Lauren Wood

Urinary incontinence in women

Urinary incontinence affects women of all ages. History, physical examination, and certain tests can guide specialists in diagnosing stress urinary incontinence, urgency urinary incontinence, and mixed urinary incontinence. First line management includes lifestyle and behavior modification, as well as pelvic floor strength and bladder training. Drug therapy is helpful in the treatment of urgency incontinence that does not respond to conservative measures. In addition, sacral neuromodulation, intravesical onabotulinumtoxinA injections, and posterior tibial nerve stimulation can be used in select patient populations with drug refractory urgency incontinence. Midurethral synthetic slings, including retropubic and transobturator approaches, are safe and efficacious surgical options for stress urinary incontinence and have replaced more invasive bladder neck slings that use autologous or cadaveric fascia. Despite controversy surrounding vaginal mesh for prolapse, synthetic slings for the treatment of stress urinary incontinence are considered safe and minimally invasive.

Preoperative Testing for Urethral Sling Surgery for Stress Urinary Incontinence: Overuse, Underuse and Cost Implications

PURPOSE We identify areas of overuse and underuse in the preoperative evaluation of patients undergoing mid urethral sling surgery. We also estimate the effect of overuse of preoperative testing on health care costs. MATERIALS AND METHODS We conducted a retrospective review of women who underwent sling surgery with or without concomitant prolapse repair between 2012 and 2013. Physician orders for preoperative electrocardiogram, chest x-ray, basic metabolic panel, complete blood count, coagulation studies and urinalysis were classified as appropriate or inappropriate based on summary guidelines from the American Academy of Family Physicians. The additional costs of inappropriate tests were estimated using the 2014 Medicare clinical laboratory and physician fee schedules. RESULTS A total of 101 women who underwent mid urethral sling surgery were identified and 346 preoperative tests were ordered. Overall 76% of coagulation profiles, 73% of complete blood counts, 47% of basic metabolic panels, 39% of chest x-rays and 21% of electrocardiograms ordered did not have an appropriate clinical indication. In addition, 6% of electrocardiograms, 22% of chest x-rays and 10% of urinalyses were not ordered despite an appropriate indication. The estimated charges of overused tests were

The Truth Behind Transvaginal Mesh Litigation: Devices, Timelines, and Provider Characteristics

1,844.15 for the cohort, or

Limitations of the National Comprehensive Cancer Network® (NCCN®) Guidelines for Prediction of Limited Life Expectancy in Men with Prostate Cancer

18 per patient. CONCLUSIONS Preoperative testing is overused as well as underused in patients undergoing sling surgery. The greatest variation occurred with the use of electrocardiograms, chest x-rays and urinalysis. Poor adherence to national guidelines leads to increased health care costs and warrants increased awareness in following evidence-based guidelines.

PD44-05 WRITING IN THE MARGINS OF SEXUAL FUNCTION QUESTIONNAIRES: A QUALITATIVE ANALYSIS FROM WOMEN WITH PELVIC FLOOR DISORDERS

Objectives Following Food and Drug Administration communications about the safety of transvaginal prolapse, more than 73,000 patients with complications from treatment of pelvic organ prolapse (POP) or stress urinary incontinence (SUI) have filed product liability claims. This research analyzes the transvaginal mesh claims filed in the United States to identify key characteristics that may inform clinical decision-making. Methods We evaluated a 1% random sample from the Bloomberg Law Database: 2000 to 2014 and associated legal documents. Outcomes and measures used included annual rate of claim, mesh type, time interval between surgery and claim, defendants, and surgeon training. Results The search returned 76,865 results, and 2979 were excluded, leaving 73,915 claims. Of 739 claims (1%), 63.3% involved slings for SUI, 13.3% mesh for POP, and 165 (23.2%) involved both. The mesh named most often in claims was retropubic slings at 30.3% and transobturator slings at 27.1%. The number of cases filed increased significantly from 730 in 2011 to 11,798 in 2012, which then almost tripled in 2013 to 34,017. The interval from surgery to claim filing ranged from 4.8 to 5.3 years. Only 12% of implanting surgeons were or became board certified in Female Pelvic Medicine and Reconstructive Surgery. Only 4 cases named providers as codefendants. Conclusions Most legal claims involved slings for SUI and began after the 2011 Food and Drug Administration communication about mesh for POP. The rise in lawsuits does not reflect the acceptably low complication rates for slings for SUI reported in the literature.

Teaching mid-urethral sling surgery to residents: Impact on operative time and postoperative outcomes

Purpose: National Comprehensive Cancer Network prostate cancer guidelines for the prediction of life expectancy recommend subtracting 50% of life table predicted longevity for those in the lowest quartile of health. However, it is unclear how to identify these men and if their survival is uniform. Materials and Methods: We sampled records of 1,482 men diagnosed with prostate cancer from 1998 to 2004 at 2 VA hospitals. We identified men in the lowest quartile of health by age using Charlson scores, calculated their NCCN predicted life expectancy, and compared this with observed median survival in aggregate and across comorbidity subgroups. Results: Men with Charlson scores of 2+ (age less than 75 years) and 3+ (age 75 years or older) comprised the lowest quartile of health. Among those younger than 65, 65 to 69, 70 to 74, 75 to 79 and 80 years or older, observed survival vs NCCN predicted life expectancy in years was similar at 10.4 vs 11.1, 10.0 vs 7.8, 6.2 vs 6.4, 4.4 vs 4.9 and 3.7 vs 3.3, respectively. Yet within the lowest quartile there was significant heterogeneity in survival among men with differing Charlson scores. For example, men age 65 to 69 years with Charlson scores 2, 3 and 4+ had an observed median survival greater than 13.3, 9.4 and 4.3 years, respectively. NCCN guidelines misclassified 10‐year life expectancy in 24% and 56% of men age less than 65 and 65 to 69 years, and 5‐year life expectancy in 18% of men age 70 to 74 years. Conclusions: While NCCN predictions matched observed survival on average for the lowest quartile of health, there was substantial heterogeneity in survival by Charlson scores. More granular assessments of life expectancy should be used for those at highest risk for mortality.

MP31-11 OPERATIONALIZING THE NATIONAL COMPREHENSIVE CANCER NETWORK GUIDELINES FOR PREDICTING LIFE EXPECTANCY IN MEN WITH PROSTATE CANCER

I-PSS score (6.8 vs 6.9, p 1⁄40.69), nor mean FSFI score (22.9 vs 23.2, p1⁄4 0.68) compared to lower intensity cyclists. High intensity cyclists were more likely to develop perineal numbness, OR 1.6 (95% CI 1.3-2), and saddle sores, OR 2.2 (95% CI 1.8-2.8). Bike seat type had no significant effect in any of the above mentioned results. CONCLUSIONS: Contrary to previous literature, we demonstrate that cycling has no appreciable effect on female sexual or urinary function. However; our study suggests that cycling may increase the risk of UTI and perineal numbness.

PD21-07 FACTORS AFFECTING ROBOTIC OPERATIVE TIMES IN A LARGE COHORT OF PATIENTS AT A SINGLE INSTITUTION

The purpose of this study was to determine the impact of resident teaching on outcomes of mid‐urethral sling surgery.

2315 TRENDS IN BODY MASS INDEX AFTER DONOR NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: Beyond age and comorbidity, functional status shapes the long-term survival potential of patients with cancer. In this context, we sought to explore the relationship between preexisting disability and treatment utilization among older adults with kidney cancer. METHODS: From the SEER-Medicare database, we sampled 28,326 patients aged 66 and older diagnosed with primary kidney cancer from 2000-2009. Disability was quantified using functionrelated indicators (FRI), a collection of claims indicative of patient dysfunction (e.g., mobility-assist devices, falls). We assessed the relationship between FRI score and non-cancer mortality using competing risk regression, accounting for age, comorbidity, and other demographical data. Generalized estimating equations were then employed to estimate the probability of cancer-directed surgery according to FRI score, adjusting for patient and tumor characteristics. RESULTS: Overall, we identified 13,619 (48.1%) adults with 1 FRI. Functional disability was associated with older age, greater comorbidity, female gender, unmarried status, lower socioeconomic position, and more aggressive tumors (p<0.001). Patients with a FRI score of 1 (SHR 1.10, 95% CI 1.04-1.16) and 2 (SHR 1.52, 95% CI 1.44-1.60) had significantly higher likelihoods of non-cancer death compared to those with a FRI score of 0. Predicted 10-year incidence of non-cancer death stood at 35.1, 37.9, and 48.2% while the cumulative incidence of kidney cancer death reached 25.7, 28.0, and 28.9% for patients with FRI score of 0, 1, and 2 respectively. Patients with 2 or more FRIs received surgical treatment less often than those without disability (OR 0.61, 95% 0.560.66) though treatment probabilities remained overall high for patients with loco-regional disease and low for adults with metastatic cancer (Figure). CONCLUSIONS: Among older adults with kidney cancer, functional status stands as a major predictor of long-term survival. Although preexisting disability modulates treatment use to some degree, receipt of cancer-directed surgery appears largely determined by cancer stage. Patient functionality should be considered more heavily when deciding treatment for kidney cancer.

Neurological Work-Up for Urge Urinary Incontinence: When and in Whom?

INTRODUCTION AND OBJECTIVES: Robotic surgery has a variable learning curve with multiple factors potentially affecting operative times. We sought to measure the effect of patient, provider, and system-related variables on operative time. METHODS: Retrospective data was collected over a 3.5 year period on 1,099 patients undergoing 11 robotic surgeries by 23 urologists and gynecologists at Cedars-Sinai Medical Center in Los Angeles. Data included patient age, BMI, comorbidities, operative time, surgeon volume, and type of robot (da Vinci Standard vs da Vinci S System). Analyses were performed by linear regression modeling. RESULTS: Average procedure time was 4.87 þ/1.33 hours. Surgeons performed an average of 49 þ/83 surgeries (range 1 to 362, median 1⁄4 8). The upper 25th percentile of surgeons by volume performed 60 or more procedures, and the lower 25th percentile performed four or less. Patients with 25 30) was 0.35 þ/0.08 hours longer vs BMI < 25 (p < 0.001). Diabetes was also associated with increased procedure time, but age and heart disease were not. After performing a subset analysis of surgeons who performed 20 or more surgeries (n 1⁄4 10), the average procedure time for the first 10 surgeries was 4.82 þ/2.83 hours and for the last 10 was 5.03 þ/2.90 hours. The upper (n1⁄45) and lower (n1⁄46) 25th percentile of surgeons had an average procedure time of 5.31 þ/0.74 hours and 4.36 þ/0.77 hours, respectively (p 1⁄4 0.067). After accounting for covariates such as robot type and BMI, high volume surgeons took 0.90 þ/0.44 hours longer than low volume surgeons (p1⁄40.042). The average time for the da Vinci Standard was 4.70 þ/1.12 hours (n1⁄4639 procedures) and for the da Vinci S was 5.10 þ/1.55 hours (n1⁄4493 procedures) (p < 0.001). After accounting for surgeon volume, BMI, department and procedure type, the first generation da Vinci Standard had procedure times 0.35 þ/0.08 hours shorter than the second generation da Vinci S (p < 0.001). CONCLUSIONS: Unexpectedly, surgeon operative times did not tend to improve over time, and operative times were not significantly different between high and low volume surgeons. Also surprisingly operative times were not faster with the newer generation da Vinci model. After overcoming learning curves, surgeons may have an inherent “pace” that dictates their operative time.