Adam Rensing

Magnetic resonance imaging-targeted vs. conventional transrectal ultrasound-guided prostate biopsy: Single-institution, matched cohort comparison

OBJECTIVES To compare magnetic resonance imaging-targeted biopsy (MRITB) and conventional transrectal ultrasound-guided biopsy (TRUSGB) in the detection of prostate cancer (PCa) at our institution. METHODS Our prospective registry of patients undergoing prostate MRITB from December 2010 to July 2013 was analyzed. Patients were matched one-to-one to patients who underwent TRUSGB based on the following characteristics: age, prostate-specific antigen level, prostate volume, race, family history of PCa, initial digital rectal examination (DRE), prior use of 5-alpha reductase inhibitor, and prior diagnosis of PCa. MRITB was performed using a TargetScan system with the patient under general anesthesia. Magnetic resonance imaging suspicious regions (MSRs) were targeted with cognitive registration, and a full TargetScan template biopsy (TSTB) was also performed. RESULTS In total, 34 MRITB patients were matched individually to 34 TRUSGB patients. As compared with TRUSGB, patients who underwent MRITB had a greater overall rate of PCa detection (76% vs. 56%, P = 0.12) and a significantly higher number with Gleason score≥7 (41% vs. 15%, P = 0.03), whereas the rates of Gleason score 6 PCa detection were similar between MRITB and TRUSGB (35% vs. 41%, P = 0.80). As compared with the TSTB, magnetic resonance imaging suspicious regions-directed biopsies during MRITB had a significantly higher overall PCa detection (54% vs. 24%, P<0.01) and Gleason score≥7 PCa detection (25% vs. 8%, P<0.01). When compared with TSTB, TRUSGB had similar detection rates for benign prostate tissue (76% vs. 79%, P = 0.64), Gleason score 6 PCa (16% vs. 14%, P = 0.49), and Gleason score ≥7 PCa detection (8% vs. 7%, P = 1.0). CONCLUSIONS Cognitive registration MRITB significantly improves the detection of Gleason score≥7 PCa as compared with conventional TRUSGB.

Differences in the Treatment of Benign Prostatic Hyperplasia: Comparing the Primary Care Physician and the Urologist

Introduction: Benign prostatic hyperplasia is a prevalent chronic condition with expenditures exceeding

MP66-06 IS SURGICAL ANTIBIOTIC PROPHYLAXIS NECESSARY FOR PEDIATRIC ORCHIOPEXY?

1 billion each year. Little is known about the treatment of patients by primary care physicians compared to urologists. We assessed changes in management after medication initiation in these 2 settings. Methods: From the Chronic Condition Warehouse 5% sample of Medicare beneficiaries linked to Medicare Part D data, we defined a cohort of men, 66 to 90 years old, with initial prescriptions for an alpha blocker and/or 5&agr;‐reductase inhibitor. We assessed the initial change in therapy for up to 4 years after medication initiation, whether adding a medication, switching medication, stopping medication or having surgery/retention. We estimated the cumulative incidence functions from competing risks data and tested equality across groups (primary care physician vs urologist). Results: Overall 5,714 men started medication with a primary care physician and 1,970 did so with a urologist. The most common change in treatment after medication initiation across all groups was medication discontinuation (55% alpha blocker, 46% 5&agr;‐reductase inhibitor, 30% combination therapy cumulative incidence at 3 years). Patients who started treatment with primary care physicians were more likely to discontinue benign prostatic hyperplasia related medications than those who started treatment with urologists (HR 1.19, 95% CI 1.09–1.29). The majority of patients who stopped alpha blocker therapy did not receive further benign prostatic hyperplasia therapy. Conclusions: Men given combination therapy are most likely to continue medication use. Surgical therapy and retention are relatively rare events. Patients who initiate care with urologists are more likely to continue medical therapy than those who initiate care with primary care providers.

First-ever Reported Obstructing Ureteral Nephrogenic Adenoma in a Child and Subsequent Robotic-assisted Laparoscopic Ileal Ureter

INTRODUCTION AND OBJECTIVES: Surgeons frequently use surgical antibiotic prophylaxis (SAP) despite limited evidence to support its efficacy. We hypothesized that children who received SAP prior to orchiopexy would have no reduction in surgical site infection (SSI) risk but an increased risk of antibiotic-associated adverse events. METHODS: We performed a retrospective cohort study of all males between 30 days and 18 years of age who underwent an orchiopexy (ICD-9 CM 62.5) with or without herniorraphy (ICD-9 CM 53.0 or 53.1) in an ambulatory or observation setting from January 2004 to December 2015 using the Pediatric Health Information System database. We excluded inpatients and those with any concomitant procedures. We used Chi-square or Fisher’s exact tests to determine the association between SAP and allergic reaction (defined as a charge for epinephrine or ICD-9 diagnosis code for allergic reaction on the date of surgery) and any of the following within 30 days: SSI, hospital readmission or any repeat hospital encounter. We performed mixed effects logistic regression controlling for age, race, insurance and clustering of similar practice patterns by hospital. RESULTS: A total of 71,767 patients were included: median age 4.6 years; 61.4% white; 49.3% with public insurance. 33.5% received SAP. A total of 1.4% of patients had a perioperative allergic reaction and <0.1% of patients were diagnosed with a SSI. On mixed effects logistic regression, patients who received SAP had 1.2 times the odds of a perioperative allergic reaction compared to those who did not receive SAP (p1⁄40.005). SAP was not associated with SSI, hospital readmission, or any repeat encounter within 30 days. CONCLUSIONS: In patients undergoing orchiopexy we found that SAP did not reduce the risk of postoperative SSI, readmissions or hospital visits. Patients who received SAP, however, had significantly increased odds of perioperative allergic reaction. This suggests that the risks of SAP may outweigh the benefits in children undergoing orchiopexy.

The Diagnosis and Treatment of Vesicoureteral Reflux: An Update

To report the first known case of a completely intracorporeal robotic-assisted laparoscopic ileal ureter in the pediatric population, a 12-year-old boy with near-complete replacement of his right ureter with nephrogenic adenoma and resulting debilitating renal colic. Intracorporeal robotic-assisted laparoscopic ileal ureter was performed without complication. A detailed description of our surgical technique is included. The patient had improvement in hydronephrosis and complete resolution of renal colic symptoms with minimal incisional length compared to traditional laparotomy. Intracorporeal robotic-assisted laparoscopic ileal ureter provides the benefits of minimally invasive surgery when complete ureteral replacement is needed.

MP77-15 PRESENCE OF MRI SUSPICIOUS LESION PREDICTS CLINICALLY SIGNIFICANT PROSTATE CANCER FOR BIOPSY NAÏVE PATIENTS

Vesicoureteral reflux (VUR) remains a common problem seen by pediatric providers. Despite a great deal of research, the debate regarding how to screen and treat patients reremains tense and controversial. This review seeks to summarize the management of VUR with emphasis on recent published findings in the literature and how they contribute to this debate. The goals of managing VUR include preventing future febrile urinary tract infections (FUTI), renal scarring, reflux nephropathy and hypertension. The topdown approach with upper tract imaging and selective vesicocystourethrogram (VCUG) is an emerging alternative approach in the evaluation of children after their first FUTI. The elimination of bladder and bowel dysfunction (BBD) is an important management strategy to prevent further FUTIs, regardless of treatment choice. Antibiotic prophylaxis is a safe and effective modality to sterilize the urinary tract. Endoscopic treatment of VUR is an attractive modality in select patients, although some concerns remain regarding its effectiveness and durability as compared to the gold standard of open or laparoscopic ureteroneocystostomy. Lastly, further research is required to determine the most effective algorithm to evaluate the pediatric patient after the first febrile UTI.

MP24-14 DIFFERENCES IN TREATMENT OF BENIGN PROSTATIC HYPERPLASIA BY THE UROLOGIST AND PRIMARY-CARE PHYSICIAN

prostate as MRI targets, and only 2 (20%) demonstrated dominant Gleason pattern 4. CONCLUSIONS: In men with suspicion for PCa and no previous biopsy, MRF-TB reduces detection of indolent disease while significantly improving the detection and proper risk-stratification of high grade cancer. Gleason 7 cancers found on SB and missed by MRFTB were most often Gleason 3þ4 and in close proximity to targeted MRI lesions suggesting a likelihood of MRF-TB targeting error. Pre-biopsy MRI followed by MRF-TB alone may thus serve as a reliable predictor of clinically significant disease and reduce over-detection of indolent cancers in men with no previous biopsy.

1261 UNDERTREATMENT OF PT1A RENAL LESIONS IN AFRICAN AMERICAN PATIENTS WITH NEPHRON-SPARING SURGERY

INTRODUCTION AND OBJECTIVES: Lower urinary tract symptoms associated with BPH are highly prevalent among aging men and place a large socioeconomic burden on the US health care system. Few nationally representative datasets are available that have evaluated patterns of non-surgical care for men with BPH. To examine national practice patterns for incident BPH in men age 18þ, stratified by age 30 days apart, based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes 600.x (BPH), 596.0 (bladder neck obstruction), 788.20 (urinary retention), and 788.21 (incomplete bladder emptying), were included between 7/1/2009 and 6/30/2012. Other inclusion criteria for incident BPH (vs prevalent disease) were continuous enrollment for 1 year before and 6 months after the first diagnosis date, and no BPH diagnosis during the previous year. Pts with ICD-9 diagnoses of neurologic conditions or urologic malignancy were excluded. Overall outcomes through 9/30/2013 were analyzed. Variables of interest included pt comorbidities, demographics, diagnostic tests, and medication prescriptions. RESULTS: A total of 38,252 men were included. The majority (24,814, 65%) were aged 65þ, and 41% had 1þ comorbid conditions. Diagnostic tests included post-void residual measurement in 21%, renal ultrasound in 9%, cystoscopy in 6%, prostate ultrasound in 3%, and urodynamics in 1% of pts. A total of 58% of men were prescribed BPH medications, including alpha blockers (50%) and/or 5-alpha reductase inhibitors (24%). Older men had higher rates of prescriptions for both alpha blockers and 5-alpha reductase inhibitors than younger men (Table 1). CONCLUSIONS: Men aged 65þ had higher rates of prescriptions overall, possibly due to more severe symptoms among older men. The relatively low rate of renal ultrasound and other diagnostic tests may reflect adherence to the 2010 American Urological Association BPH guidelines. Source of Funding: No financial support was received for this study.

Nephrogenic Adenoma of the Pediatric Ureter

as compared to the use of RN. The aim of the current study is to evaluate the method of surgery (RN vs. PN) and NCSM. METHODS: The files of 1235 patients treated by nephrectomy (1987 2009) due to renal cell carcinoma were evaluated. 605 (48.9%) and 650 (51.5%) had PN and RN respectively. The variables used for the analysis included age at time of surgery, gender, co-morbidities, tumor’s location, size, TNM and histology, creatinine level prior and following surgery, intraand postoperative complications, mortality’s data and cause. Multivariate analysis was calculate by COX regression. RESULTS: NCSM was demonstrated in 172 patients – 30 (17%) were treated by PN and the rest 142 (83%) by RN (p 0.001). The probability of NCSM following RN was 2.79 (CI 95% 1.33–5.87) compared to patients treated by PN (p 0.007). Additional predictors for NCSM by multivariate analysis were age above 65, length of hospital stay and tumor size (p 0.05). The major survival benefit was found among patients younger then 65. CONCLUSIONS: The use of RN has a major impact on NCSM among patients treated by nephrectomy due to renal cell cancer. The major survival benefit was found in patients younger then 65 at time of surgery.