic tissue remodeling that has been well-studied. Further characterization of fibrosis can be gained by analysis of collagen fibers with picrosirius red stain (PSR), where thinner fibers appear green and thicker fibers appear yellow, orange, or red. It has been suggested that green represents type III collagen and yellow, orange and red type I collagen. The purpose of this study was to define and compare pathological fibrosis in patients with synthetic MUS removed for pain vs. exposure.

Methods:

Thirty-three mesh-vagina complexes (exposure, n=20; pain, n=13) were compared to 14 full thickness vaginal biopsies taken at the time of mesh excision from an uninvolved area on the anterior wall (control). TGF- β levels were measured by ELISA immunoassay and histologic comparisons made performed with H&E, Masson’s trichrome, and PSR stains. PSR slides were analyzed under polarized light microscopy by applying custom threshold color filters to quantify areas of red, orange, yellow, and green, consistent with thickness of collagen fibers in the area of mesh fibers. Appropriate statistical analyses were performed.

Results:

Demographic data did not differ between groups. Age was independently associated with TGF-β; decreasing levels were observed with increasing age (p=0.001). TGF-β was higher in mesh-vagina explants compared to control tissue (p=0.004), but was not significantly different between exposure and pain groups (p=0.56). We found a moderate negative correlation with time of implantation (R −0.422; p=0.057). There was significant inflammatory infiltrate at the host-tissue/biomaterial interface on H&E and trichrome stains in both groups. Analysis of PSR slides demonstrated a greater area of green (thin) fibers in the exposure group (p=0.039) and red (thick) fibers in the pain group (p<0.001). We also calculated a ratio of area green/(yellow + orange + red) and found that the mean value was significantly greater in the exposure group (p=0.01). There was a moderate positive correlation between the area of orange (thick) fibers and length of mesh implantation (R 0.504; p<0.02), as well as total collagen and length of implantation (R 0.512; p=0.02), supporting collagen deposition and maturation over time.

Conclusions:

In women with complications, MUS induce an inflammatory tissue response characterized by elevated TGF-β levels, which are also correlated with length of implantation. Patients who had mesh removed for pain had thicker collagen fibers compared to those with exposure, which supports progressive fibrosis as a potential mechanism contributing to pain.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S192–S193.

P84: Liquid buccal mucosal grafting for urethral stricture disease: A preliminary animal study

Jared Manwaring 1, Tiffany Caza 1, Steve Landas 1, Leszek Kotula 1, Dmitriy Nikolavsky 1

Abstract

Background:

We describe a method of treatment of urethral stricture using liquid-suspended buccal mucosal micro-grafts (LBMMG) to augment direct vision internal urethrotomy (DVIU). A rabbit stricture model was used to test this method.

Methods:

In Phase 1, DVIU was performed in three rabbits and augmented by immediate intra-urethral injection of autologous buccal mucosal micro-grafts suspended in fibrin glue. Animals were sacrificed at 2–3 weeks. Their urethras were examined for presence of buccal mucosa engraftment. In Phase 2, strictures were induced in nine rabbits and divided into two groups: 1) treatment with DVIU and LBMMG (six animals) and 2) control with DVIU and injection of fibrin glue (threer animals). Two treated and one control animals were sacrificed at eight, 16, and 24 weeks. Prior to sacrifice, animals underwent retrograde urethrograms (RUG) and urethroscopy. Histologic specimens were examined for presence of buccal mucosal engraftment.

Results:

In Phase 1, two of the three demonstrated engraftment of buccal mucosa within the urethra after injection of LBMMG. In Phase 2, all six treated animals demonstrated engraftment of micro-grafts and showed resolution or improvement of strictures on RUG and on cystoscopy. The control animals had no buccal engraftment and had varying degrees of fibrosis and chronic inflammation. One of the three controls had persistent stricture while the other two showed radiographic and cystoscopic improvement of their strictures.

Conclusions:

This proof-of-concept study demonstrates the feasibility of liquid buccal mucosa micro-graft use for minimally invasive urethral stricture repair. Additional studies are needed to optimize micro-graft preparation and delivery.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S193.

P85: Early oncological failure after robot-assisted radical cystectomy: Results from the International Robotic Cystectomy Consortium

Ahmed A Hussein 1, Matthias Saar 2, Syed Johar Raza 1, John Binkowski 1, Lee Richstone 3, Andrew Wagner 4, Joan Palou Redorta 5, Prokar Dasgupta 6, James Peabody 7, Peter Wiklund 8, Franco Gaboradi 9, Alex Mottrie 10, Alon Weizer 11, Koon-ho Rha 12, Douglas Scherr 13, Ashok Hemal 14, Khurshid Guru 1, Michael Stockle 15

Abstract

Background:

Despite being performed for over a decade with satisfactory early oncologic outcomes, there are still concern regarding the induction of local recurrence and port site metastasis following robot-assisted radical cystectomy (RARC). To our knowledge, no major clinical study evaluating early oncological failure (EOF) with long-term followup has been presented regarding RARC. We attempt to assess the oncological safety of RARC with emphasis on rapid local recurrence and port site metastasis in a multi-institutional cohort.

Methods:

The IRCC database comprising of 1586 patients from 22 institutions in 13 countries performing RARC was queried for EOF. EOF was defined as any presence of rapid local spread disproportional to the primary stage within one month and any port site metastasis after surgery. Additionally, the lead surgeons from each institution were contacted to confirm any reports of early failure. Each incidence was analyzed to identify common variables which may be associated with EOF.

Results:

In the entire database of 1549 patients, EOF was reported in six patients (0.3%). Majority patients were males (90%) with ASA of >3 in 75% of them. Mean age was 67 years (range 42–80 years). No inadvertent spillage of urine was reported. No major postoperative complication was noted in all of the eight patients. All of the patients had high-grade disease, with negative margins, while only two patients had lymphovascular invasion on final histopathology. Additionally, in the database, three cases of port site metastasis were reported (0.15%). All of these patients had >T2 final pathological staging, with 2/12 and 1/8 positive lympho nodes in two cases. Specimen retrieval was performed using the standard lap-bag, without any reported urine spillage. Mean time to port site metastasis was four months (range 3–6 months). Two metastases were in isolation, while one case had additional lung lesions.

Conclusions:

Early oncological failure and port site metastasis are rare but a significant outcome after RARC. Further prospective collection of factors associated with early failure can help in better understanding this rare, yet significant outcome.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S193.

P86: Interrogating exosome miRNA in bladder cancer differential expression by disease status

Ilija Aleksic 1, Winnie Wang 2, Tucker Conklin 2, Greg DiRienzo 2, Badar Mian 1, Martin Tenniswood 2

Abstract

Background:

Exosomes, small membrane-bound vesicles, contain onco-specific cargo implicated in the diagnosis of malignancy. A number of studies have investigated exosome messenger RNA and protein levels in bladder cancer. However, none have interrogated micro RNA (miRNA) in exosomes of bladder cancer. It is postulated that malignant cells have an upregulated production of exosomes with mechanisms to preferentially sort RNA. Exosome miRNA has promising results in other malignancies. miRNAs have shown promising results in bladder cancer, however, not in the context of exosomes. Standard exosome extraction methods involve ultracentrifugation not feasible for the clinical setting. Our objective is to extract RNA from urine exosomes in bladder cancer patients using a commercially available kit and interrogate differential levels of miRNA that distinguish disease status.

Methods:

Urine was prospectively collected from 42 subjects, with 14 positive for bladder tumor on cystoscopy and pathology that is high-grade (HG) in 53.8% and low-grade (LG) in 46.2%. Exosome RNA in urine was extracted using a commercially available kit (Norgen). Total RNA and small length RNA <250 nts, including miRNA, was measured with a Bioanalyzer. Specific miRNA targets were interrogated with Q PCR. An additional 112 miRNA targets were interrogated with open array (Life Sciences).

Results:

Bladder tumor patients had a mean age of 67.0 years (range 35–90), 61.5% male and 37.5% female, while controls had a mean age 67.7 years (range 42–95), 56.5% male and 43.5% female. Total exosome RNA was higher in tumor patients than controls, 36.9 ng/uL vs. 11.2 ng/ uL (p<0.02). In addition, total miRNA concentration was 8.0 vs. 1.1 ng/ uL (p<0.01) in tumor-positive urines vs. controls. In interrogating specific miRNA sequences, miRNA −452, 210, and 10 b were expressed at a lower level in urine exosomes of patients with bladder tumors (p<0.05), with clustering illustrated on target-centric heat map with Pearson’s correlation. Differential expression in urine exosomes of HG and LG tumors was also illustrated, with miRNA 210, 113, and 152 expressed in higher levels in LG than HG and heat map clustering by grade.

Conclusions:

Exosomal RNA can be extracted using a commercially available kit and interrogated for miRNA targets that show difference in expression between patients with and without bladder cancer, and differing pathologies.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S194.

P87: 30-day readmissions: An opportunity for quality improvement and education

Jathin Bandari 1, Timothy S Anderson 1, Aaron Dailey 1, Gregory M Bump 1

Abstract

Background:

Thirty-day inpatient readmissions are costly, common, and variable across institutions, thus they have become a national quality measure for both medical and surgical services, which impact Medicare reimbursement. Our institution is a large integrated delivery system, with over 284 000 annual inpatient admissions across over 20 hospitals. There is no standard protocol for notifying physicians of readmissions (defined as an admission to a hospital within 30 days of a discharge from the same or another subsection of a hospital system). It is unclear how often and through what manner physicians are made aware that inpatients they have cared for have been readmitted.

Methods:

We first identified all patients discharged during the month of August 2015, who were subsequently readmitted within 30 days using The Advisory Board CrimsonTM program to extract patient-level data from our electronic medical records. We limited our study to two medicine services lines (general medicine and cardiology) and two surgical service lines (surgical oncology and urology). Thirty-two attending physicians were surveyed: 12 internal medicine, eight cardiology, four urology, and eight surgical oncology. Seventeen resident physicians were surveyed, including six internal medicine, four cardiology, five urology, and two surgical oncology. Surveys were administered to attending and senior resident physicians caring for patients on the day of initial discharge.

  • Part 1 of the survey consisted of multiple choice questions on preferences on modalities of notification of patient readmissions, goals in being notified, and their practices in notifying other physicians.

  • Part 2 of the survey participants were asked if and how they were notified of patient-specific readmissions after discharge from their service in August.

Results:

Survey response rate was 65% (32/49) with similar rates between medical (20/30 or 66%) and surgical services (12/19 or 63%). Physicians were aware of only 51% of 30-day readmissions with similar rates between surgical and medical services and between attendings and residents. Two-thirds of physicians expressed a preference to be notified of all readmissions. The majority of residents stated that being notified of readmissions would be educationally valuable (11/13). The majority of physicians preferred to be notified by email from the admitting service or an automated system within 24 hours of admission.

Conclusions:

Standardized readmission notifications are desired by physicians for purposes of care delivery and education. In response to this study, our institution’s Center for Quality, Safety, and Innovation will be exploring an automated 30-day readmission notification service across all specialties.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S194.

P88: Acceptability and feasibility of an advanced simulation-based preclinical surgical skills curriculum for medical students

Kevin Tsai 1, Manizheh Eghbali 1, Jennifer Park 1, Gabrielle Santangelo 1, Aisha Siebert 1, Jonathan Stone 1, Ahmed Ghazi 1

Abstract

Background:

Surgical skill training for medical students traditionally occurs in the operating room and can vary greatly in both quality and quantity. Improving meaningful preparation prior to beginning a surgical clerkship should result in enhanced confidence and ability to participate in surgery. Surgical simulation is an effective training platform that is part of most postgraduate surgical education programs. There is a lack of available hands-on surgical simulation models and no studies were found that evaluated the use of advanced surgical simulation for medical student presurgical education.

Methods:

We developed a preclinical medical student surgical skills curriculum using advanced polymer hydrogel models to test feasibility and assess usefulness. First- and second-year medical students at our institution completed a survey to determine prior exposure to surgical skills training/simulation and the need for a formal pre-surgical curriculum. Sixteen second-year medical students were randomly selected from a larger pool of volunteers and completed a six-week elective, rotating through open, laparoscopic, endoscopic, and robotic surgical simulations. A final project included a simulated surgery using predeveloped hydrogel simulations (transurethral resection of bladder tumor, robotic partial nephrectomy, robotic myomectomy and open carotid endarterectomy) and a presentation of the indications, techniques and complications. Participants were surveyed weekly and on completion of the elective to assess satisfaction and confidence in the operating room.

Results:

A total of seventy-eight first- and second-year medical students completed a needs assessment survey which identified that most students had either limited or no prior exposure to surgical skills training, surgical simulation, instrument handling/knot-tying, and sterile technique. Most students felt that medical schools should offer preparation for the surgical clerkship (93.6%) and that this should be conducted as a formal curriculum in the preclinical years (88.3%). 79.5% would participate in a preclinical surgical elective if available. In a post-elective survey, most participants felt that a hands-on, simulation-based curriculum increased their confidence and familiarity performing a complete simulated procedure requiring advanced surgical skills and increased confidence in skills required for third-year surgical clerkships.

Conclusions:

While the role of surgical simulation in postgraduate surgical education is well-established and continues to expand, our study suggests that a simulation-based advanced surgical curriculum is both feasible and desired at the medical student level.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S194–S195.

P89: An interview day surgical simulation session: A burden or blessing in disguise?

Kevin Tsai 1, Jennifer Park 1, Jonathan Stone 1, Ahmed Ghazi 1

Abstract

Background:

While not mandated by the ACGME for urology postgraduate training, surgical simulation is an established training platform that is voluntarily integrated into the curriculum of many programs. Following the establishment of a Simulation Center for Advanced Surgical Training (Sim-CAST) by our department, prospective candidates participated in a surgical simulation workshop incorporated into the interview day. We tested the feasibility of conducting a simulation session during the interview day and assessed our candidates’ impressions of partaking in a simulator session.

Methods:

Fourteen of 22 urology residency applicants visiting our institution during the 2015 application cycle were scheduled in 30-minute rotating blocks between morning faculty interviews to spend in Sim-CAST. Applicants rotated in groups of two between endoscopic, laparoscopic and robotic simulator stations to complete supervised, standardized, task-based exercises. Applicants responded to a survey upon completion of the interview day requesting information about prior exposure to surgical skills training/simulation, importance of simulation in residency training, influence of simulation on choice of residency program, and whether the session interrupted the interview day. Additional feedback was obtained from open-ended responses regarding the simulation experience. Applicants were not graded and our data was not used for the purposes of applicant ranking. Admissions committee members were blinded to all data collected.

Results:

Our results revealed that half of surveyed applicants had prior exposure to surgical skills training and surgical simulation. All felt that surgical simulation should be an integral part of urology residency training and most agreed that the presence of a simulation lab would influence their choice of residency program. 93% of surveyed applicants felt that the simulator session did not disrupt the interview day. Open-ended responses revealed an unintended effect of reducing stress involved with the interview day.

Conclusions:

Urology residency applicants are interested in the availability of surgical simulation as part of a training curriculum. The presence of a dedicated simulation space positively influenced our candidates’ selection of a residency program. We acknowledge that the potential for responder bias exists. Our results suggest that a simulation session can be feasibly incorporated into an interview day to highlight a urology program’s simulation resources and possibly reduce interview day stress.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S195.

P90: Can surgical mentor’s mind become the key to trainee performance?

Somayeh B Shafiei 1, Ahmed A Hussein 2, Justen Kozlowski 2, Youssef Ezz 2, Thomas Fiorica 2, Sanna Raheem 2, Khurshid A Guru 2

Abstract

Background:

Cognitive metrics may provide valuable, real-time and objective assessment of surgical training. We used cognitive metrics to evaluate the degree of satisfaction of a mentor surgeon with trainee while performing robot-assisted surgery (RAS).

Methods:

We recorded the brain activity of a master robotic surgeon while mentoring trainees during RAS, while simultaneously assessing his satisfaction with their performance using a validated National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire. Technique: electroencephalogram (EEG) recording was done using 24-channel wireless EEG recording equipment. EEG data from each channel was processed at 256 samples/sec. EEG features assessed were: mental workload, eye-blink duration, frustration, aiming period, and high-level engagement. Statistical analysis: EEG features associated with mentor satisfaction were identified using three SVM classifiers, the linear, the polynomial, and the radial basis function kernel (RBF). Additionally, the leave-one-out cross- validation (LOOCV) method was used to evaluate the accuracy of these parameters in determining mentor’s satisfaction. Data was analyzed using matrix laboratory (MATLAB) environment (Math Works Inc., Natick, MA, USA).

Results:

Fifteen pelvic lymph node dissections (pLNDs) and 29 urethrovesical anastomoses (UVAs) were included. Mental workload, eye-blink duration and frustration were the most significant features in discriminating mentor satisfaction of trainee’s performance for pLND (93% accuracy) and UVA (93% accuracy) (Fig. 1).

Conclusions:

We found that cognitive characteristics of mentor (mental workload, eye-blink duration, and frustration) allowed determining his satisfaction level with the surgical performance. This study opens new horizons for surgical skills assessment in a real-time, objective fashion.

Fig. 1.

Fig. 1.

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Linear (blue), polynomial (green), and RBF (red) SVM classifiers applied on first two principal components of all selected features in LND task (Panel A) and UVA (Panel B). LOOCV showed accuracy of 93.3% for pLND and 93.1% for UVA.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S195–S196.

P91: Effective handover and challenges in implementation: A quality improvement project

Douglas C Cheung 1, Alexandra L Millman 1, Imraan Nagdee 1, Lex Wei 1, Martin A Koyle 1

Abstract

Background:

Effective handovers are important components of patient care. Numerous studies demonstrate a clear association between the quality and quantity of handover information, and patient care outcomes. Because missing, inaccurate information can result in deleterious outcomes, most handovers include a structured tool to ensure vital information is communicated. Current data have focused on the information and communication in handover. However, few studies address the difficulty implementing a new handover system, in particular, optimizing the framework for successful stakeholder engagement. Herein, we report on the introduction of a pilot handover system.

Methods:

A new system for urology resident handover was implemented at two institutions in Toronto, from July 2015 to April 2016. The primary outcome was handover information inclusion rate (IIR) assessed on a nine-item scale prior to, and at two time-points after introducing the structured handover. Handover items were decided through stakeholder meetings, including: patient name, age, responsible physician, postoperative day, diagnosis, medical history, active issues, diet, and discharge planning. Incomplete fields were considered negative responses. Results were analyzed using descriptive statistics. Secondary outcomes assessing satisfaction with handover and subjective improvement of handover communication were anonymously collected and graded on five-point Likert scale to rate handover experience.

Results:

At one institution (A), the new handover system had strong uptake and utilization. However, the other institution (B) failed to adopt the handover system. At institution A, the original handover achieved an IIR of 63% of handover items prior to the introduction of the handover by a chief resident. Handover continued to be used throughout the study period, even as residents joined and left the team. By the end of our study, institution A improved to an IIR of 80% (Table 1). Satisfaction with the document was 4.0/5. Most residents felt that the system had improved (4.2/5). The most common area for improvement was handover length to better highlight active issues for a high turnover service (urology). At institution B, the handover system was introduced by a junior resident and had reverted to a verbal, non-documented system within two days of attempted initiation. The IIR at site B remained stagnant at 42%.

Conclusions:

Effective handover checklists have been described, but stakeholder buy-in remains a challenge. Handover quality improved with the use of a structured tool, but was subject to its utilization. Further research correlating these findings with patient outcomes is required.

Table 1.

Information inclusion rate following handover

Patient factor Institution A – Prior to introduction Institution A – Following introduction Institution B
Name 100% 100% 92%
Age 45% 90% 0%
Responsible staff physician 95% 100% 8%
Postoperative/admission day 69% 85% 8%
Diagnosis/procedure 83% 100% 100%
Past medical history 20% 54% 0%
Active issues 76% 100% 83%
Diet 31% 44% 42%
Discharge planning 46% 50% 42%
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S196.

P92: Patients’ knowledge of their prostate cancer profile: Do provider communication strategies matter?

Kyle Plante 1, Telisa Stewart 1, Elias Hyams 2, John Seigne 2, Gennady Bratslavsky 1, Margaret Formica 1

Abstract

Background:

Treatment decisions for localized prostate cancer patients depend on unique clinical factors, such as Gleason score and cancer stage. Prostate cancer patients’ knowledge and understanding of their clinical information has not been well-documented in the literature. The current research seeks to explore patient knowledge and understanding of personal Gleason score and cancer stage and to assess the impact of provider communication methods and the use of a treatment decision aid (video).

Methods:

Men with localized prostate cancer who received care from 2007–2013 at Dartmouth-Hitchcock Medical Center Oncology clinics were included in the study (N=411). All subjects received an information packet regarding prostate cancer, types of treatment, and a video decision aid. Provider communication methods prior to the initial clinical oncology encounter (ICOE) were identified. One method included both a phone call and a personalized letter with the patient’s unique cancer profile, while the second method provided no prior personal communication. As part of standard of care, all patients completed a survey before their ICOE that included questions about demographics, Gleason score, Gleason score meaning, cancer stage, cancer stage meaning, and the video. Chart reviews confirmed clinical pathology. Chi-square tests and logistic regression were used to compare correctly reported information about Gleason score and cancer stage across groups.

Results:

Overall, subjects who correctly reported their Gleason score, Gleason score meaning, cancer stage, and cancer stage meaning were 64.0%, 54.5%, 31.4%, and 32.6%, respectively. Thirty-five percent of subjects received the personalized communication method. Subjects who received personalized communication were more likely to correctly report their Gleason score (p<0.0001), cancer stage (p<0.0001), and cancer stage meaning (p=0.048) compared to those who did not receive personalized communication. In multivariable models, subjects who watched the video were more likely to correctly report their Gleason score (OR 2.11, 95% CI 1.31–3.41) and cancer stage (OR 2.0, 95% CI 1.18–3.37). Subjects who received personalized communication were also more likely to correctly report their Gleason score (OR 2.72, 95% CI 1.61–4.60) and cancer stage (OR 2.84, 95% CI 1.73–4.66).

Conclusions:

Subjects who received personalized communication about their clinical profile and those who reported watching the video are more knowledgeable about their Gleason score and cancer stage information. These findings indicate that a more personalized communication method along with a decision aid may help patients better understand the clinical information about their prostate cancer, which may influence patient counseling and have implications for treatment decisions.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S196–S197.

P93: Positive vs. negative intraoperative surgeons’ leadership: Which behaviors have greatest impact on surgical team performance?

Michael Di Lena 1, Julian Barling 2, Amy Akers 2, Darren Beiko 1

Abstract

Background:

Most leadership research to date has focused on the effects of a single type of leadership — most commonly transformational leadership — despite the importance of negative effects of passive leadership, abusive supervision, and over-controlling leadership. The purpose of this study was to examine the simultaneous effects of these four different leadership behaviors by surgeons on surgical team performance. We hypothesized that transformational leadership behaviors have a positive influence on surgical team performance and abusive supervision, passive and over-controlling leadership negatively affect team performance.

Methods:

Trained observers attended randomly selected operations at a single large teaching hospital and recorded instances of transformational leadership, passive leadership, abusive supervision, and over-controlling leadership behaviors enacted by the surgeon. Postoperatively, all team members — scrub nurses, circulating nurses, anesthesiologists, anesthesiology residents, surgeons, and surgery residents — completed validated questionnaires rating psychological safety and collective efficacy. To test our hypotheses, multiple regression analyses were computed with psychological safety and collective efficacy as separate outcome variables. Potential confounders, such as age, gender, ASA rating, and surgeon-rated complexity were controlled statistically before the effects of the different leadership behaviors were examined. The sample included repeat surgeons, so in order to account for the higher-level variance in all models, the “complex” modeling option in Mplus was used to control for a possible leader effect.

Results:

A total of 150 (126 elective, 24 emergency) operations were studied, including 20 urology cases. Surgeons’ abusive supervision was negatively associated with psychological safety (unstandardized b=−0.352; p<0.01). There were no significant associations between the other three leadership types and psychological safety (p>0.05). Both surgeons’ abusive supervision (unstandardized b=−0.237; p<0 01), and over-controlling leadership (unstandardized b=−0.230; p<0.05) were negatively associated with collective efficacy. Neither transformational leadership nor passive leadership were linked with collective effective.

Conclusions:

Analysis of surgeons’ intraoperative leadership behaviors showed that transformational leadership behaviors did not positively influence team performance. Significant effects only surfaced for negative leadership behaviors. Surgeons’ intraoperative negative leadership behaviors appear to suppress the effects of transformational leadership behaviors. These findings highlight the need to go beyond an examination of single leadership behaviors in isolation. Since surgeons enact more than one type of leadership, characterization of surgeons in terms of one leadership style (e.g., a “transformational” or “abusive” surgeon) is likely inaccurate. Educating surgeons about both positive and negative leadership behaviors offers the opportunity to enhance intraoperative team performance.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S197.

P94: Prospective, comparative evaluation of adult urologic consultation in an American and a Nigerian academic institution

Alexandra Rehfuss 1, Matthew Bruha 2, Alex Arnouk 1, Oluwaseun Akinola 3, Charles Welliver 1

Abstract

Background:

Urological consultations at academic medical centers can occur at unpredictable times and can cover a variety of urologic problems. Data has previously been reported on urologic consultations in the pediatric population, but there have not been attempts to quantify or qualify adult urologic consultations. This information may impact residency curriculum, call coverage and resource allocation. Lagos, Nigeria is the most populous city in Nigeria, but has a poorly structured healthcare system. Unfortunately, more than 50% of people live below the poverty line. Our primarily goal was to compare consultation patterns between two hospitals that share similar functions in their respective healthcare systems, but differ significantly with regards to location and patient access to resources. Therefore, we analyzed requested consults at two tertiary care teaching hospitals, one in the U.S. and one in Nigeria.

Methods:

Prospective, consecutive adult (>18 years old) urologic consult data from May 2015 through the end of September 2015 at both Albany Medical Center in Albany, NY and Lagos State University Teaching Hospital in Lagos, Nigeria were recorded. Identical surveys were completed by the urology resident who received the consultation. Reason for consultation, location of consult (floor, ER, ICU), date and time of consult, and patient demographics were recorded.

Results:

Over five months, 499 U.S. (3.3/day) and 145 Nigerian (0.95/day) adult urologic consults were requested. Mean age was similar between populations and majority of consultations were for male patients (Table 1). In both geographic locations, the most common overall reason for consultation was urinary retention. 29% of Nigerian consults were for cancer (only 3% in U.S.). In the U.S., the majority of consults were generated on the floors; in Nigeria the majority came from the emergency room. Almost half of all Nigerian consults were seen by the on call night resident (consult after 5:00 pm).

Conclusions:

Overall, urinary retention is the most common reason for consultation, regardless of location. Furthermore, less than half of consults for catheter placement were considered difficult. Therefore, resources for managing retention should be readily available and nurses should receive formal education on catheter insertion. Nigeria sees many more consults for cancer than the U.S. This is largely due to lack of easy access to routine or preventative medical care in this densely populated city.

Table 1.

Albany, NY, US Lagos, Nigeria
Total number of consults 499 145
Mena age (years) 59 57
Male:female (%) 71:29 93:7
ER/floor/ICU(%) 39/50/9 63/34/3
Time of day (day:night, %) 70:30 51:49
Overall most common reasons for consult Urinary retention (17%) Urinary retention (26%)
Hematuria (15%) Cancer (17%)
Urolithiasis (14%) Hematuria (14%)
Most common ER consults Urolithiasis (23%) Urinary retention (33%)
Trauma (17%) Cancer (13%)
Hematuria (12%) Trauma (12%)
Most common floor consults Urinary retention (26%) Cancer (29%)
Hematuria (16%) Already placed Foley/stent (18%)
Hydronephrosis/solid mass (16%) Urinary retention (17%)
Consult for catheter placement 48 (10%) 22 (16%)
Attempt before urology called 40 (83%); Nurse 35 (87%) 13 (59%); Nurse 0
Difficult placement per resident 20 (42%) 9 (41%)
Cystoscopy required 6 (12%) 0
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Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S197–S198.

P95: Quality of administrative studies in urology: A review

Justin Kwong 1, Blayne Welk 1

Abstract

Background:

Administrative data is a powerful tool for researchers. Using this data to conduct studies is often rapid, cost-efficient, and population-based. In urology, the use of administrative databases for research has grown substantially over the last several years. However, there are important aspects of these administrative data studies that should be considered in judging their quality and validity. In 2015, the REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) checklist was published as a guideline to improve the reporting of administrative data studies. Using the RECORD checklist as a guideline, we assessed the current status of administrative studies in the urologic literature.

Methods:

We manually identified all administrative data studies published in Journal of Urology (J Urol) and European Urology (EU) in 2014. Data from J Urol and EU were combined, representing a cross-section of the urologic literature from two well-respected journals. Using the RECORD checklist, we assessed the level of reporting of each administrative data study. Data was summarized using descriptive statistics.

Results:

Of 608 articles reviewed, 57 administrative data studies were identified (41 J Urol, 16 EU). The subject area where the majority of articles were published was cancer (61.4%) and the majority of senior authors were from the U.S. (75.4%). On average, J Urol and EU articles reported 53.7% of all items on the RECORD checklist. Among all checklist items, J Urol and EU articles most consistently reported the study time frame (94.7%) and extent to which the authors could access the population database (86.0%). Few articles explained data linkage (0.0%) or discussed data cleaning (1.8%).

Conclusions:

To our knowledge, this is the first study to quantify and assess the current status of administrative data studies in the urologic literature. Our review indicates specific areas that should be considered for those reading or reviewing studies based on administrative data.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S198.

P96: Reducing same-day OR delays and cancellations using the model for improvement

Martin A Koyle 1, Megan Saunders 2, Melyssa Stoute 2, Vannessa Chin 2

Abstract

Background:

Delays and cancellations in the operating room (OR) are both costly and inconvenient. In our institution, >20% of first cases do not start on time or are cancelled. We hypothesized that patient-related factors (PF), rather than systems factors (SF) were primarily responsible for OR delays and cancellations. In an effort to reduce them, we employed the “model for improvement” (MFI) in an attempt to reduce these occurrences.

Methods:

The MFI uses plan-do-study-act (PDSA) cycles in order to promote continuous process improvement (CPI). A series of such cycles were instituted, in particular increasing NPO by an additional hour and having the patient arrive one hour earlier than usual protocol to assess their impact on cancellations and on time first case starts.

Results:

Delays prior to this initiative were found to be primarily related to SFs, while cancellations were almost always PF in etiology (illness>NPO). After changing NPO and arrival instructions, 13/14 (92%) consecutive days started at or before scheduled starting time, while the last one started within 15 minutes of schedule. 100% of 67 consecutive patients were NPO compliant. Of these patients, three cancelled same day due to a change in their decision, not other factors. Importantly, all 67 families surveyed were satisfied with revised NPO and arrival instructions and nursing touchback identified that they were well-understood. Stakeholder engagement, however, was complex and demonstrated polarity within different components of the care team.

Conclusions:

With healthcare costs and value being increasingly scrutinized, Lean/Six sigma and the MFI have been increasingly used to promote CPI. Although CPI in OR start times occurred in our study, this may be due to “Hawthorne effect”, as this series involved a single surgeon. As a result, PDSAs are ongoing with expansion of this methodology to all surgeons. In addition, studying changes in OR booking and scheduling, enhancing patient and family education and buy-in, are ongoing in order to further improve OR efficiency and maximize use, and assess whether our interventions are sustainable. Silos and inherent institutional culture represent formidable obstacles.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S198.

P97: Robotic surgical skills acquisition in trainees: A randomized comparison of the two robotic trainers and trainees’ skills transfer to a 3-D printed simulated surgical task in the operating room

Yanbo Guo 1, Nathan C Wong 1, Jen Hoogenes 1, Badr Alharbi 1, Saahil Vij 1, Kevin Kim 1, Elisa Bolognone 1, Bobby Shayegan 1, Edward Matsumoto 1

Abstract

Background:

Technical ability is essential to surgical competency. With competency-based education on the horizon, there is a growing need for more objective evaluation methods for teaching surgical skills. Two virtual reality robotic surgical simulators are currently available, both of which emulate the da Vinci Surgical Robotic system. We developed a rigorous training curriculum using the dV-Trainer and the da Vinci Surgical Skills Simulator (dVSSS), which both use the same software and objective metrics. We aimed to determine whether skills acquired on these two simulators transfer to performing an urethrovesical anastomosis (UVA) on a high-fidelity 3-D printed bladder model in the operating room using the da Vinci robot.

Methods:

Medical students (MS) and junior residents (JR) (year 1–3) were recruited at our university through program directors via email. Participants were randomized to conduct their simulator training sessions on either the dV-Trainer or dVSSS. All participants completed the identical curriculum: “Thread the ring,” “Knot the ring,” and “Tubes.” Each participant did warm-up exercises and performed each task three times. They then watched a video of a live UVA and subsequently performed in on the high fidelity model. Pre- and post-training surveys were collected. Scores from the simulators (out of 100) were obtained from the software and three robotic surgeon at our center independently evaluated videos and final end product of the UVA in accordance to previously validated scoring systems (GEARS [/25] and RACE [/25]). All analysts and evaluators were blinded.

Results:

A total of 26 participants (11 MS and 15 JR) were recruited and equally randomized to the dV-Trainer and dVSSS. Mean age was 25.5 and 53.8% were females. The average “Tubes” score for the dV-Trainer and dVSSS were 10/100 and 48.5/100 respectively. Scores of MS and JR were similar (p=0.36). GEARS scores of participants who initially used the dVSSS compared to the dV-Trainer were significantly higher (21/25 vs. 17.2/25, p=0.04). Similarly, RACE scores of participants who used the dVSSS were also significantly higher compared to the dV-Trainer (23.2/25 vs. 17.8/25, p=0.02). Scores of MS and JR were similar for GEARS (p=0.50) and RACE score (p=0.57). Intraclass correlation coefficient for the GEARS and RACE scoring were 72.6 and 89.3 respectively.

Conclusions:

The dVSSS trainer lead to superior scores in performing UVA in the OR for both MS and JR compared to the dV-Trainer. The dVSSS can be used to improve teaching in surgical trainees in a safe and effective manner.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S198–S200.

P98: Simulation-based mastery learning using deliberate practice demonstrates surgical skills resistant to decay

Aisha L Siebert 1, Ravie Abozaid 1, Ahmed Ghazi 1

Abstract

Background:

Many institutions have optimized simulation-based training by incorporating deliberate practice (DP) protocols. We previously demonstrated that, medical student, simulation-based deliberate practice achieved equivalency to senior urology resident real-time training. Such acquired skills, especially if rarely used in clinical practice, may deteriorate over time in the absence of ongoing simulator training, and trainees may lack the appropriate skill when called to perform in the operating room. Mastery learning is a rigorous form of competency-based education where skills are measured against high achievement standards. We report our experience with skill retention following a simulation-based, deliberate practice skills curriculum utilizing expert-based mastery level proficiency benchmarks.

Methods:

13 medical students without prior surgical experience completed a simulation-based, deliberate practice skills curriculum on the da Vinci surgical skills simulator. Students trained with expert feedback to mastery level proficiency benchmarks (average overall score + time and economy of motion scores of four experts + no critical errors). Following training, students were evaluated for retention of mastery levels in four curriculum-based tasks (peg board 2, camera and clutch 2, ring walk 2, and suture sponge 3) and baseline scores in two evaluation tasks (tubes and ring rail 3) at six months, and 18 months post-training.

Results:

Mastery learning resulted in 100% skill retention in overall score in three of four curriculum based tasks (camera and clutch 2, peg board 2, and ring walk 2), and 75% retention in the remaining task (suture sponge 3). There was a slight, but statistically insignificant increase in overall score for evaluation-based tasks (tubes, ring rail 3). We found no significant change in overall score (p=0.3157), time (p=0.6970), and economy of motion (p=0.0547) for all six exercises across post-training evaluation, six and 18 months followup assessments [two-way ANOVA]. Training to mastery required an average of 16 hours and 26 repetitions per student. Time on the simulator following training of all 13 students was <5 hours total over the 18-month followup period.

Conclusions:

Simulation-based mastery learning using deliberate practice results in effective and durable retention of skills even in the absence of practice for up to 18 months. This is the first report of long-term skill retention following a virtual reality, surgical simulator-based training curriculum in novice learners.

Fig. 1.

Fig. 1.

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Summary statistics (mean ± standard deviation) of total score, time, and economy of motion by evaluation time (post-training, 6-, and 18-month followup).

Table 1.

Summary statistics of total score, time, and economy of motion show no significant difference by evaluation time (post-training, 6- and 18-month followup)

Total Post-training 6-month 18-month
Mean SD N Mean SD N Mean SD N
Camera & clutch 2 96.0 1.0 13 95.1 2.7 8 95.4 3.0 12
Peg board 2 97.6 4.6 12 97.6 3.3 8 96.6 3.9 12
Ring walk 2 99.4 1.2 13 99.1 1.1 8 98.5 1.8 11
Suture sponge 3 96.7 7.5 13 90.4 6.8 8 87.3 11.4 12
Tubes 84.9 7.4 16 80.2 14.2 8 84.1 15.5 12
Ring rail 3 87.6 7.9 16 90.6 7.7 8 90.2 9.6 12
Time Post-training 6-month 18-month
Mean SD N Mean SD N Mean SD N
Camera & clutch 2 65.1 8.4 13 78.9 19.8 8 61.9 13.0 12
Peg board 2 69.0 18.6 12 74.2 8.5 8 73.1 16.5 12
Ring walk 2 80.7 14.1 13 78.2 16.2 8 77.0 18.3 11
Suture sponge 3 211.6 36.2 13 215.8 44.1 8 220.0 66.0 12
Tubes 204.8 30.6 16 226.1 88.8 8 216.1 61.8 12
Ring rail 3 222.6 59.8 16 168.9 36.5 8 172.7 48.4 12
EOM Post-training 6-month 18-month
Mean SD N Mean SD N Mean SD N
Camera & clutch 2 216.6 14.9 13 210.4 19.9 8 214.3 25.2 12
Peg board 2 204.5 46.5 12 211.3 27.0 8 217.6 36.6 12
Ring walk 2 161.2 25.6 13 169.4 14.3 8 175.5 48.6 11
Suture sponge 3 251.2 29.8 13 277.6 38.0 8 275.5 49.9 12
Tubes 294.6 74.3 16 366.7 67.9 8 339.5 72.7 12
Ring rail 3 341.0 51.2 16 334.5 39.1 8 340.7 55.5 12
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EOM: economy of motion; SD: standard deviation.

Footnotes

Funding by the da Vinci surgical skills simulator was provided through the Intuitive Surgical Standalone Simulator Loan program

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S200.

P99: Streamlining surgical instrumentation-reducing and standardizing for pediatric inguinal hernia repair (PIHR)

Martin A Koyle 1, Naif AlQarni 2, Louis Konstant 2, Ross Baker 3

Abstract

Background:

Attempts to reduce costs by reducing waste and maintaining or improving quality are paramount in today’s healthcare arena. Unnecessary instruments in surgery have been shown to be costly to the system. Pediatric inguinal hernia repair (PIHR) is one of the most common procedures performed in pediatric urology/surgery (PU/PS) and in our institutional culture, each surgeon had his/her own reference card. Our goal was to create a single preference card for PIHR for 14 surgeons which reduced total instruments in a nine-month period

Methods:

Using LEAN methodology, we observed instrument use for PIHR in at least two cases per surgeon, and after doing so, compiled a single instrument tray that comprised only of instruments that were used in >50% of cases. Surveys of operating room (OR) nurses and all PU/ PS were performed prior to and then three months after the trays were assembled. Tray weights and sterilizing times (ST) for PU and PS PIHR sets were measured before and after the intervention.

Results:

Pre-intervention PS and PU instrument trays for PIHR were comprised of 51 and 96 instruments, with weights of 13.5 and 11.2 lbs, respectively. On average, 16 instruments were used in a single PIHR/surgeon. Final instrument tray contained 28 instruments and weighed 8 lbs. ST was reduced to five minutes from 11 minutes in PU and 7.67 minutes in PS. There was virtually universal consensus by nursing and surgeons that standardization improves patient care, OR efficiency, reduces cost, does NOT compromise safety, and should be expanded to other procedures.

Conclusions:

The concept of instrument standardization can be accomplished using LEAN and is well-accepted by both OR nursing and surgeons. This results in cost and ergonomic benefits due to reduced ST and tray weights.

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S200.

P100: Withdrawn

Can Urol Assoc J. 2016 Sep 5;10(9-10Suppl4):S200.

P101: Utilization of race for evaluation of surgical competency during UVA

Justen Kozlowski 1, Ahmed A Hussein 1, Mohamed Sharif 1, Youssef Ezz 1, Thomas Fiorica 1, Sana Raheem 1, Khurshid A Guru 1

Abstract

Background:

Urethravesical anastomosis (UVA) is a challenging and critical step during robot-assisted radical prostatectomy (RARP). Robotic anastomosis competency evaluation (RACE) was used to evaluate the progress of a surgical trainee while performing UVA.

Methods:

Fifteen UVAs were performed during RARP over one-year fellowship. RACE evaluations in addition to the proportions of the UVA performed were recorded. Patient continence at six weeks and six months (defined as the number of self-reported absorbent pads/day), and UVA-related complications were also recorded for the 15 patients. Effect significance was determined using linear regression analysis.

Results:

RACE showed significant improvement over the length of the study (p=0.13) (Fig. 1). There were no reported UVA-related complications and no significant correlation between RACE score and continence (p=0.41) (Fig. 2). The trainee began by performing only the anterior portion of the UVA before eventually advancing to performing the posterior plate of the UVA.

Conclusions:

RACE can be used as an objective measure of surgical performance during training. Self-reported urinary continence did not worsen with performance of trainee in UVA.

Fig. 1.

Fig. 1.

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RACE scores over time. N=15 surgeries over 170 days.

Fig. 2.

Fig. 2.

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Continence by RACE scores. N=30 followups. RACE scores are between 0 and 30.

Articles from Canadian Urological Association Journal are provided here courtesy of Canadian Urological Association

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