Simone Thavaseelan

Relationship Between Serum Vitamin D and 24-Hour Urine Calcium in Patients With Nephrolithiasis

OBJECTIVE To examine the relationship between serum 25-OH vitamin D and 24-hour urine calcium in patients with nephrolithiasis. METHODS A retrospective review was performed. Patients evaluated in 2 metabolic stone clinics were included for analysis. Multivariate linear regression models were adjusted for known risk factors for stone disease (age, gender, body mass index, hypertension, diabetes mellitus, gout, relevant medications, and 24-hour urine composition). RESULTS One-hundred sixty-nine patients were included in the study. Female to male ratio was 69:100, mean age was 50.9 years (SD 13.7), and mean body mass index was 27.4 (SD 6.4). Vitamin D deficiency (25-OH vitamin D <20 ng/mL) was present in 18.9% of patients, vitamin D insufficiency (>20, <30 ng/mL) was present in 34.9% of patients, and vitamin D was within normal limits (≥ 30 ng/mL) in 46.1% of patients. On age-adjusted and multivariate linear regression, serum 25-OH vitamin D was not related to 24-hour urine calcium (age adjusted β = -0.31 m 95% CI -1.9 to 1.3; multivariate adjusted β = 0.08, 95% CI -1.3 to 1.5). CONCLUSION Although 25-OH vitamin D is involved in the bodys calcium homeostasis, our study does not show a relationship between serum vitamin D level and 24-hour urine calcium excretion in stone-formers. This information may have implications regarding the safety of vitamin D repletion in patients with nephrolithiasis.

Hand-Assisted Laparoscopic Versus Robot-Assisted Laparoscopic Partial Nephrectomy: Comparison of Short-Term Outcomes and Cost

INTRODUCTION Robot-assisted laparoscopic partial nephrectomy (RALPN) and laparoscopic partial nephrectomy (LPN) have become standard for the surgical management of small renal masses (SRMs). However, no studies have evaluated the short-term outcomes or cost of RALPN as compared with hand-assisted laparoscopic partial nephrectomy (HALPN) in a standardized fashion. METHODS A retrospective review of all patients who underwent HALPN or RALPN from 2006 to 2010 were assessed for patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, radiographic tumor size, nephrometry (radius, endo/exophytic, nearness to collecting system, anterior/posterior, lines of polarity [RENAL]) scores, operative and room times, hospital length of stay (LOS), estimated blood loss (EBL), requirement of hilar vessel clamping, warm ischemia time (WIT), pre- and postprocedural creatinine and hemoglobin levels, and complications. Total costs of the procedures were estimated based on operating room component (operative staff time, anesthesia, and supply) and hospital stay cost (room and board, pharmacy). A robotic premium cost, estimated based on the yearly overall cost of the da Vinci S surgical system divided by the annual number of cases, was included in the RALPN cost. Cost figures were obtained from hospital administration and applied to the mean HALPN and RALPN patient. RESULTS Forty-seven patients underwent HALPN since 2006 and 21 patients underwent RALPN since 2008. ASA, BMI, EBL, tumor size, nephrometry score, positive margin rate, change in creatinine, change in hemoglobin, morphine equivalents used, and complication rate were all similar in both groups (p>0.05). Room time and operative time were significantly shorter for the HALPN cohort (p=0.001) whereas LOS was significantly shorter in the RALPN cohort (p=0.019). Despite the shorter LOS, RALPN was associated with a

Histopathologic changes after bipolar resection of the prostate: depth of penetration of bipolar thermal injury.

1165 increased cost, mainly due to increased operating room time and premium cost of the robot. CONCLUSIONS While early in our experience, RALPN offered no significant advantage in short-term outcomes over HALPN and was associated with an increased cost of over

The Representation of Women in Urologic Leadership

1150.

Critical Analysis of a New Generation Electrohydraulic Lithotripter: A Single Institution Experience with the Medispec E3000

BACKGROUND AND PURPOSE While the power needed to initiate bipolar vaporization is higher than conventional monopolar resection, the energy needed to maintain bipolar vaporization is significantly lower and may result in less thermal tissue injury. This may have implications for hemostasis, scarring, and perioperative morbidity. The objective of this study is to assess histopathologic changes in prostatic tissue after bipolar transurethral vaporization of the prostate. PATIENTS AND METHODS Male patients older than 40 years with a diagnosis of benign prostatic hyperplasia (BPH) who elected to undergo bipolar transurethral vaporization of the prostate were included in this study. Patients were excluded if they had a previous transurethral resection of the prostate (TURP) or prostate radiation therapy. An Olympus button vaporization electrode was used to vaporize prostate tissue. A loop electrode was then used to obtain a deep resection specimen. The vaporized and loop resection surfaces were inked and sent for pathologic analysis to determine the presence of gross histologic changes and the depth of penetration of the bipolar vaporization current. RESULTS A total of 12 men underwent bipolar TURP at standard settings of 290 W cutting and 145 W coagulation current. Mean patient age was 70±10.2 years (range 56-88 years). Mean surgical time was 48.7±20.2 minutes (range 30-89 min). Mean depth of thermal injury was 2.4±0.84 mm (range 0.3-3.5 mm). Histopathologic evaluation demonstrated thermal injury in all specimens, but no gross char was encountered. CONCLUSIONS In bipolar systems, resection takes place at much lower peak voltages and temperatures compared with monopolar systems. Theoretically, this leads to less collateral thermal damage and tissue char. Our tissue study illustrates that the button vaporization electrode achieves a much larger depth of penetration than previous studies of bipolar TURP. This may be because thermal injury represents a gradual continuum of histologic changes.

What's Gender Got to Do with It: Difference in the Proportion of Traditionally Female Cases Performed by General Urologists of Each Gender

Introduction: While urology has historically been a male dominated field, the number of female urologists is increasing. In 2015 women made up 7.7% of practicing urologists and 17.1% of urologists younger than age 45 years. In the medical field overall females have been markedly underrepresented in leadership positions. We assess the current prevalence of women in urological leadership roles. Methods: Using data from the Accreditation Council for Graduate Medical Education, and society and journal leadership boards, we compiled a list of editorial staff, boards of directors, department chairs and program directors in July 2016. Queried societies included the American Board of Urology, American Urological Association, Society of Genitourinary Reconstructive Surgeons, Societies for Pediatric Urology, Society of Urologic Oncology, Society of Academic Urologists, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, and the Large Urology Group Practice Association. Editorial boards examined were from The Journal of Urology® and Urology. We also included committee members who wrote American Urological Association guidelines between 2011 and 2016. Results: Women represent 10% of leadership positions in the queried organizations and are underrepresented in advanced leadership positions. There were no women on the American Urological Association board of directors and women made up 1.6% of department chairs. Of the committees 76% included at least 1 woman. Overall, 75% of women on committees were urologists. By comparison, 95% of men on committees were urologists. Conclusions: Overall, women are fairly represented in a broad cross‐section of leadership roles. Women are less well represented in the upper echelon of urological leadership, especially department chairs.

MP76-13 SCRIBES IN AMBULATORY UROLOGIC PRACTICE: FINANCIAL ANALYSIS AND PRACTICE MANAGEMENT CONSIDERATIONS

BACKGROUND AND PURPOSE The Medispec E3000(™) is a new generation electrohydraulic lithotripter with a wider focal width comparable to the Dornier HM3(™). We evaluate the efficacy of this machine for management of urinary stones at our institution by shockwave lithotripsy (SWL). MATERIALS AND METHODS There were 168 urinary calculi managed using the Medispec E3000 lithotripter over a 14-month period (10/2010-12/2011). During the first 6 months (10/2010-6/2011), a low power ramping protocol of 11-12-17 kV was used, and for the remaining 6 months (6/2011-12/2011), stones were managed with a higher power ramping protocol of 15-17-22.5 kV. A subanalysis of these groups was performed, as well as for stone location. The major end point was stone-free rate (SFR), defined as fragments <4 mm on follow-up imaging. Data were analyzed using the Fisher exact test and two-tailed Student t test. RESULTS The study included 102 males and 66 females with an average age of 52.8 years. Mean stone size was 6.9 × 7.2 mm, which was significantly associated with SFR (P<0.0010). The overall SFR was 64.9%, with no significant difference between stones managed with the low power protocol (61.3%) and the high power protocol (70%). SFR varied by location across the upper pole (64.9%), midpolar area (57.1%), lower pole (68.4%), renal pelvis (79.2%), proximal ureter (66.6%), midureter (83.3%), and distal ureter (53.8%), but these differences were not significant (P=0.59). Efficiency quotient for the Medispec E3000™ was 54%. CONCLUSIONS Overall, we achieved SFR of 64.9% in our initial experience with the Medispec E3000™. Optimizing treatment parameters may further improve success rates, and further outcomes follow-up may allow a more comprehensive evaluation of the lithotripters overall efficacy.

The Impact of Multidisciplinary Care in a Large Volume Robot-Assisted Radical Prostatectomy Program: A Paradoxical Stage Migration toward More Aggressive Disease

OBJECTIVE To examine surgical case volume characteristics in certifying urologists to evaluate practice patterns, given the long-standing understanding but unproven hypothesis that non-fellowship trained female general urologists perform more urogynecologic procedures compared with their equally trained male counterparts. MATERIALS AND METHODS Case log data from certifying and recertifying urologists from 2000 to 2015 were obtained from the American Board of Urology. Thirty-seven Current Procedural Terminology (CPT) codes were chosen to represent traditionally urogynecologic cases. Logistic regression analysis models were used to determine the percentage of total CPT codes logged during the certification period made up by traditionally urogynecologic cases. Male and female non-fellowship trained, self-described general urologists were compared. RESULTS The case logs of 4032 non-fellowship trained general urologists were reviewed from 2000 to 2015, 297 of whom were female and 3735 of whom were male. Urogynecologic cases made up 1.27% of the total CPT codes logged by the women and 0.59% of those codes logged by the men (P <.001), an increase of 2.2 times (P <.001). This statistically significant difference persisted regardless of certification period, geographic location, population density, or full-time vs part-time employment. CONCLUSION Traditional urogynecologic cases represented a significantly greater percentage of the total cases logged by non-fellowship trained female general urologists compared with their non-fellowship trained, generalist male colleagues. The percentage of total cases performed by both is very small. However, it supports a belief that patient populations differ for male and female general urologists, which may impact training or career choices.

2235 SHOULD 25-OH VITAMIN D BE CHECKED IN ALL STONE-FORMERS WITH HYPERCALCIURIA AND ELEVATED PTH?

INTRODUCTION AND OBJECTIVES: Projections demonstrate a worsening shortage of urologists in the United States in the next decade. Advanced practice providers (APPs) are increasingly used in urology and other fields to improve physician productivity. While APPs have become common in urology clinics, little data exists regarding the use of APPs in the surgical setting. Though in the past, urologists were often assisted by a second surgeon for complicated operations, we hypothesized that APPs are increasingly filling that role. This study aims to quantify the change in surgical assist patterns over time for commonly performed urologic operations. METHODS: We used data derived from the Medicare Physician/Supplier Procedure Summary Master File to examine the rates of APP-assisted and surgeon-assisted procedures performed by urologists from 2003-2014, as identified by CPT codes and modifiers. The annual frequency is reported by assist type for six common urologic operations: robotic prostatectomy, open prostatectomy, radical cystectomy, open nephrectomy, open partial nephrectomy, and laparoscopic nephrectomy. The average annual rates of change were determined using least squares regression and tested using ttests (a1⁄40.05). RESULTS: Of the 677,111 urologic operations analyzed, 5.0% of cases were assisted by APPs compared to 27.0% assisted by a second surgeon. The proportion of cases assisted by an APP rose significantly for all procedures (Figure 1); conversely, the proportion of cases assisted by a second surgeon declined significantly for all procedures, except for open partial nephrectomy. The largest changes were seen in robotic prostatectomies; similar proportions of robotic prostatectomies are now performed by APPs as by second surgeons. CONCLUSIONS: Urologists are increasingly using APPs as assistants in surgery, particularly in laparoscopic and robotic cases. This trend will likely continue as the shortage of urologists worsens in coming years. At the same time, surgical assistance is less frequently being performed by a second surgeon, which may decrease opportunities for refining operative skills. APPs can be a valuable part of the surgical team, but further consideration of the impacts of this shift in practice is needed.

Bilateral manual externalization of testis with self-castration in patient with prion disease.

Introduction: With the widespread use of robot-assisted radical prostatectomy (RARP), a stage migration to less aggressive prostate cancer (CaP) may be expected in pathological specimens due to over-treatment of low risk disease. It is unclear whether implementation of a multidisciplinary clinic (MDC) model would offset this phenomenon. We sought to analyze our database for possible stage migration in prostatectomy specimens in the setting of MDC. Methods: A total of 262 patients who underwent open prostatectomy (OP) from 2004 to 2006 and 757 patients who underwent RARP from 2007 to 2011 were identified from our prospective database. The implementation of MDC occurred concurrently at the time of RARP initiation. Demographic data, pathology, positive margin rates along with standard CaP reporting data were recorded. The two groups were compared with regards to percentage of cases stratified by Gleason grade. Results: The number of CaP cases managed at our institution increased considerably after the introduction of robotics and MDC. There was a significant decrease in the patients with Gleason 6 CaP undergoing RARP as compared with OP (p = 0.001). Additionally, RARP was performed on a significantly greater percentage of Gleason 7 disease (p < 0.001). When comparing pathological stage, there was a significant increase in the incidence of pT3 disease following RARP (p < 0.0001). Conclusions: The introduction of a MDC and minimally invasive radical prostatectomy did not result in an increased application of surgery for the treatment of low risk prostate cancer. This highlights the importance of MDC in a large volume RARP program.