Jaclyn Milose

Prevalence of 24-Hour Urine Collection in High Risk Stone Formers

PURPOSE Secondary prevention has an important role in urinary stone disease. The core of secondary prevention is the identification of modifiable risk factors by a 24-hour urine collection, which then directs selective medical therapy. While this decreases the recurrence rate, little is known about the frequency with which 24-hour urine collections are obtained. MATERIALS AND METHODS Using medical claims from 2002 to 2006 we identified adults with incident urinary stone episodes. With appropriate diagnosis codes we determined those at high risk for recurrence. Of these patients we determined the proportion in whom a 24-hour urine collection was done within 6 months of diagnosis. Finally, we fitted regression models to measure associations between patient and provider level factors, and obtaining a 24-hour urine collection. RESULTS We identified 28,836 patients at high risk for recurrence. The prevalence of 24-hour urine testing increased from 7.0% in 2003 to 7.9% in 2006 (p = 0.011), although the overall prevalence was exceedingly low at 7.4%. Multivariable regression revealed that region of residence and level of comorbid illness were independently associated with 24-hour urine collection, as was the type of physician who performed the followup. For instance, the odds of metabolic evaluation were 2.9 times higher when a patient was seen by a nephrologist (OR 2.92, 95% CI 2.32-3.67), and more than threefold higher when seen by a urologist (OR 3.87, 95% CI 3.48-4.30). CONCLUSIONS Obtaining 24-hour urine collections in stone formers at high risk is uncommon, raising a quality of care concern.

Role of biochemical markers in testicular cancer: diagnosis, staging, and surveillance

Testis cancer is one of the few solid organ malignancies for which reliable serum tumor markers are available to help guide disease management. Human chorionic gonadotropin, alpha fetoprotein, and lactate dehydrogenase play crucial roles in diagnosis, staging, prognosis, monitoring treatment response, and surveillance of seminomatous and nonseminomatous germ cell tumors. Herein we discuss the clinical applications of germ cell tumor markers, the limitations of these markers in the management of this disease, and additional serum molecules that have been identified with potential roles as novel germ cell tumor markers.

PD39-04 COMBINED PLACEMENT OF ARTIFICIAL URINARY SPHINCTER AND INFLATABLE PENILE PROSTHESIS DOES NOT INCREASE RISK OF PERIOPERATIVE COMPLICATIONS OR IMPACT LONG-TERM DEVICE SURVIVAL

OBJECTIVE To determine the impact of concurrent inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) implantation on perioperative complications and long-term device survival, among men with postprostatectomy erectile dysfunction and urinary incontinence. METHODS We identified men older than 65 treated with radical prostatectomy in the Surveillance, Epidemiology, and End Results Medicare database between 2002 and 2016. IPP or AUS placement was determined by current procedural terminology (CPT) code, with dual implantation (DI) defined as IPP and AUS placement on the same date. Device survival was assessed using CPT codes for device removal, replacement, and/or repair. Complications were assessed within 90 days using ICD-9 codes. Statistical analysis was performed using SAS v9.3 (Cary, NC). RESULTS A total of 37,599 men underwent radical prostatectomy, with AUS placed in 793 (2.1%), IPP placed in 644 (1.7%), and DI in 62 (0.2%). Relative to AUS placement alone, men undergoing DI were younger (68.8 vs 70.2 years, P = 0.03), but had equivalent Charlson comorbidity index, tumor grades, and rates of prior radiotherapy. Relative to IPP placement alone, men were more likely to undergo DI if treated with adjuvant or salvage radiotherapy. The incidence of complications within 30 and 90 days of prosthetic implantation did not differ between groups. Long-term device survival on Kaplan-Meier analysis was not impacted by DI relative to single device implantation with median follow-up of 61 months. CONCLUSION Combined AUS and IPP placement does not adversely affect perioperative complications or device survival relative to placement of either device alone.

MP36-18 PATTERNS AND TIMING OF ARTIFICIAL URINARY SPHINCTER FAILURE

INTRODUCTION AND OBJECTIVES: The gold standard treatment for severe post-prostatectomy incontinence is implantation of an artificial urinary sphincter (AUS). There is a paucity of data regarding the timing of AUS placement after prostatectomy and other factors which predict device failure. METHODS: We identified all patients who underwent prostatectomy and subsequent AUS placement in SEER-Medicare from 2002-2011. These patients’ demographic, clinical and pathologic characteristics were included in multivariable cox proportional hazard models, to identify predictors for device survival. We also analyzed factors impacting the time to revision or explantation from initial AUS implantation and prostatectomy. RESULTS: 841 men underwent AUS placement at a median 23 months (IQR:15-40.6) after prostatectomy. 236 (28%) men ultimately required revision or explantation. There were no differences in age, race or hospital setting for those undergoing reoperation vs. not (p 0.2). Patients who underwent reoperation were more likely to have had higher clinical stage cancer, undergone open prostatectomy, or had prior sling placement (p<0.01). There were no differences in rates of diabetes, smoking status, prior radiation therapy, or Charlson Comorbidity Index scores between those requiring reoperation vs. not (all p >0.15). Patients with delayed AUS placement (29%), defined as >3 years after prostatectomy, experienced prolonged device survival (Figure). Delayed patients were significantly more likely to have received radiation therapy [36.5% vs. 10.5% (p<0.001)]. Nonetheless, delayed repair was confirmed to be protective on multivariate analysis, after controlling for patient and disease characteristics including radiation history [HR:0.44 (95% CI: 0.32-0.62); p<0.01]. Factors independently associated with a shorter interval time until reoperation included history of radiation [HR: 1.69 (95% CI: 1.16-2.44);p<0.01] and history of prior sling [HR:1.88 (95% CI: 1.19-2.97); p<0.01]. CONCLUSIONS: Delayed AUS implantation in the Medicare population is associated with prolonged device survival, while radiation exposure and prior urethral sling surgery predict for early reoperation. Further work is required to identify patient specific factors which may explain variability in timing for AUS after prostatectomy and how such factors contribute to device longevity.

MP88-13 MALE SLING AND ARTIFICIAL URETHRAL SPHINCTER FOR INCONTINENCE AMONGST CERTIFYING AMERICAN UROLOGISTS

INTRODUCTION AND OBJECTIVES: We examined surgical case volume characteristics among certifying urologists performing male sling and AUS to evaluate practice patterns in the care of male stress urinary incontinence (SUI). METHODS: Six month case log data of certifying urologists (2003 to 2013) was obtained from the American Board of Urology (ABU). Cases specifying a CPT code for male sling, AUS, and removal or revision in male patients 18 years were analyzed for surgeonspecific variables. RESULTS: Among 1615 urologists (568 certifying and 1047 recertifying) logging at least one male incontinence procedure, 2109 (48% of all procedures) male sling and 2284 (52%) AUS cases were identified. Mean age of patients undergoing AUS was 74.9 years, compared to 67.3 years in sling patients (p<0.001). Median number of male slings performed was two (range 1-40), with 32.7% placing male slings exclusively. Increase in overall number of incontinence procedures from 2004 to 2014 was greater than the growth in number of urologists applying for certification. Sling and AUS revisions remained relatively stable at a mean of 2.5% and 14% of cases, respectively. The rate of male sling increased from 32.7% of incontinence surgeries in 2004 to 45.5% in 2013 (p<0.001) with a peak in 2011, when placement of a sling was 1.6 times more frequently performed than AUS (sling 62.2%, AUS 37.8%). Academically-affiliated urologists are 1.5 times more likely to perform AUS than male sling for SUI, whereas the proportion of procedures were equal amongst non-academic affiliated urologists (p<0.001). A small group of urologists (27 surgeons, 3.4%) accounted for 22% (464 cases) of all male slings placed. This same cohort of surgeons logged 10.2% (234 cases) of all AUS procedures. Surgical management of male SUI varies widely across states, with slings performed between 21-70%. The states with the highest volume of slings (CA, TX, FL) were also high volume for AUS, accounting for 26.6% of slings and 30.2% of AUS. Five states reported no male slings during this period (DE, ND, NM, VT, WY). CONCLUSIONS: The number of male incontinence procedures has increased over time, with a growing proportion of male slings. Most slings and AUS cases are performed by high-volume surgeons. Regional disparity exists for male slings, with several states reporting no male slings over ten years of certification. Source of Funding: none