Matthew E. Pollard

Unnecessary imaging for the staging of low-risk prostate cancer is common.

OBJECTIVEnTo quantify the rate of overuse of preoperative imaging procedures in a referral cohort of low-risk patients. International evidence-based best practice guidelines discourage routine imaging for staging purposes in low-risk patients with newly diagnosed prostate cancer.nnnMATERIAL AND METHODSnAn institutional database comprised of all patients undergoing robotic-assisted laparoscopic prostatectomy was queried for low-risk patients between May 2005 and January 2010. Low-risk was defined by the most inclusive criteria for imaging recommendations: prostate-specific antigen ≤10 ng/mL and Gleason score ≤6. We defined staging imaging as a bone scan, computed tomography (CT) of the pelvis or endorectal magnetic resonance imaging performed after the diagnosis of prostate cancer and before prostatectomy for the indication of prostate cancer. Six-hundred seventy-seven patients were identified as having low-risk disease and comprised our study population.nnnRESULTSnOf the 677 patients identified as low risk, 328 (48%) underwent at least one preoperative imaging procedure despite the guideline recommendations. Two-hundred two of 677 (30%) patients were administered at least 2 of the 3 modalities, and 18/677 (3%) patients received all 3 imaging examinations before prostatectomy. Suspicious results from the CT (7/265%, 2.7%) or bone scan (21/241%, 8.7%) resulted in 27 patients undergoing additional radiographic imaging, none of which resulted in suspicious lesions requiring intervention or biopsy.nnnCONCLUSIONSnDespite international evidence-based guidelines for the staging of newly diagnosed prostate cancer patients, many urologists continue to refer low-risk patients for unnecessary imaging studies. This may place the patient at increased risk from radiation or contrast exposure and places an unnecessary financial burden on the patient and health care system.

Health literacy and disease understanding among aging women with pelvic floor disorders.

Objectives Few studies on health literacy and disease understanding among women with pelvic floor disorders have been published. We conducted a pilot study to explore the relationship between disease understanding and health literacy, age, and diagnosis type among women with urinary incontinence and pelvic organ prolapse. Methods The study subjects were recruited from urology and urogynecology specialty clinics based on a chief complaint suggestive of urinary incontinence or pelvic prolapse. Subjects completed questionnaires to assess symptom severity, and health literacy was measured using the Test of Functional Health Literacy in Adults. Patient-physician interactions were audiotaped during the office visit. Immediately afterward, patients were asked to describe diagnoses and treatments discussed by the physician and record them on a checklist, with follow-up phone call, where the same checklist was administered 2 to 3 days later. Results A total of 36 women with pelvic floor disorders, aged 42 to 94 years, were enrolled. We found that health literacy scores decreased with increasing age. However, all patients had low percentage recall of their pelvic floor diagnoses and poor understanding of their pelvic floor condition despite high health literacy scores. Patients with pelvic prolapse seemed to have worse recall and disease understanding than patients with urinary incontinence. Conclusions High health literacy as assessed by the Test of Functional Health Literacy in Adults may not correlate with patients’ ability to comprehend complex functional conditions such as pelvic floor disorders. Lack of understanding may lead to unrealistic treatment expectations, inability to give informed consent for treatment, and dissatisfaction with care. Better methods to improve disease understanding are needed.

Decisional regret after robotic-assisted laparoscopic prostatectomy is higher in African American men

OBJECTIVESnLongitudinal studies report racial disparities in prostate cancer (PCa) including greater incidence, more aggressive tumor biology, and increased cancer-specific mortality in African American (AA) men. Regret concerning primary treatment selection is underevaluated in patients with PCa. We investigated the relationships between clinicopathologic variables across racial and socioeconomic lines following robotic-assisted laparoscopic prostatectomy.nnnMATERIALS AND METHODSnWe assessed treatment decisional regret using a validated questionnaire in a total of 484 white and 72 AA patients with PCa who were followed up for a median of 16.6 months post-robotic-assisted laparoscopic prostatectomy. Socioeconomic status (SES) information was aggregated from 2010 US census zip code data. Perioperative clinicopathologic characteristics and functional outcomes were compared between groups. Univariate and multivariate regression analyses were used to evaluate the influence of race, aggregate SES, and other clinical and demographic characteristics on decisional regret.nnnRESULTSnThe majority (87.7%) of the population was not regretful of their decision to undergo treatment. However, a greater proportion of AA vs. white patients were regretful (20.6% vs. 11.2%, respectively; P = 0.03). AA and white men were similar on all functional, clinical, and pathologic features with the exception of younger age among AA men (56 vs. 60 y, respectively; P<0.001). Although there were significant differences in SES by race (P<0.001), regret did not differ by SES (β =-1.53; P = 0.15). Race, postoperative sexual dysfunction, pad usage, and length of hospital stay, however, were significantly associated with decisional regret.nnnCONCLUSIONSnAA men were more regretful than white men, after adjusting for clinicopathologic characteristics and postoperative functional outcomes.

Outcomes of pregnancy following surgery for stress urinary incontinence: a systematic review.

PURPOSEnAlthough few data have been published on the safety of childbearing after surgery for stress urinary incontinence, a large proportion of physicians recommend that women wait to complete childbearing before pursuing surgical treatment for stress urinary incontinence. We systematically reviewed the available literature to examine the safety of pregnancy after stress urinary incontinence surgery, and to measure the effect of such pregnancy on continence outcomes.nnnMATERIALS AND METHODSnThe review was conducted according to the recommendations of the MOOSE (Meta-Analysis of Observational Studies in Epidemiology) group. We performed a systematic review to identify articles published before January 2011 on pregnancy after incontinence surgery. Databases searched include PubMed®, EMBASE® and the Cochrane Review. Our literature search identified 592 titles, of which 20 articles were ultimately included in the review.nnnRESULTSnData were tabulated from case reports, case series and physician surveys. The final analysis in each category included 32, 19 and 67 patients, respectively. Urinary retention developed during pregnancy in 2 women, 1 of whom was treated with a sling takedown and the other with intermittent catheterization. Of these 2 women 1 also had an episode of pyelonephritis during pregnancy, possibly related to the intermittent catheterization. The incidence of postpartum stress urinary incontinence ranged from 5% to 18% after cesarean delivery and from 20% to 30% after vaginal delivery.nnnCONCLUSIONSnAlthough the data on outcomes in the literature are limited and further studies need to be performed on the subject, the current data suggests that any increase in risks for pregnancy after surgery for stress incontinence may be small. A low risk of urinary retention during pregnancy may exist. Although some data suggest that cesarean deliveries may result in a lower rate of recurrent stress urinary incontinence than vaginal deliveries, a formal analysis could not be performed with the available data.

Cost-effectiveness analysis of treatments for metastatic castration resistant prostate cancer

Objective Treatment options for metastatic castration resistant prostate cancer (mCRPC) have expanded rapidly in recent years. Given the significant economic burden, we sought perform a cost-effectiveness analysis (CEA) of the contemporary treatment paradigm for mCRPC. Methods We devised a treatment protocol consisting of sipuleucel-T, enzalutamide, abiraterone, docetaxel, radium-223, and cabazitaxel. We estimated number and length of treatments for each therapy using dosing schedules or progression free survival data from published clinical trials. We estimated treatment cost using billing data and Medicare reimbursement values and performed a CEA. Our analysis assumed US

Abdominal approaches to pelvic prolapse repairs.

100,000 per life year saved (LYS) as the threshold societal willingness to pay. Results Incremental cost-effectiveness ratios (ICER) for strategies incorporating sipuleucel-T that were not eliminated by extended dominance exceeded the societal threshold willingness-to-pay of US

Time-Driven Activity-Based Costing Analysis of Urologic Stone Disease

100,000 per LYS, the lowest of which was sipuleucel-T + enzalutamide + abiraterone + docetaxel at US

PD06-02 DECISIONAL QUALITY AND THE IMPACT OF SHARED DECISION MAKING AMONG PATIENTS WITH UROLOGIC STONE DISEASE

207,714 per LYS. Enzalutamide + abiraterone + docetaxel exhibited the most favorable ICER among strategies without sipuleucel-T at US

PD09-07 THE IMPACT OF SHARED DECISION MAKING SOFTWARE ON DECISIONAL QUALITY OF MEN UNDERGOING TREATMENT FOR BPH: AN INTERIM ANALYSIS

165,460 per LYS. Conclusion Based on the available survival data and current costs of treatment, all treatment strategies greatly exceed a commonly assumed societal willingness-to-pay threshold of US

Heterogeneity of Outcomes in D'Amico Intermediate-Risk Prostate Cancer Patients after Radical Prostatectomy: Influence of Primary and Secondary Gleason Score

100,000 per LYS. Improvements in this regard can only come with a reduction in pricing, better tailoring of treatment or significant enhancements in survival with clinical use of treatment combinations or sequences.