A. Budía

Evaluation of a severity score to predict the prognosis of Fournier's gangrene.

Study Type – Prognosis (case series)
Level of Evidence 4

Costes y procesos hospitalarios en un servicio de urología de un hospital terciario. Análisis de los grupos relacionados por el diagnóstico

INTRODUCTION The health care system has management tools available in hospitals that facilitate the assessment of efficiency through the study of costs and management control in order to make a better use of the resources. OBJECTIVE The aim of the study was the calculation and analysis of the total cost of a urology department, including ambulatory, hospitalization and surgery activity and the drafting of an income statement where service costs are compared with income earned from the Government fees during 2014. MATERIAL AND METHODS From the information recorded by the Economic Information System of the Department of Health, ABC and top-down method of cost calculation was applied by process care activity. The cost results obtained were compared with the rates established for ambulatory and hospital production in the Tax Law of the Generalitat Valenciana. The production was structured into outpatient (external and technical consultations) and hospital stays and surgeries (inpatient). RESULTS A total of 32,510 outpatient consultations, 7,527 techniques, 2,860 interventions and 4,855 hospital stays were made during 2014. The total cost was 7,579,327€; the cost for outpatient consultations was 1,748,145€, 1,229,836 Euros for technical consultations, 2,621,036€ for surgery procedures and 1,980,310€ for hospital admissions. Considered as income the current rates applied in 2014 (a total of 15,035,843€), the difference between income and expenditure was 7,456,516€. CONCLUSIONS The economic balance was positive with savings over 50% and a mean adjusted hospitalization stay rate (IEMAC) rate of 0.67 (33% better than the standard). CMA had a favorable impact on cost control.

Fitoterapia en Urología. Evidencia científica actual de su aplicación en hiperplasia benigna de próstata y adenocarcinoma de próstata

OBJECTIVE To evaluate the usefulness of phytotherapy in the treatment of the benign prostatic hyperplasia (BPH) and prostatic adenocarcinoma (ADCP). ACQUISITION OF EVIDENCE Systematic review of the evidence published until January 2011 using the following scientific terms: phytotherapy, benign prostate hyperplasia, prostatic adenocarcinoma, prostate cancer and the scientific names of compounds following the rules of the International Code of Botanical Nomenclature. The databases used were Medline and The Cochrane Library. We included articles published until January 2011 written in English and Spanish. We included studies in vitro/in vivo on animal models or human beings. Exclusion criteria were literature not in English and Spanish or articles with serious methodological flaws. SYNTHESIS OF THE EVIDENCE We included 65 articles of which 40 met the inclusion criteria. BPH: the most studied products are serenoa repens and pygeum africanum. There are many studies in favour of the use of phytotherapy but its conclusions are inconsistent due to the small number of patients, the lack of control with placebo or short follow-up. However the use of these products is common in our environment. ADCP: there is no evidence to recommend phytotherapy in the treatment of the ADCP. There are works on prevention but only at experimental level so there is no evidence for its recommendation. CONCLUSIONS The scientific evidence on the use of phytotherapy in prostatic pathology is conclusive not recommend ing the use of it for BPH or the ADCP.

Comparison of Extracorporeal Shock Wave Lithotripsy versus Ureteroscopy Holmium Laser Lithotripsy in the Management of Ureteral Stones: A Cost-effectiveness Analysis

Objective: To determine the better cost-effective treatment strategy for ureteral stones in a health district of Eastern Spain. Methods: A total of 180 patients were treated between June 2012 and December 2013 for ureteral stones using two different strategies (SWL as initial treatment and URS as rescue technique vs URS and laser lithotripsy (up to 2 procedures). We performed an economic evaluation through a cost effectiveness analysis comparing costs and outcome. We performed a differentiating model in patients with lithiasis less than 1 cm or equal to or larger than 1 cm. The effectiveness parameter was the stone free rate (SFR), defined as the absence of lithiasis fragments or the presence of clinically insignificant residual fragments (CIRFs) - less than 3 mm at the 3 month follow up. A decision tree was developed and a Monte Carlo simulation was performed to establish uncertainty. Results: The SWL as first line was equally or more effective and cheaper than URS as first line of treatment for ureteral stones regardless of location or size. The overall cost for SWL (plus URS as second line) was 1,445,86 € and its SFR was 99.7%, and 2,369,21 and 97.62% for URS group. After the Montecarlo sensitivity analysis, the SWL showed dominance or cost-effectiveness in the vast majority of times, for each position and size. Conclusions: SWL as first line of treatment was more efficient in terms of cost effectiveness than first line URS with Ho: YAG laser lithotripsy for ureteral stones. Given its level of stone clearance, a non-invasive, outpatient based treatment like lithotripsy should remain the first-line treatment option for ureteral stones

Fitoterapia en Urología. Evidencia científica actual de su aplicación en urolitiasis, dolor pélvico crónico, disfunción eréctil e infecciones urinarias

OBJECTIVE To assess the usefulness of phytotherapy in urolitiasis, urinary tract infections, erectile dysfunction (ED) and chronic prostatitis/chronic pelvic pain (CP/CPP). ACQUISITION OF THE EVIDENCE Systematic review of the evidence published until January 2011 using the following scientific terms:phytotherapy, urinary lithiasis, Chronic prostatitis, chronic pelvic pain, erectile dysfunction, urinary tract infection, cystitis and the scientific names of compounds following the rules of the International Code of Botanical Nomenclature. The databases used were Medline and The Cochrane Library.We included articles published until January 2011 written in English and Spanish. We included studies in Vitro/in vivo on animal models or human beings. Exclusion criteria were literature not in English and Spanish or articles with serious methodological flaws. SYNTHESIS OF THE EVIDENCE We included 86 articles selecting 40 that met the inclusion criteria. In Urolitiasis there are few works in humans. The phytate has its main use as prevention and in reducing the growth of residual fragments after extracorporeal shock wave lithotripsy (ESWL). In CP/CPP the only compound that has shown effectiveness was the extract of pollen in a field of multimodal treatment. In DE ther is no evidence for the use of herbal medicine.Most of the works have limitations in the design or low sample size. In urinary tract infections most of the products are diuretics .There is only evidence for the cranberry as prevention in young or pregnant women. It must not be used as a treatment for urinary tract infections. CONCLUSIONS Phytotherapy is usefull in repeat urinary tract infections and the CP/CPP. It has some role in the urolitiasis and lacks useful in the DE.

Aplicación de la metodología Lean healthcare en un servicio de urología de un hospital terciario como herramienta de mejora de la eficiencia

OBJECTIVE To describe the application of the Lean methodology as a method for continuously improving the efficiency of a urology department in a tertiary hospital. MATERIAL AND METHODS The implementation of the Lean Healthcare methodology in a urology department was conducted in 3 phases: 1) team training and improvement of feedback among the practitioners, 2) management by process and superspecialisation and 3) improvement of indicators (continuous improvement). The indicators were obtained from the Hospitals information systems. The main source of information was the Balanced Scorecard for health systems management (CUIDISS). The comparison with other autonomous and national urology departments was performed through the same platform with the help of the Hospitals records department (IASIST). A baseline was established with the indicators obtained in 2011 for the comparative analysis of the results after implementing the Lean Healthcare methodology. RESULTS The implementation of this methodology translated into high practitioner satisfaction, improved quality indicators reaching a risk-adjusted complication index (RACI) of 0.59 and a risk-adjusted mortality rate (RAMR) of 0.24 in 4 years. A value of 0.61 was reached with the efficiency indicator (risk-adjusted length of stay [RALOS] index), with a savings of 2869 stays compared with national Benchmarking (IASIST). The risk-adjusted readmissions index (RARI) was the only indicator above the standard, with a value of 1.36 but with progressive annual improvement of the same. CONCLUSIONS The Lean methodology can be effectively applied to a urology department of a tertiary hospital to improve efficiency, obtaining significant and continuous improvements in all its indicators, as well as practitioner satisfaction. Team training, management by process, continuous improvement and delegation of responsibilities has been shown to be the fundamental pillars of this methodology.

MP78-17 EAU GUIDELINES INCLUSION CRITERIA FOR CONSERVATIVE ENDOSCOPIC TREATMENT IN UPPER TRACT UROTHELIAL CARCINOMA: ARE THEY TOO STRICT?

INTRODUCTION AND OBJECTIVES: Upper tract urothelial carcinoma (UTUC) is an uncommon malignancy, accounting for only five percent of urothelial cancers. Traditionally, nephroureterectomy (NU) with removal of an ipsilateral bladder cuff has been the standard for treatment of this disease entity. However, less invasive, kidneysparing techniques are becoming more widely embraced. The use of ureteroscopy for the management of UTUC has been advocated in select circumstances such as in patients with a solitary kidney or bilateral disease. Based on our multiple decade experience with this technique, however, we champion a more robust role for this technique and present here our patient experience and outcomes with the use of endoscopy in the management of UTUC. METHODS: An extensive retrospective review was performed of over two hundred patients with UTUC initially managed by a single endourologic surgeon. Patients were seen over a 21 year period from 1994-2015 with initial evaluations occurring from 1994-2008.Evaluations were performed on patient and tumor characteristics as well as surgical parameters. Statistical analyses were utilized to determine factors affecting patient outcomes. RESULTS: A total of 258 patients diagnosed with UTUC were initially evaluated and managed by a single surgeon. 1486 procedures were performed with mean of 7.0 procedures per patient over the period of evaluation. Average tumor size on initial ureteroscopic excision was 16.8 mm (range 1-60) while average recurrent tumor size was 6.4 mm (range 1-50). Of this patient cohort, 94.2% were white and 66% were male. Patients with low grade tumors were successfully managed longterm, with 70.6% of patients avoiding NU. Even in cases of patients with high tumor volume, ureteroscopic management was associated with relatively long-term patient survival. Seventy patients ultimately underwent NU for reasons including conversion to high grade, tumor burden, patient choice and difficult endoscopic access. Multivariate analysis revealed no association of tumor location with survival. Patients with at least a 5 year follow up had overall survival 46.3% and recurrence free survival (RFS) 22%. In this subpopulation, patients with initial grade 1 tumors had RFS of 37.8%. Their average follow up was 7.1 years (range 5-20). CONCLUSIONS: We have demonstrated that ureteroscopic management of UTUC is a successful alternative to NU for patients with low grade tumors. This work presents a comprehensive investigation of tumor characteristics as well as patient outcomes over a twenty one year period of management of patients with UTUC by a single initial surgeon.

Papel del IGF-1 y la distribución de la grasa corporal para disminuir el número de rebiopsias prostáticas

OBJECTIVE To assess the usefulness of IGF-1 and internal organ fat measured by bioelectrical impedance audiometry to avoid rebiopsies in patients with persistently high prostate-specific antigen (PSA) levels. MATERIAL AND METHOD A prospective study was conducted with 92 patients who underwent prostate rebiopsy due to high PSA levels with negative results in the rectal examination and a lack of preneoplastic lesions. The patients previously had their IGF-1 levels measured and had undergone an impedance audiometry test using the abdominal Fat Analyser AB-140 TANITA system. We calculated the receiver operating characteristic (ROC) curves for the PSA levels, %PSA, internal organ fat and IGF-1 and PSA density. RESULTS Twenty-five patients were diagnosed with prostate cancer. These patients had significantly higher PSA, PSAd and IGF-1 values and a tendency towards higher internal organ fat levels and lower %PSA readings (p=.001, p=.003, p=.001, p=.24 and P=0.28, respectively). The ROC curve showed an area under the curve for IGF-1 and PSA of .82 and .81, respectively. Using the cutoff points for 95% sensitivity and using the 3 criteria as an indication of rebiopsy, 74% of the biopsies would have been spared, leaving undiagnosed only 1 patient with clinically significant cancer -Gleason score>7 (4+3)-. The positive and negative predictive values for the set of variables were higher than for each one separately (PPV: 66/NPV: 63). The cost of both determinations was 82 euros. CONCLUSIONS Our results suggest that measuring IGF-1 could significantly decrease the number of unnecessary rebiopsies in an inexpensive and safe manner.

MP80-11 COMPARISION OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY VERSUS URETEROSCOPY HOLMIUM LASER LITHOTRIPSY IN THE MANAGEMENT OF URETERAL STONES: A COST-EFFECTIVENESS ANALYSIS

laterality, rate of positive urine cultures or stone size. Total score > 1.7 was marginally correlated with recurrent status (78% vs. 25%, p1⁄40.071) and BD score > 0.6 approached significance (55% vs. 0%, p1⁄40.057). RP score > 1.1 was not associated with recurrent status (p1⁄40.85). CONCLUSIONS: This standardized grading system suggests Bellini duct plugging on ureteroscopy may be associated with recurrent stones. Future studies with larger numbers of patients will help further determine the utility of this grading system.

91 Comparison of extracorporeal shock wave lithotripsy versus ureteroscopy holmium laser lithotripsy in the management of ureteral stones: A cost-effectiveness analysis

laterality, rate of positive urine cultures or stone size. Total score > 1.7 was marginally correlated with recurrent status (78% vs. 25%, p1⁄40.071) and BD score > 0.6 approached significance (55% vs. 0%, p1⁄40.057). RP score > 1.1 was not associated with recurrent status (p1⁄40.85). CONCLUSIONS: This standardized grading system suggests Bellini duct plugging on ureteroscopy may be associated with recurrent stones. Future studies with larger numbers of patients will help further determine the utility of this grading system.