Tudor Borza

Technical Refinement and Learning Curve for Attenuating Neurapraxia During Robotic-Assisted Radical Prostatectomy to Improve Sexual Function

BACKGROUND While radical prostatectomy surgeon learning curves have characterized less blood loss, shorter operative times, and fewer positive margins, there is a dearth of studies characterizing learning curves for improving sexual function. Additionally, while learning curve studies often define volume thresholds for improvement, few of these studies demonstrate specific technical modifications that allow reproducibility of improved outcomes. OBJECTIVE Demonstrate and quantify the learning curve for improving sexual function outcomes based on technical refinements that reduce neurovascular bundle displacement during nerve-sparing robot-assisted radical prostatectomy (RARP). DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective study of 400 consecutive RARPs, categorized into groups of 50, performed after elimination of continuous surgeon/assistant neurovascular bundle countertraction. SURGICAL PROCEDURE Our approach to RARP has been described previously. A single-console robotic system was used for all cases. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Expanded Prostate Cancer Index Composite sexual function was measured within 1 yr of RARP. Linear regression was performed to determine factors influencing the recovery of sexual function. RESULTS AND LIMITATIONS Greater surgeon experience was associated with better 5-mo sexual function (p = 0.007) and a trend for better 12-mo sexual function (p = 0.061), with improvement plateauing after 250-300 cases. Additionally, younger patient age (both p<0.02) and better preoperative sexual function (<0.001) were associated with better 5- and 12-mo sexual function. Moreover, trainee robotic console time during nerve sparing was associated with worse 12-mo sexual function (p=0.021), while unilateral nerve sparing/non-nerve sparing was associated with worse 5-mo sexual function (p = 0.009). Limitations include the retrospective single-surgeon design. CONCLUSIONS With greater surgeon experience, attenuating lateral displacement of the neurovascular bundle and resultant neurapraxia improve postoperative sexual function. However, to maximize outcomes, appropriate patient selection must be exercised when allowing trainee nerve-sparing involvement.

Patterns of care and outcomes of radiotherapy for lymph node positivity after radical prostatectomy

To evaluate the use and outcomes of adjuvant radiation therapy (ART) for men with lymph node (LN)‐positive disease after radical prostatectomy (RP) using a population‐based approach.

Early Detection, PSA Screening, and Management of Overdiagnosis

Prostate cancer diagnosis and treatment rates have increased significantly since the introduction of prostate-specific antigen (PSA) screening. Although it was initially thought that most prostate cancers would lead to death or significant morbidity, recent randomized trials have demonstrated that many patients with screening-detected cancer will not die of their disease. Modifications to PSA screening, screening guideline statements, and novel screening markers have been developed to minimize the risk and morbidity associated with overdiagnosis and overtreatment. Less aggressive management strategies such as active surveillance may lead to lower treatment rates in men who are unlikely to benefit while maintaining cure rates.

The Role of Transurethral Resection in Trimodal Therapy for Muscle-Invasive Bladder Cancer.

While radical cystectomy (RC) with pelvic lymph node dissection (PLND) represents the accepted gold standard for the treatment of muscle-invasive bladder cancer, this treatment approach is associated with significant morbidity. As such, bladder preservation strategies are often utilized in patients who are either deemed medically unfit due to significant comorbidities or whom decline management with RC and PLND secondary to its associated morbidity. In a select group of patients, meeting strict criteria, bladder preservation approaches may be employed with curative intent. Trimodal therapy, consisting of complete transurethral resection of bladder tumor (TURBT), chemotherapy, and radiation therapy has demonstrated durable oncologic control and long-term survival in a number of studies. The review presented here provides a description of trimodal therapy and the role of TURBT in bladder preservation for patients with muscle-invasive bladder cancer.

MP75-04 VARIATION IN NATIONAL OPIOID PRESCRIBING PATTERNS FOLLOWING OUTPATIENT NEPHROLITHIASIS PROCEDURES

have recently instituted several quality improvement initiatives, one of which includes decreased hospital reimbursement for re-admissions within 30 days. We attempted to identify trends surrounding outpatient ureteroscopy in hopes of decreasing future ED visits. METHODS: A retrospective chart review from 7/1/2015 to 12/ 31/2015 was performed to identify patients who returned to the ED within 30 days of elective ureteroscopy. CPT codes 52351-6 and 52344-6 were used as search parameters. Patient demographics, operative characteristics, and ED presentation data were collected and analyzed. RESULTS: A total of 330 ureteroscopies were performed, resulting in 47 ED visits (14.2%) occurring an average of 8.4 days [1e28] postoperatively. 29 were female and 18 male with an average age of 48.2 [16-86]. 27 (57.4%) were pre-stented an average of 11.5 days preoperatively. All patients were discharged with a stent in place, and 26 (55.3%) with a string attached with instructions to remove at home. 40 (85.1%) were discharged with either Tylenol#3 or Tramadol for pain control. The most common presenting complaint was flank pain (59.6%). Of these patients, 13 (46.4%) presented after the stent was self-pulled, 3 (10.7%) presented after the stent was inadvertently removed, 4 (14.3%) after it was removed via cystoscopy in clinic, and 8 (28.6%) with the stent in place. CONCLUSIONS: The rate of ED visits following ureteroscopy is estimated to be from 5% to 16%. Our results were in line with previous data demonstrating pain as the most common presenting complaint in the ED following ambulatory surgery. The cause of the pain may be due to issues with self-removal of stents and inadequate postoperative pain management. Some evidence exists that pre-stenting improves stone free rates, which intuitively would lead to decreased ED visits. However, this was not the case in our data as a majority of patients had been prestented. This hypothesis-generating study elicits the need to explore potential methods, including improved pain management and expectations, particularly with self-pulled stents, in order to possibly decrease ED visit rates.

Reimbursement and use of intensity-modulated radiation therapy for prostate cancer

Abstract The use of intensity-modulated radiation therapy (IMRT) for prostate cancer increased through the mid-2000s, in association with acquisition of the devices by large urology groups. More recently, reimbursement for IMRT in the office setting (generally representing freestanding facilities owned by physicians) has been declining. The aim of the study was to examine trends in IMRT use and related payments in the office versus hospital outpatient setting over time. In this retrospective cohort study, a total of 66,967 men aged 66 years or older, with newly diagnosed prostate cancer from 2007 through 2012 were identified in a 20% national sample of Medicare claims. IMRT use in the office versus hospital outpatient setting was examined over time, adjusted for patient characteristics using multivariable logistic regression models. Mean reimbursement for IMRT treatments and total IMRT-related payments were plotted by year. IMRT use increased from 28.6% to 38.0% of newly diagnosed men with prostate cancer over the study period, exclusively related to growth in the office setting. In particular, use in the office setting increased from 13.2% in 2007 to 22.1%, whereas use in the hospital outpatient setting remained essentially steady throughout the period around 15%. During the same period mean reimbursement for IMRT in the office setting declined from

MP04-06 PERSONALIZED DECISION SUPPORT TOOL TO PREVENT HOSPITAL READMISSION FOR PATIENTS TREATED WITH RADICAL CYSTECTOMY

504 per individual radiation treatment to

MP32-20 UROLOGIST PRACTICE STRUCTURE AND VALUE OF PROSTATE CANCER CARE

381, whereas it increased from

MP32-07 ASSOCIATION BETWEEN HOSPITAL ACCOUNTABLE CARE ORGANIZATION STATUS AND READMISSION FOLLOWING CYSTECTOMY AND OTHER MAJOR SURGERY

283 to

PD34-08 REAL-WORLD EFFECTIVENESS OUTCOMES FOR URETHROPLASTY

380 in the hospital outpatient setting. However, total IMRT-related payments in the office setting increased through 2011 due to increased utilization, falling only in 2012 (to