Michael J. Naslund

Application of argon beam coagulation in urological surgery

Argon beam coagulation is a new form of electrocautery that has proved useful to control diffuse bleeding in other surgical specialties. We report its application to urology. Three cases are presented in which argon beam coagulation provided excellent hemostasis in situations that are often difficult to control, such as partial nephrectomy for penetrating trauma, hemorrhagic cystitis refractory to other forms of treatment and after anterior exenteration for bladder cancer. The basis, technique and advantages of argon beam coagulation are discussed, as well as other instances in urological surgery in which it may have application. Argon beam coagulation is an alternative to conventional methods of hemostasis whenever there is a diffusely bleeding operative site.

Laparoscopy: Its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotropin stimulation

Laparoscopy has been used to help evaluate patients with a unilateral nonpalpable testis. This procedure can be performed quickly just before exploration with the patient under the same anesthetic. With laparoscopy it has been possible to localize either a testis or the course of the spermatic vessels in 100 per cent of the patients. Preoperative knowledge of testis location is helpful to plan the location of the incision as well as the type of repair. The incidence of vanishing testis in our series is much higher than that reported previously. This difference is attributed to a careful examination with the patient under anesthesia and preoperative treatment with human chorionic gonadotropin, which made many testes palpable. These results indicate that laparoscopy can be performed safely and quickly, and that it is helpful to manage patients with a unilateral nonpalpable testis.

Malignant renal schwannoma.

Renal schwannomas are rare tumors. There have been only 4 cases (2 benign and 2 malignant) reported in the literature. We report a third case of a malignant renal schwannoma and review the literature on this subject.

THE SOCIOECONOMIC IMPLICATIONS OF PROSTATE-SPECIFIC ANTIGEN SCREENING

Widespread PSA screening will increase overall health care costs. This increase will not result from the detection of clinically insignificant prostate cancer, but rather from the stage migration caused by prostate cancer screening. This stage migration will result in a larger percentage of men with prostate cancer undergoing early treatment options, which are more expensive than treatment of late disease. More importantly, early detection of prostate cancer will lead to treatment several years earlier than would have occurred otherwise. Because treatment then will be paid for in current rather than future dollars, the opportunity costs of money will make treatment costs resulting from PSA screening greater than treatment costs resulting from traditional detection. The critical question is what benefits will be obtained by the expenditure of these additional health care dollars. If early treatment of clinically localized cancer has little or no effect on cause-specific survival, the additional health care costs will have been spent only to limit eventual treatment of local symptoms in the screened men. If early treatment of prostate cancer can increase survival, the added expense is more worthwhile. Because there are not adequate data available to address this issue, several approaches have been used to develop models to estimate cost-effectiveness. Decision analysis models have been used to evaluate the effectiveness of prostate cancer screening and treatment and have found little or no benefit. The current review has demonstrated how assumptions used in the models can influence the results. Benoit et al also have constructed a model of the effectiveness and cost-effectiveness of prostate cancer, but in this study only concrete parameters such as cost, published complication rates, and survival data were used. This quantitative analysis demonstrated that prostate cancer screening is an effective and cost-effective health care intervention compared with currently accepted medical interventions. Although men aged 50 to 70 years will potentially benefit the most from PSA screening, this benefit will not be realized until these men are in their seventh and eighth decades of life. Society must decide if the years of life saved in these men warrants the use of its limited health care resources. This decision will be easier when randomized, controlled trials are available to quantify the costs and benefits of PSA screening.

Detection of latent prostate cancer from routine screening: Comparison with breast cancer screening

OBJECTIVESnOne criticism of routine prostate cancer screening is the possibility that latent prostate cancer would be detected and treated in men who would otherwise never need treatment for their prostate cancer. This increase in latent cancer detection with screening could lead to overtreatment, with its resulting increases in morbidity, mortality, and health care costs. In contrast, breast cancer screening is widely accepted, and there is little concern about latent breast cancer detection and overtreatment of breast cancer due to screening. This study compares the detection of latent prostate cancer from screening with the detection of latent cancer in an established cancer screening program (breast cancer screening) and examines the risk that screening leads to an increase in detection of latent cancer over traditional methods of detection for both breast and prostate cancer.nnnMETHODSnThe present study reviews outcomes data from several large prostate and breast cancer screening trials. The natural history of latent prostate and breast cancer is then reviewed. By applying this information, the rate of latent prostate cancer detection and latent breast cancer detection with screening is compared.nnnRESULTSnRecent large-scale prostate cancer screening studies have reported a latent cancer detection rate of 2.9% to 8.0%. This rate of detection is virtually the same as that found by traditional methods of detection. Ductal carcinoma in situ (DCIS) is a noninvasive breast cancer that accounts for 16.2% to 23.7% of breast cancers detected in screening programs using mammography. The literature estimates that DCIS will remain latent in 50% to 66% of patients. These data suggest that the latent breast cancer detection rate in screening programs is 8.1% to 15.6%, which is a threefold to fivefold increase compared with the detection rate of latent breast cancer prior to screening with mammography.nnnCONCLUSIONSnThese results suggest that the latent prostate cancer detection rate from screening is similar to or less than the latent breast cancer detection rate from screening. Furthermore, prostate cancer screening does not appear to increase the detection rate of latent cancer over traditional methods of detection. This should eliminate concern that prostate cancer screening will lead to overtreatment of prostate cancer.

Twitter Mentions and Academic Citations in the Urology Literature

OBJECTIVEnTo quantify the relationship between the number of Twitter mentions and the number of academic citations a urologic publication receives.nnnMATERIALS AND METHODSnTwo hundred and thirteen papers from 7 prominent urologic journals were examined 37 months after publication. Articles were evaluated with 2 citation based bibliometrics (Scopus, Google Scholar) and Twitter mentions were tracked using the Altmetric Bookmarklet. The number of article citations and Twitter mentions were compared using one-way Analysis of variance (ANOVA) and bivariate fit analysis.nnnRESULTSnSeventy-three percent of articles had at least 1 Twitter mention. Forty-two percent of Twitter mentions occurred within the first week of the online publication date. Articles mentioned on Twitter had 2.0-fold more Scopus citations (P <.01), and 2.3-fold more Google Scholar citations (P <. 01) compared to articles with no Twitter mentions. Female urologic articles had the greatest number of Twitter mentions (5.7 mentions/article) while pediatric urology had the fewest mean number of Twitter mentions (0.8 mentions/article). A total of 8.9% of papers were tweeted by their authors. Author tweeted articles were associated with a 12.3 (2.0-fold) and 15.5 (1.8-fold) mean citation increase for Scopus and Google Scholar (P <. 01 and P = . 01) compared to articles not shared by their authors on Twitter.nnnCONCLUSIONnThe majority of urologic publications are being shared on Twitter. The number of citations a urologic publication receives up to 3 years after release is positively associated with the number of mentions it has on Twitter. Twitter activity may be an early indicator of ultimate academic impact of an academic urologic paper.

MP69-05 TWITTER MENTIONS AND ACADEMIC CITATIONS IN UROLOGY LITERATURE

INTRODUCTION AND OBJECTIVES: Clinical trials have suggested that pelvic floor rehab (PFR) can improve early urinary control following radical prostatectomy. However, the details surrounding its use in clinical practice and its contribution to cost and value are not well understood. In this context, we examined the use of PFR in a diverse statewide quality improvement collaborative, including patient characteristics, implementation patterns, and costs. METHODS: Using registry data from the Michigan Urological Surgery Improvement Collaborative and claims data from Michigan Value Collaborative, we identified all men who underwent a laparoscopic radical prostatectomy from 04/2014 through 11/2015 with insurance from Medicare or a large commercial payer. All men reported pre-operative urinary function using the STAR questionnaire with scores ranging from 0 (worst) to 21 (best). We compared patient demographics, cancer characteristics, pre-operative urinary function, and 90-day total episode costs of patients who did and did not receive PFR. RESULTS: 142 menmet our inclusion criteria, of whom 53 (37%) received pelvic floor rehab. There were no differences in patient or cancer characteristics among patients who did and did not receive PFR. Patients initiated PFR an average of 34 days after discharge (range 15-83 days). Mean baseline urinary function scores were worse for PFR patients (17.8 vs 19.3, p1⁄40.01). Ninety-day episode costs were similar in the two cohorts, with PFR contributing an average of

An Examination of Treatment Patterns and Costs of Care Among Patients With Benign Prostatic Hyperplasia

422, or 3% of total episode costs. CONCLUSIONS: In a statewide collaborative, PFR is used in the minority of cases, but its use appears to be concentrated among patients with worse baseline urinary function. Incremental costs from PFR are modest, accounting for 3% of 90-day episode costs. In the era of value-based care, decisions about further expanding this therapy will depend on studying its comparative impact on post-operative patient reported outcomes in large groups of non-clinical trial patients.