Jared Schober

Predictors of Nerve Stimulator Success in Patients With Overactive Bladder

Purpose To identify factors associated with successful sacral nerve stimulator (SNS) trial after SNS implantation for the treatment of medication refractory overactive bladder (OAB). Methods Patients undergoing treatment for OAB at Lahey Hospital and Medical Center between 2004 and 2016 were identified. Patients undergoing SNS placement were identified; SNS success was defined as permanent implantation of the SNS. Demographic, clinical and treatment data were extracted from patient charts; uni- and multivariate analyses were conducted to identify factors associated with SNS treatment success. Results A total of 128 patients were included. On univariate analysis, male sex, prior diagnosis of benign prostatic hyperplasia, and lower volume at first urge on urodynamics (UDS) were associated with unsuccessful SNS trial. On multivariate analysis, male sex (odds ratio [OR], 0.145; 95% confidence interval [CI], 0.036–0.530) and lower volume at first urge on UDS (OR, 0.982; 95% CI, 0.967–0.995) were associated with unsuccessful SNS trial. A threshold value of 100 mL at first urge during preoperative UDS had a specificity of 0.86 in predicting SNS success in men. Conclusions SNS is frequently successful at relieving OAB symptoms. Male patients and those with lower volumes at first urge on UDS, particularly below 100 mL, are more likely to have an unsuccessful SNS trial. Patients in these groups should be counseled on the lower likelihood of SNS success.

Effect of Urethroplasty on Anxiety and Depression

Purpose: To our knowledge anxiety and depression in patients with urethral stricture disease and the impact of urethroplasty on mental health has never been explored. We hypothesized that patients with urethral stricture disease would have higher than normal anxiety and depression levels, and urethroplasty would improve mental health. Materials and Methods: We retrospectively reviewed the records of patients in a multi‐institutional reconstructive urology database who underwent anterior urethroplasty. Preoperative and postoperative evaluation of anxiety and depression, and overall health was recorded using the validated EQ‐5D™‐3L Questionnaire. Sexual function was evaluated with the IIEF (International Index of Erectile Function) and the Mens Sexual Health Questionnaire. Stricture recurrence was defined as the need for a subsequent procedure. Results: Median followup in the 298 patients who met study inclusion criteria was 4.2 months. Preoperative anxiety and depression was reported by 86 patients (29%). Those with anxiety and depression reported higher rates of marijuana use, a worse preoperative IIEF score (17.5 vs 19.6, p = 0.01) and a lower image of overall health (66 vs 79, p ≤0.001). Improvement or resolution of anxiety and depression was experienced by 56% of patients treated with urethroplasty while de novo postoperative anxiety and depression were reported by 10%. These men reported a decreased flow rate (16 vs 25 ml per second, p = 0.01). Clinical failure in 8 patients (2.7%) had no effect on the development, improvement or resolution of anxiety and depression. Conclusions: Of patients with preoperative anxiety and depression 56% reported improvement or resolution after urethroplasty. Although new onset anxiety and depression was rare, these patients had a significantly lower postoperative maximum flow rate, possibly representing a group with a perceived suboptimal surgical outcome. A urethral stricture disease specific questionnaire is needed to further elucidate the interplay of urethral stricture disease with anxiety and depression.

PD37-07 TREATMENT TRENDS FOR METASTATIC PROSTATE CANCER OVER THE LAST DECADE: INSIGHTS FROM THE NATIONAL CANCER DATABASE

rates at 2-year were evaluated for patients diagnosed between 2004 and 2011. Temporal trends were quantified using the annual percentage change (APC) with the least squares linear regression. RESULTS: Overall, 700 (5.7%) M1a, 9,192 (74.8%) M1b and 2,399 (19.5%) M1c patients were identified. The prevalence of M1c stage significantly decreased from 21.7% in 2004 to 15.6% in 2013 (APC: 5.46%: 95% CI: 3.21-7.82; p<0.01). Local T staging significantly changed over the study period. Specifically, an increasing rate has been observed of individuals with local T1 disease, ranging from 22.8% in 2004 to 36.1% in 2013 (APC: 4.72%; 95% CI: 3.41-6.07; p<0.001). The proportion of patients with T2 disease decreased from 48.7% in 2004 to 36.1% in 2013 (APC: -3.09%; 95% CI: 2.25-3.94; p<0.001). No statistically significant variation has been observed for T3þ stage (p1⁄40.1). Similarly, a decrease in the proportion of patients with gleason score of 6 or 7 was observed (both p<0.001). This was accompanied by a significant increase in the proportion of patients with gleason score of 8 or higher, which increased from 67.2% in 2004 to 84.4% in 2013 (APC: 2.54%; 95% CI: 2.14-2.94; p<0.001). The 2-year mortality rates after diagnosis decreased from 43.7% in 2004 to 39.0% in 2011 (APC: 1.89%; 95% CI: 1.33-2.45; p<0.001). CONCLUSIONS: The stage migration phenomenon that has been described in surgically-treated PCa holds valid also in the metastatic setting. This results in a higher proportion of high-grade cancer when diagnosed at metastatic stage. However, early detection efforts resulted in a decreasing rate of patients with visceral metastases (stage M1c) and decreasing 2-year mortality rates.

MP02-08 HOLEP IN PATIENTS WITH LOW RISK PROSTATE CANCER IS SAFE AND EFFECTIVE

INTRODUCTION AND OBJECTIVES: The optimal management option for BPH/LUTS for prostates >80g is unclear. Theoretical advantages of GLEP include improved hemostasis due to the absorption spectrum of 532nm laser, better tissue handling due to the sidefiring laser fiber, better visualization of the prostate capsule, and more versatility with concomitant vaporization. We study the safety and feasibility of en-bloc GLEP with prostate morcellation using a side-firing laser as a new technique for definitive management of symptomatic LUTS in patients with prostates >80g. METHODS: We performed a retrospective analysis of 82 consecutive patients who underwent GLEP from 9/2014 to 8/2016. Primary outcomes were AUA symptom score, maximum flow rate, and post-void residual volume. Secondary outcomes were quality of life score, IIEF-5 score, and PSA. Technique: Using 26 Fr Wolf resectoscope and side-firing 2090 GreenLight laser fiber, we incise the apical mucosa, separating the prostate from the external sphincter. Using the laser energy and blunt dissection, prostate lobes are enucleated on either side of the verumontanum. Dissection is carried out circumferentially until the bladder neck is reached. Hemostasis is achieved with laser coagulation. Once the enucleated adenoma is pushed into the bladder, morcellation is completed using the Wolf Piranha morcellator. RESULTS: Mean age was 71 years, with 47.6% of patients on anticoagulation and/or antiplatelet therapy. Mean procedure time was 140 min 55. The mean preoperative prostate size was 145ml 86.46, with a mean size morcellated volume of 66mL 54. 75% of patients were discharged home on postoperative day (POD) 1 and 75% of patients had catheters removed by POD2. Primary and secondary outcomes can be found in Table 1, with statistically significant improvement in all parameters (p<0.05) except IIEF-5, which demonstrated no change. Complication rates included 1.2% blood transfusion, 6.1% clot retention, 4.9% urinary tract infection, and 13.4% stress urinary incontinence. The majority of patients regained continence at later follow-up. There was no incidence of urethral stricture, capsular perforation, bladder or ureteral injury. CONCLUSIONS: In experienced hands, GLEP is a safe and feasible option for management of large prostates.

MP33-03 USPSTF FALLOUT: IS DISEASE BURDEN AT DIAGNOSIS OF METASTATIC DISEASE RISING?

INTRODUCTION AND OBJECTIVES: The impact of the USPSTF on PSA screening behavior would not be expected to impact metastatic disease rates (mPCa) for several years. However a delay in diagnosis for men with prevalent mPCa might be measurable in the near term. Since PSA is a rough surrogate for disease burden, we sought to determine if the PSA at the time of diagnosis of mPCa is rising in the National Cancer Database (NCDB). METHODS: The NCDB was used to examine prostate cancer diagnoses from 2004-2014. To minimize reporting bias, only hospitals contributing at least one case per year for the entire decade were included. Cases with cM1 disease were defined as metastatic. PSA at initial cancer diagnosis was divided into 4 groups: 0.2-3.9, 4.0-10.0, 10.1-20, and >20 ng/ml. The ratio of mPCa compared to total PCa diagnoses were compared for each year. Descriptive statistics and a multivariate logistic regression were performed in Stata. RESULTS: The proportion of mPCa present at initial diagnosis increased over the 10-year period for every PSA group. The most significant proportional increase was observed in patients with PSA >20, from 8.5% (2004) to 22.9% (2014). The most significant rate of increase was observed after 2007 (Figure 1). On multivariate regression, PSA category was independently associated with the presence of metastatic disease at initial diagnosis (p<0.001). The percentage of patients with mPCa at initial diagnosis who had a PSA>20 was 54% in 2004 vs. 72% in 2014. Patients with a PSA <4 had a higher rate of metastatic disease at diagnosis when compared to the PSA 4-10 group. Those with PSA <4 experienced a proportional increase in mPCa from 0.92% (2004) to 2.65% (2014). CONCLUSIONS: As expected, the presence of mPCa increases with increasing PSA, but the new finding of disproportionately more men with PSA >20 at diagnosis of mPCa in recent years is notable. We hypothesize this may represent higher disease burden at diagnosis as a near term result of USPSTF recommendations. Secondary observation of a proportionate increase in overall mPCa in the NCDB must be interpreted with caution, given that this is a registry rather than a population based dataset. Further studies are needed to elucidate if these trends equate to a greater burden of disease at diagnosis of mPCa, and whether screening behavior is causative.

MP33-02 DISADVANTAGED SOCIOECONOMIC STATUS IS STRONGLY ASSOCIATED WITH METASTATIC PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: In a clinical setting, 12-core TRUS biopsy (12-TRUS-Bx) instead of sextant biopsy (6-TRUS-Bx) increases the low-grade (LG; Gleason 3+3) and highgrade (HG; Gleason >1⁄43+4) prostate cancer (PCa) detection. MRI +/target biopsy (TBx) detects less LG PCa and tends to detect more HG PCa, especially after previous negative biopsy. In this study we compare the performance of 6-TRUS-Bx vs 12-TRUS-Bx vs MRI +/TBx in a pre-screened population-based cohort. METHODS: Men in the 5th screening round of the ERSPC Rotterdam (2013 e 2016) with PSA >1⁄43.0 ng/ml received 6-TRUS-Bx or were included in the MRI side study. Men in the side study received MRI, blinded 12-TRUS-Bx and afterwards fusion target biopsy of PIRADS >1⁄43 lesions if present. The PCa detection rates of the 6-TRUSBx vs 12-TRUS-Bx vs MRI +/TBx strategy were compared after stratification for previous biopsy. RESULTS: A total of 177 men received 6-TRUS-Bx; 158 men received MRI with 12-TRUS-Bx +/TBx. Mean age and mean PSA were resp. 73.2 yrs (SD 1.1) and 5.1 ng/ml (SD 2.8). A total of 78/177 (44%) men who received 6-TRUS-Bx and 74/158 (47%) men who received 12TRUS-Bx +/TBx were biopsy naive. The rate of men with a non-suspicious MRI in the side study was 110/158 (70%).The HG PCa detection rates of 6-TRUS-Bx (17%), 12-TRUS-Bx (20%) and MRI +/TBx (19%) in previously screened but biopsy naive men were comparable. The LG PCa detection rate in biopsy naive men of MRI +/TBx (7%) was significantly lower as compared to 6-TRUS-Bx (23%) and 12-TRUS-Bx (34%). The HG PCa detection rates of 6-TRUS-Bx (5%), 12-TRUS-Bx (5%) and MRI +/TBx (4%) in previously screened and biopsied (>1⁄41 times) men were comparable. The LG PCa detection rate in previously biopsied men of 12-TRUS-Bx (24%) was significantly higher as compared to 6-TRUS-Bx (12%) and MRI +/TBx (7%). CONCLUSIONS: In population-based screening with multiple visits the HG PCa detection rates of 6-TRUS-Bx, 12-TRUS-Bx and MRI +/TBx are comparable, both in biopsy naive and previously biopsied men. Only 5% of previously biopsied men harbor HG PCa at repeat biopsy, confirming the need of better risk-stratification. An MRI +/TBx screening strategy has the potential to reduce biopsy procedures (70%) and overdiagnosis of LG PCa. Source of Funding: none

MP85-17 FACTORS ASSOCIATED WITH DURABILITY OF THERAPEUTIC BOTULINUM TOXIN A INJECTION FOR OVERACTIVE BLADDER

CONCLUSIONS: This is the first study to demonstrate safety and efficacy of intravesical incobotulinumtoxin A in patients with neurogenic or idiopathic detrusor overactivity. Incobotulinumtoxin A may be an attractive alternative to onabotulinumtoxin A, especially given its lower cost. Small sample size limits this data, however early results suggest improvements in quality of life and bladder dynamics. A larger, prospective study will be required to validate these findings.

MP85-18 GENDER DIFFERENCES IN THE SUCCESS OF SACRAL NERVE STIMULATION IN PATIENTS WITH OVERACTIVE BLADDER

CONCLUSIONS: This is the first study to demonstrate safety and efficacy of intravesical incobotulinumtoxin A in patients with neurogenic or idiopathic detrusor overactivity. Incobotulinumtoxin A may be an attractive alternative to onabotulinumtoxin A, especially given its lower cost. Small sample size limits this data, however early results suggest improvements in quality of life and bladder dynamics. A larger, prospective study will be required to validate these findings.