Remy Lamberts

Contemporary Use of Partial Nephrectomy: Are Older Patients With Impaired Kidney Function Being Left Behind?

OBJECTIVE To assess whether patient factors, such as age and preoperative kidney function, were associated with receipt of partial nephrectomy in a national integrated healthcare system. MATERIALS AND METHODS We identified patients treated with a radical or partial nephrectomy from 2002 to 2014 in the Veterans Health Administration. We examined associations among patient age, sex, race or ethnicity, multimorbidity, baseline kidney function, tumor characteristics, and receipt of partial nephrectomy. We estimated the odds of receiving a partial nephrectomy and assessed interactions between covariates and the year of surgery to explore whether patient factors associated with partial nephrectomy changed over time. RESULTS In our cohort of 14,186 patients, 4508 (31.2%) received a partial nephrectomy. Use of partial nephrectomy increased from 17% in 2002 to 32% in 2008 and to 38% in 2014. Patient race or ethnicity, age, tumor stage, and year of surgery were independently associated with receipt of partial nephrectomy. Black veterans had significantly increased odds of receipt of partial nephrectomy, whereas older patients had significantly reduced odds. Partial nephrectomy utilization increased for all groups over time, but older patients and patients with worse baseline kidney function showed the least increase in odds of partial nephrectomy. CONCLUSION Although the utilization of partial nephrectomy increased for all groups, the greatest increase occurred in the youngest patients and those with the highest baseline kidney function. These trends warrant further investigation to ensure that patients at the highest risk of impaired kidney function are considered for partial nephrectomy whenever possible.

Incident CKD after Radical or Partial Nephrectomy

The comparative effectiveness of partial nephrectomy versus radical nephrectomy to preserve kidney function has not been well established. We determined the risk of clinically significant (stage 4 and higher) CKD after radical or partial nephrectomy among veterans treated for kidney cancer in the Veterans Health Administration (2001-2013). Among patients with preoperative eGFR≥30 ml/min per 1.73 m2, the incidence of CKD stage 4 or higher after radical (n=9759) or partial nephrectomy (n=4370) was 7.9% overall. The median time to stage 4 or higher CKD after surgery was 5 months, after which few patients progressed. In propensity score-matched cohorts, partial nephrectomy associated with a significantly lower relative risk of incident CKD stage 4 or higher (hazard ratio, 0.34; 95% confidence interval [95% CI], 0.26 to 0.43, versus radical nephrectomy). In a parallel analysis of patients with normal or near-normal preoperative kidney function (eGFR≥60 ml/min per 1.73 m2), partial nephrectomy was also associated with a significantly lower relative risk of incident CKD stage 3b or higher (hazard ratio, 0.15; 95% CI, 0.11 to 0.19, versus radical nephrectomy) in propensity score-matched cohorts. Competing risk regression models produced consistent results. Finally, patients treated with a partial nephrectomy had reduced risk of mortality (hazard ratio, 0.55; 95% CI, 0.49 to 0.62). In conclusion, compared with radical nephrectomy, partial nephrectomy was associated with a marked reduction in the incidence of clinically significant CKD and with enhanced survival. Postoperative decline in kidney function occurred mainly in the first year after surgery and appeared stable over time.

Relationship between Vasectomy and Sexual Frequency.

INTRODUCTION Men who are considering vasectomy as a means of contraception may have significant anxiety about their future sexual potency. As a result, couples may choose other forms of contraception with lower efficacy. AIM We sought to determine the relationship between vasectomy and the frequency of sexual intercourse. METHODS We analyzed data from cycles 6 (2002) to 7 (2006-2008) of the National Survey of Family Growth to compare the frequency of sexual intercourse of men who had undergone vasectomy with men who had not. Analysis was performed using data from male and female responders, and excluded men who had never had sex and those below age 25. We constructed a multivariate logistic regression model to adjust for demographic, socioeconomic, reproductive, and health factors. MAIN OUTCOME MEASURE The main outcome measure was the sexual frequency in the last 4 weeks. RESULTS Among male responders, a total of 5838 men met criteria for our study; 353 had undergone vasectomy. For vasectomized men, the average frequency of sexual intercourse was 5.9 times per month compared with 4.9 times for nonvasectomized men. After adjusting for age, marital status, race, education, health, body mass index, children, and income, vasectomized men had an 81% higher odds (95% confidence interval [CI] 6-201%) of having intercourse at least once a week compared with nonvasectomized men. A total number of 5211 female respondents reported 670 of their partners had undergone vasectomy. For partners of vasectomized men, the average frequency of intercourse was 6.3 times per month, compared with 6.0 times for partners of nonvasectomized men. After adjustment, women with vasectomized partners had a 46% higher odds (95% CI 5-103%) of having sexual intercourse at least once a week compared with women with nonvasectomized partners (P = 0.024). CONCLUSION Vasectomy is not associated with decreased sexual frequency. This finding may be helpful to couples as they consider contraceptive options.

The Relationship Between Offspring Sex Ratio and Vasectomy Utilization

OBJECTIVE To determine if there was an association between vasectomy utilization and offspring sex ratio (male offspring : total offspring), as offspring sex preference may have an impact on family planning in the United States. METHODS Using data from the National Institutes of Health-AARP Diet and Health Study, we calculated the number of sons and daughters of all men stratified by vasectomy status. We utilized a logistic regression model to determine if vasectomy utilization varies based on offspring sex ratio while accounting for known factors that impact vasectomy utilization. RESULTS Of these men, 30,927 (30.8%) underwent vasectomy. Marital status, race, age, education level, region or state, and number of offspring were all significantly correlated with vasectomy utilization (P < .01). The sex ratio for vasectomized fathers (51.3%) was significantly higher than for fathers who had not undergone vasectomy (50.7%, P < .01). This difference remained even after we stratified by the total number of offspring: vasectomized men with 4 or more children had a sex ratio of 947 girls per 1000 boys, whereas the no vasectomy group had a sex ratio of 983 girls per 1000 boys (P < .01). For men with at least 2 children, each additional son increased the likelihood of vasectomy by 4% (P < .01), whereas each additional daughter led to a 2% decrease in vasectomy utilization (P = .03). CONCLUSION Vasectomized fathers have a higher proportion of sons compared with non-vasectomized fathers, suggesting that offspring sex ratio is associated with a mans decision to undergo vasectomy. Further research is indicated to understand how offspring sex ratio impacts a mans contraceptive decisions.

Minimizing the Cost of Treating Asymptomatic Ureterolithiasis

Introduction: Treatment of patients with ureterolithiasis who report resolution of their symptoms but do not recall passing the stone presents a clinical challenge. We analyzed the cost of different therapeutic strategies for these patients. Methods: We performed a cost minimization analysis using published efficacy data and Medicare reimbursement costs. We compared 1) up‐front ureteroscopy with planned lithotripsy, 2) followup imaging to determine presence or absence of stone using computerized tomography, abdominal plain film or ultrasound and 3) observation. We performed sensitivity analyses on the factors driving cost, including the probability of stone passage and ultrasound sensitivity. Results: Observation was associated with the lowest costs for patients likely to spontaneously pass the ureteral stone (greater than 62%). Initial imaging with computerized tomography was the least costly approach for patients with an intermediate probability of stone passage (21% to 62%). When the sensitivity of ultrasound was modeled to be high (greater than 79%), it surpassed computerized tomography as the least costly approach across a wide range of spontaneous passage rates. Ureteroscopy was associated with the lowest costs when the probability of spontaneous stone passage was low (less than 21%). Conclusions: The probability of spontaneous passage of a ureteral stone can be used to optimize treatment strategies for patients. Observation minimizes costs for patients with stones likely to pass spontaneously, whereas ureteroscopy minimizes costs for stones unlikely to pass. For ureteral stones with an intermediate probability of spontaneous passage computerized tomography to guide treatment is associated with the lowest estimated costs.

PD21-02 MINIMIZING THE COST OF TREATING ASYMPTOMATIC URETEROLITHIASIS

requirements were lower in the SWL group than in the URSL group (0.3 0.08 vs. 0.9 0.20; p < 0.001). Multivariate analysis identified age and analgesic requirements as predictors of lower HRQoL on the RCS summary scale (p1⁄40.029 and p1⁄40.002, respectively). CONCLUSIONS: Patients who underwent SWL had a higher post-lithotripsy HRQoL, but lower stone-free rates, compared to those who underwent URSL. Higher postoperative pain appeared to be the primary cause of the lower HRQoL in the URSL group. In order to determine the appropriate treatment approach, it is essential to understand not only the surgical outcomes and recurrence rates but also the HRQoL associated with each treatment strategy.

MP25-04 COST-EFFECTIVENESS OF IPP VERSUS INJECTION TREATMENT IN PATIENTS WHO FAIL ORAL MEDICATION

disease (PD), diabetes (DM), number of vascular comorbidities, BMI >30 and patient age. RESULTS: 901 patients were analyzed. Mean age 56.6 10.6 years. Mean BMI 30.2 5.1. Comorbidity profile was: diabetes 75%, dyslipidemia 44%, hypertension 33%, cigarette smoker 32%, PD 34%. 76% had a malleable implant and 24% an inflatable implant. 31% had a minor complication and 9% a major complication. 93% had high satisfaction (1⁄44). Patients with any complication had a reduced rate of high satisfaction compared to those without (88% vs 98%; p<0.001) and likewise with a major complication (64% vs 98%; p<0.001). On MVA, BMI >30, number of vascular risk factors, type of implant and DM were not predictive of high satisfaction. Only the absence of a major complication was a significant predictor of high satisfaction (OR 20, 95% CI 9-50, p <0.001). The presence of PD was almost statistically significant. CONCLUSIONS: A high percentage of men are satisfied after penile implant surgery. Only the presence of a major complication is robustly linked to a lower likelihood of achieving high satisfaction.