Christopher S. Elliott

Robot-Assisted Versus Open Sacrocolpopexy: A Cost-Minimization Analysis

PURPOSE Abdominal sacrocolpopexy is considered a standard of care operation for apical vaginal vault prolapse repair. Using outcomes at our center we evaluated whether the robotic approach to sacrocolpopexy is as cost-effective as the open approach. MATERIALS AND METHODS After obtaining institutional review board approval we performed cost-minimization analysis in a retrospective cohort of patients who underwent sacrocolpopexy at our institution between 2006 and 2010. Threshold values, that is model variable values at which the most cost effective approach crosses over to an alternative approach, were determined by testing model variables over realistic ranges using sensitivity analysis. Hospital billing data were also evaluated to confirm our findings. RESULTS Operative time was similar for robotic and open surgery (226 vs 221 minutes) but postoperative length of stay differed significantly (1.0 vs 3.3 days, p <0.001). Base case analysis revealed an overall 10% cost savings for robot-assisted vs open sacrocolpopexy (

Interstitial cystitis and the overlap with overactive bladder.

10,178 vs

The Performance of Prostate Specific Antigen, Prostate Specific Antigen Density and Transition Zone Density in the Era of Extended Biopsy Schemes

11,307). Tornado analysis suggested that the number of institutional robotic cases done annually, length of stay and cost per hospitalization day in the postoperative period were the largest drivers of cost. Analysis of our hospital billing data showed a similar trend with robotic surgery costing 4.2% less than open surgery. CONCLUSIONS A robot-assisted approach to sacrocolpopexy can be equally or less costly than an open approach. This depends on a sufficient institutional robotic case volume and a shorter postoperative stay for patients who undergo the robot-assisted procedure.

The Predictive Value of a Cystocele for Concomitant Vaginal Apical Prolapse

The overlap between interstitial cystitis–painful bladder syndrome and overactive bladder can present a diagnostic challenge to the treating practitioner. Both can present with similar patient symptoms. Further compounding this dilemma is the fact that no gold standard test exists to differentiate one from the other. This review will serve to highlight their similarities and distinguishing features.

To Sling or Not To Sling at Time of Abdominal Sacrocolpopexy: A Cost-Effectiveness Analysis

PURPOSE Prostate specific antigen, prostate specific antigen density and transition zone density have been previously identified as prostate cancer detection tools. Recent studies suggest that prostate specific antigen may be increasingly accurate for detecting clinically significant high grade prostate cancer (Gleason grade 7 or greater). We defined the performance of these measures in a referral based population undergoing an extended prostate biopsy scheme. MATERIALS AND METHODS We retrospectively reviewed prospectively collected data on 1,708 men referred for prostate needle biopsy. All participants were men who had not undergone biopsy in the past. From these data ROC curves were constructed for prostate specific antigen, prostate specific antigen density and transition zone density for the presence of cancer, high grade (Gleason 3 + 4 or greater) and high volume (50% or greater of cores positive) disease. RESULTS Prostate specific antigen density had a statistically higher AUC than prostate specific antigen for detecting all prostate cancers (0.737 vs 0.633, p <0.001) as well as high grade (0.766 vs 0.673, p <0.001) and high volume (0.843 vs 0.755, p <0.001) disease. Additionally, prostate specific antigen and prostate specific antigen density performed better for detecting high grade and high volume disease compared to overall prostate cancer detection. The performance of transition zone density was similar to that of prostate specific antigen density. CONCLUSIONS Prostate specific antigen and prostate specific antigen density show improved performance characteristics for detecting clinically significant high grade and high volume prostate cancer in referral populations undergoing extended scheme prostate needle biopsy. Prostate specific antigen density shows better performance characteristics than prostate specific antigen. No advantage was seen when using transition zone density over prostate specific antigen density.

Epidemiologic trends in penile anomalies and hypospadias in the state of California, 1985-2006.

PURPOSE Recent studies showing a correlation between descent of the anterior and apical vaginal compartments suggest that cystoceles may recur if associated apical prolapse is not corrected. However, to date the anatomical relationship of apical prolapse with respect to cystocele has been incompletely reported. We present the predictive value of a cystocele for clinically significant vaginal apical prolapse. MATERIALS AND METHODS We retrospectively reviewed the records of all new patient visits to a urogynecology clinic in a 30-month period. Women with a point Ba value of -1 or greater (stage 2 cystocele and above) were included in analysis. Predictive values of clinically significant apical prolapse, defined as point C -3 or greater, were calculated and stratified by cystocele stage. RESULTS A total of 385 women were included in study. Point Ba was the leading edge of prolapse in 83.9% of cases. The position of Ba strongly correlated with that of the vaginal apex (Spearman ρ = 0.769, p <0.001). Overall 59.7% of patients had a point C of -3 or greater. The finding of clinically significant apical prolapse increased significantly with increasing Ba values. Of patients with stage 2, 3 and 4 cystocele point C was -3 or greater in 42%, 85% and 100%, respectively. CONCLUSIONS The finding of stage 2 or greater cystocele is highly suggestive of clinically significant apical vaginal descent to -3 or greater. Furthermore, as cystocele stage increases, the predictive value of apical prolapse also increases. Surgeons contemplating cystocele repair should have high suspicion for vaginal apical prolapse and consider concomitant repair.

Maximum Isometric Detrusor Pressure to Measure Bladder Strength in Men With Postprostatectomy Incontinence

PURPOSE We compare the cost-effectiveness of 3 strategies for the use of a mid urethral sling to prevent occult stress urinary incontinence in patients undergoing abdominal sacrocolpopexy. MATERIALS AND METHODS Using decision analysis modeling we compared cost-effectiveness during a 1-year postoperative period of 3 treatment approaches including 1) abdominal sacrocolpopexy alone with deferred option for mid urethral sling, 2) abdominal sacrocolpopexy with universal concomitant mid urethral sling and 3) preoperative urodynamic study for selective mid urethral sling. Using published data we modeled probabilities of stress urinary incontinence after abdominal sacrocolpopexy with or without mid urethral sling, the predictive value of urodynamic study to detect occult stress urinary incontinence and the likelihood of complications after mid urethral sling. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost-effectiveness ratio per quality adjusted life-years gained. In addition to base case analysis, 1-way sensitivity analyses were performed. RESULTS In our model, universally performing mid urethral sling at abdominal sacrocolpopexy was the most cost-effective approach with an incremental cost per quality adjusted life-year gained of

Posterior Compartment Prolapse: A Urogynecology Perspective

2,867 compared to abdominal sacrocolpopexy alone. Preoperative urodynamic study was more costly and less effective than universally performing intraoperative mid urethral sling. The cost-effectiveness of abdominal sacrocolpopexy plus mid urethral sling was robust to sensitivity analysis with a cost-effectiveness ratio consistently below

Racial Variations in the Performance of Prostate Specific Antigen and Prostate Specific Antigen Density in the Era of Extended Prostate Biopsy Schemes

20,000 per quality adjusted life-year. CONCLUSIONS Universal concomitant mid urethral sling is the most cost-effective prophylaxis strategy for occult stress urinary incontinence in women undergoing abdominal sacrocolpopexy. The use of preoperative urodynamic study to guide mid urethral sling placement at abdominal sacrocolpopexy is not cost-effective.

The Influence of Prostate Volume on Prostate-Specific Antigen Performance: Implications for the Prostate Cancer Prevention Trial Outcomes

PURPOSE Using statewide data, we evaluated whether the changing incidence of penile anomalies and hypospadias is reflected in the diverse California population of newborn males over the past 20 years. METHODS Discharge data from all California hospitals, prepared by the OSHPD (Sacramento, CA) was reviewed for the years 1985-2006 for male infant births with an ICD-9 code (752.6) for hypospadias, epispadias or other penile anomalies. Trends were examined by Generalized Estimation Equations for Poisson regression. RESULTS From 1985 to 2006, the birth incidence of newborn penile anomalies increased in California from 47 to 57 cases per 10,000 newborn discharges, yet the trend for hypospadias alone appears stable from 1997. The rates for penile anomalies in newborns increased 1.4% annually (p < 0.001). All racial/ethnic groups analyzed showed this increase (p < 0.001 for each). During the study period there was a 2% increase per year in plural births (p < 0.001). Interestingly, the rate of change in penile anomaly incidence was greater in males of plural births compared to their singleton cohorts (2% vs 1% annually) (p < 0.001). The birth incidence of cleft palate, another congenital anomaly known to be stable over time, remained unchanged over this period. CONCLUSIONS From 1985 to 2006 in California the incidence of penile anomalies increased in a statistically significant manner, but the incidence of hypospadias appears stable for the last decade. Our data support the notion that different racial/ethnic groups have distinct incidences of penile anomaly formation and that an association with plural births appears to be present.