William Sohn

Low-dose and Standard Computed Tomography Scans Yield Equivalent Stone Measurements

OBJECTIVE To ascertain the reliability of low-dose computed tomography (CT) compared with standard CT in the determination of stone size, density, and skin-to-stone distance (SSD). MATERIALS AND METHODS A total of 10 patients seen in the emergency room within a mean of 23 days (range 0-51) underwent both conventional CT and low-dose CT for the same stone. The radiation dose reduction was calculated according to the patients body mass index. The CT scans were performed with 2-mm section cuts, and 3-dimensional reconstruction was performed to obtain the coronal views. The stone size was measured (ie, height, width, and length), and the Hounsfield units were calculated. In addition, the SSD was calculated for the nonmoving renal stones. RESULTS No difference was found in stone size between the 2 dosage levels, as measured by the height, width, length, and volume of the stone (P = .9, P = .7, P = .8, and P = .8 respectively). In addition, no difference in Hounsfield units was appreciated between the 2 scan types (P = .6). Finally, no significant difference was found in the SSD (P = .5). Between the 2 scans, the average effective dose reduction was 73%, from 23 to 6 mSv (P = .002). CONCLUSION No significant difference was found in the measurement of stone size, Hounsfield units, or SSD between the low-dose and conventional-dose CT scans. However, the low-dose CT scans resulted in a marked reduction in the radiation dose to the patient.

Endockscope: using mobile technology to create global point of service endoscopy.

BACKGROUND AND PURPOSE Recent advances and the widespread availability of smartphones have ushered in a new wave of innovations in healthcare. We present our initial experience with Endockscope, a new docking system that optimizes the coupling of the iPhone 4S with modern endoscopes. MATERIALS AND METHODS Using the United States Air Force resolution target, we compared the image resolution (line pairs/mm) of a flexible cystoscope coupled to the Endockscope+iPhone to the Storz high definition (HD) camera (H3-Z Versatile). We then used the Munsell ColorChecker chart to compare the color resolution with a 0° laparoscope. Furthermore, 12 expert endoscopists blindly compared and evaluated images from a porcine model using a cystoscope and ureteroscope for both systems. Finally, we also compared the cost (average of two company listed prices) and weight (lb) of the two systems. RESULTS Overall, the image resolution allowed by the Endockscope was identical to the traditional HD camera (4.49 vs 4.49 lp/mm). Red (ΔE=9.26 vs 9.69) demonstrated better color resolution for iPhone, but green (ΔE=7.76 vs 10.95), and blue (ΔE=12.35 vs 14.66) revealed better color resolution with the Storz HD camera. Expert reviews of cystoscopic images acquired with the HD camera were superior in image, color, and overall quality (P=0.002, 0.042, and 0.003). In contrast, the ureteroscopic reviews yielded no statistical difference in image, color, and overall (P=1, 0.203, and 0.120) quality. The overall cost of the Endockscope+iPhone was

1-Stage Repair of Obliterative Distal Urethral Strictures With Buccal Graft Urethral Plate Reconstruction and Simultaneous Onlay Penile Skin Flap

154 compared with

MP93-18 CAVERNOUS NERVE RECONSTRUCTION BY PROCESSED NERVE ALLOGRAFT DURING ROBOT-ASSISTED RADICAL PROSTATECTOMY

46,623 for a standard HD system. The weight of the mobile-coupled system was 0.47 lb and 1.01 lb for the Storz HD camera. CONCLUSION Endockscope demonstrated feasibility of coupling endoscopes to a smartphone. The lighter and inexpensive Endockscope acquired images of the same resolution and acceptable color resolution. When evaluated by expert endoscopists, the quality of the images overall were equivalent for flexible ureteroscopy and somewhat inferior, but still acceptable for flexible cystoscopy.

PD42-09 CLINICAL COMPARISON OF CONVENTIONAL AND MOBILE ENDOCKSCOPE VIDEOCYSTOSCOPY USING AN AIR OR FLUID IRRIGANT

PURPOSE When penile skin is available, onlay flap reconstruction is an excellent choice for 1-stage repair of complex hypospadias and strictures involving the glans, fossa navicularis and penile urethra. When the urethra is deficient circumferentially, tube flaps are an option but there is a high failure rate. We report our 8-year experience with 1-stage reconstruction using a dorsal buccal mucosa graft to reconstruct the deficient urethral plate with repair completed using an onlay penile skin flap. MATERIALS AND METHODS A total of 12 patients with a mean age of 42.8 years (range 16 to 77) underwent dorsal buccal grafting with ventral skin flap repair. Buccal mucosa was quilted to the penile ventral corpora to reconstruct the dorsal urethral aspect. Most surgeries included buccal graft reconstruction of the glans and fossa navicularis. Onlay penile skin flap repair was then performed to complete the reconstruction. RESULTS All 12 patients were free of disabling chordee or urethral stricture disease at a mean 39-month followup (range 7 to 96). In 1 patient a small urethrocutaneous fistula developed, which was repaired. In another patient a fistula and medium caliber fossa navicularis narrowing developed with associated chordee, which were successfully repaired. CONCLUSIONS Dorsal buccal grafting with ventral flap reconstruction appears to be an excellent option to repair circumferential urethral deficiency when penile skin is available, especially when chordee correction with distal urethral plate reconstruction is required.

MP5-07 AN EMPIRICAL EVALUATION OF VARIATION IN INTENSITY OF SURVIVORSHIP CARE AND ITS EFFECT ON KIDNEY CANCER-SPECIFIC SURVIVAL

recurrence after radical prostatectomy (RP), due in part to underpowered cohorts and limited follow up. Herein, we evaluated the association between obesity and PCa recurrence after RP using a large institutional dataset with long-term follow-up. METHODS: We reviewed years 1987-2013 of the Mayo Clinic RP Registry to identify men with Body Mass Index (BMI) information available. Men who underwent PCa treatment prior to RP and men with metastatic disease at RP were excluded. Patients were grouped into four BMI categories: < 25, 25-29.9, 30-34.9, and > 35. BMI > 30 was defined as obese. Standard descriptive statistics compared baseline characteristics, while forced entry multivariable cox proportional hazard models assessed the association of BMI with metastasis and prostate cancer mortality (PCM). Multivariable models were adjusted for pre-RP PSA, pathologic Gleason Score, pT stage, pN stage, margin status, age, adjuvant hormone therapy, adjuvant radiation, year of surgery, and open vs robotic approach. RESULTS: In our cohort of 18,039 men (median follow-up 9.3 years after RP), 20.6% (3,707), 51.9% (9,348), 21.9% (3,936) and 5.6% (1,016) had a BMI < 25, 25-29.9, 30-34.9, and > 35, respectively. Higher BMI categories had higher rates of pathologic Gleason Score 7-10 disease: 38.7%, 40.7%, 46.1%, 54.0%, respectively (p<0.001). Obese patients also had higher positive margin rates: 23.4%, 26.3%, 30.1%, 31.9%, respectively (p<0.001). PSA, pT stage, pN stage, and adjuvant therapy did not significantly differ between BMI categories (p>0.05). Log Rank comparisons found higher Kaplan-Meier rates of metastasis and PCM for patients with a BMI of 30-34.9 and > 35 (p<0.05 for all). On multivariable cox regression for metastasis, patients with a BMI 30-34.9 (HR 1.307, 95% CI 1.0731.592, p1⁄40.008) and BMI > 35 (HR 1.421, 95% CI 1.071-1.886, p1⁄40.015) had an increased risk of metastasis relative to patients with a BMI < 25. Similarly, patients with a BMI 30-34.9 (HR 1.323, 95% 1.010-1.733, p1⁄40.042) and BMI > 35 (HR 1.620, 95% CI 1.098-2.392, p1⁄40.015) had higher PCM rates relative to patients with BMI < 25 on multivariable analysis. CONCLUSIONS: Our data supports an independent association between BMI and PCa metastasis and cancer-specific mortality after RP. There was a direct increase in the odds of metastasis and PCM between the BMI 30-34.9 and BMI > 35 groups, further strengthening this link. Further study is warranted to determine if weight loss can abrogate this effect of obesity on PCa recurrence after RP.

PD13-03 ENDOCKSCOPE: USING MOBILE TECHNOLOGY TO CREATE GLOBAL POINT OF SERVICE ENDOSCOPY

INTRODUCTION AND OBJECTIVES: Conventional videocystoscopy (CVC) requires sterile fluid irrigant, a high power external light source, a cystoscope, and a video monitor/camera system. The high equipment cost makes the widespread use of videocystoscopy prohibitive in underserved populations. We developed the Endockscope (ES), a novel and affordable videocystoscopy system, which utilizes a mobile phone for image display and a solar-rechargeable LED-flashlight as a light source and sought to compare the resultant endoscopic view with CVC in real clinical settings using both air and fluid as an irrigant. METHODS: Patients scheduled for in-office videocystoscopy for either bladder tumor surveillance or stent removal were considered eligible. Each patient first received CVC visualizing the bladder in a systematic manner using normal saline, a video monitor, external light source, and flexible fiberoptic cystoscope. Without removing the cystoscope, the ES was attached to the cystoscope using the iPhone 6S as a video monitor/camera and the flashlight as the light source. The cystoscopy was then repeated with fluid irrigant (Endockscope-Fluid, ES-F) and then the fluid was drained and replaced with the same volume of air (Endockscope-Air, ES-A). All three exams were recorded and then sent to 11 expert endourologists for grading on a variety of metrics (1-5 scale, 5 being best): image quality/resolution, brightness, color quality, sharpness, overall quality, and whether the video was acceptable for diagnostic purposes (yes/no). RESULTS: Ten patients underwent CVC, ES-F, and ES-A cystoscopy (J.L. or R.V.C.). Six of the 10 patients had CVC videos deemed acceptable for diagnostic purposes and thus were compared with ES. The CVC videos scored higher on every metric relative to both the ES-F and ES-A (p < 0.05). The largest difference noted between CVC and ES videos was brightness (p < 0.0001). ES-F videos trended toward higher ratings than ES-A on all metrics, although none reached statistical significance (p > 0.05); 52% and 44% of the ES-F and ES-A videos, respectively, were considered acceptable for diagnostic purposes (p 1⁄4 0.384). CONCLUSIONS: The Endockscope mobile cystoscopy system using a fluid irrigant may be a reasonable option in settings where electricity or access to conventional videocystoscopic equipment is unavailable.

Changing trends in pelvic lymphadenectomy in radical prostatectomy with the advent of robotic surgery.

INTRODUCTION AND OBJECTIVES: Enhanced recovery after surgery (ERAS) protocol is designed to improve perioperative care and decrease hospital stay without increasing complications. We have previously shown ERAS facilitates bowel function recovery and shortens hospital stay after radical cystectomy (RC) without increasing hospital readmission rates within the first 30-days. We now evaluate our ERAS protocol for complications in the first 90 days following RC. METHODS: All patients who underwent open RC with the ERAS perioperative protocol from 5/12 to 08/14 were included in the study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and u-opioid antagonists. Non-consenting and patients lost to follow-up were excluded. 90-day complications (Clavien-Dindo grading system), readmissions and emergency room (ER) visits were prospectively recorded and compared to a group of matched controls (non-ERAS) who underwent RC from 10/08 to 5/12 by the same surgeons. Controls were matched by: age, sex, smoking status, BMI, Charlson comorbidity index and pathology stage. RESULTS: A total of 169 consecutive patients (ERAS) and 108 controls (non-ERAS) were included in the study. The median ages of groups were 71.0 (ERAS) and 69.9 (controls). The 90-day major complication rate was 24.3%, and 22.2%; while the minor complication rate was 53.9% vs 57.4% for ERAS and controls respectively (p1⁄40.34). Furthermore, the median number of complications per patient was 1.0 and 2.0 for ERAS and controls (p1⁄40.29). The rate of Gastrointestinal (GI) complications (21.3 vs. 33.3%; p1⁄40.03) and wound complications (11.8% vs. 20.4%; p1⁄40.05) were both lower in ERAS. Finally, the 90-day readmission rate (29.6% vs 26.9%; p1⁄40.24) and ER visit rate (37.9% vs 35.2%; p1⁄40.20) were not different between ERAS and controls respectively. CONCLUSIONS: Our ERAS protocol does not increase overall complication rates, hospital readmissions or ER visits compared to matched non-ERAS patients 90-days following RC. Furthermore, ERAS significantly reduces the frequency of GI complications during the 90-day time point. Though wound complications were lower in ERAS, the borderline p-value is inconclusive in demonstrating a reduction of complications in that category.

PD12-03 IMPACT OF ADHERENCE TO QUALITY MEASURES FOR LOCALIZED PROSTATE CANCER ON HEALTH-RELATED QUALITY OF LIFE OUTCOMES

Abstract Background and Purpose: Recent advances and the widespread availability of smartphones have ushered in a new wave of innovations in healthcare. We present our initial experience with Endockscope, a new docking system that optimizes the coupling of the iPhone 4S with modern endoscopes. Materials and Methods: Using the United States Air Force resolution target, we compared the image resolution (line pairs/mm) of a flexible cystoscope coupled to the Endockscope+iPhone to the Storz high definition (HD) camera (H3-Z Versatile). We then used the Munsell ColorChecker chart to compare the color resolution with a 0° laparoscope. Furthermore, 12 expert endoscopists blindly compared and evaluated images from a porcine model using a cystoscope and ureteroscope for both systems. Finally, we also compared the cost (average of two company listed prices) and weight (lb) of the two systems. Results: Overall, the image resolution allowed by the Endockscope was identical to the traditional HD camera (4.49 vs 4.49 l...

PD12-06 INCREASED PAYMENT FOR OFFICE-BASED MANAGEMENT OF BLADDER CANCER: UNINTENDED CONSEQUENCES IN A FEE-FOR-SERVICE ENVIRONMENT

39 Background: It is important to determine whether changes in technology have impacted surgical practice. With the adoption of robotic surgery, it is our hypothesis that rates of pelvic lymphadenectomy (LND) have decreased, even when controlling for cancer risk and comorbidities. To assess whether adoption of surgical technology versus practice patterns in the extent of surgery over time changed, we propose to compare the rates of pelvic LND at the time of radical prostatectomy during the time period when robotic surgery was adopted. METHODS Data was extracted from CaPSURE, a multi-institutional, longitudinal observational database of men with prostate cancer. A total of 3,938 men diagnosed with localized prostate cancer between 2000 and 2011 were included in the analysis if they underwent surgical extirpation. The inclusion of LND was calculated for both groups. Other information included site type, age at diagnosis, comorbidities, and CAPRA risk assessment score. RESULTS A total of 3,616 open retropubic prostatectomies and 322 robotic prostatectomies were included for analysis. Among the open prostatectomies, 78.9% underwent pelvic LND. During the same time period, among robotic prostatectomies, 45.3% underwent pelvic LND. There was a statistically significant correlation between method of radical prostatectomy and the performance of LND (p < 0.001). There were no statistically significant differences between the two groups in CAPRA score, age, or comorbidities (p= 0.06, 0.29, and 0.60; respectively). The adjusted odds ratio of LND for the open group compared to the robotic group is 5.90 (95% CI [4.48,7.78]) while adjusting for clinical stage, grade, and PSA. CONCLUSIONS Controlling for other factors, the difference in rates of LND between the open and robotic groups were statistically significant. These data suggest changes in surgical practice may have been altered by the adoption of a new technique to perform surgery (rather than new scientific data supporting omission of LND).