Yongmei Qin

The Value of Urodynamics in an Academic Specialty Referral Practice

OBJECTIVE To describe and evaluate the use of urodynamics (UDS) studies for all indications in an academic specialty referral urology practice. MATERIALS AND METHODS This is a prospective questionnaire-based study wherein clinicians completed a pre- and post-UDS questionnaire on each UDS that they ordered for all clinical indications between May 2013 and August 2014. Questions pertained to patient demographics and history, the clinical indication for the UDS, the clinicians pre- and post-UDS clinical impressions, and changes in post-UDS management plans. Pre- and post-UDS diagnoses were compared using the McNemar test. RESULTS Clinicians evaluated a total of 285 UDS studies during the study period. The average age of study participants was 56.0 (±16.4) years, 59.5% were female, and 29.3% had a neurologic diagnosis. The most common indication for performing UDS was to discern the predominant type of urinary incontinence (stress vs urgency) in patients with mixed incontinence symptoms (38.5%) and to assess the safety of the bladder during filling (38.2%). UDS statistically significantly changed the ordering clinicians clinical impression of the patients lower urinary tract diagnosis for stress urinary incontinence and for urgency and urgency urinary incontinence (both had P values of <.05). Fluoroscopy was found to be helpful in 29.5% of urodynamic studies, and clinicians reported that UDS changed their treatment plans in 42.5% of the studies, most commonly pertaining to changes related to surgery (35.0%). CONCLUSION Overall, UDS was a clinically useful tool that altered the clinical impression and treatment plan in a large percentage of carefully selected patients.

Predictors and Cost of Readmission in Total Knee Arthroplasty

BACKGROUND The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost. METHODS We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population. RESULTS We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was

Population Analysis of Male Urethral Stricture Management and Urethroplasty Success in the United States

6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost. CONCLUSIONS A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.

Does Post-Void Residual Volume Predict Worsening Urological Symptoms in Patients with Multiple Sclerosis?

OBJECTIVE To examine population-based practice patterns and outcomes related to urethroplasty for urethral stricture management. METHODS We conducted a retrospective study of adult males with urethral stricture disease treated from January 2001 to June 2015 using the Clinformatics Data Mart Database. Treatment was defined as urethral dilation, direct visualized internal urethrotomy, and urethroplasty. We then examined anterior or posterior urethroplasty outcomes defining failure as any subsequent procedure specific to urethral stricture disease occurring >30 days after urethroplasty. We used multivariable and time-to-event analysis to examine factors associated with failure. RESULTS We identified 75,666 patients treated for urethral stricture disease, with 420 and 367 undergoing anterior and posterior urethroplasty, respectively. Urethroplasty utilization doubled from 2005 to 2015. One- and 5-year failure rates for anterior and posterior urethroplasty were 25% and 18%, and 40% and 25%, respectively, with median times to failure of 5.1 and 4.1 months. Failures were salvaged primarily with direct visualized internal urethrotomy, with salvage urethroplasty in 19% and 12% of anterior and posterior repairs, respectively. CONCLUSION Despite increasing population-based urethroplasty utilization over the past decade in our insured cohort, we found higher rates of salvage treatments than reported by high-volume and expert surgeon reports. Further efforts appear warranted to balance workforce expertise and quality of urethroplasty care to meet increasing urethral stricture population needs.

The effects of cystoscopy and hydrodistention on symptoms and bladder capacity in interstitial cystitis/bladder pain syndrome

Purpose: Our goal was to examine how post‐void residual urine volume relates to urinary symptoms in patients with multiple sclerosis. Materials and Methods: We retrospectively reviewed the records of patients with multiple sclerosis who had lower urinary tract symptoms and presented to a tertiary neurourology clinic. Patients for whom post‐void residual volume was recorded at the initial urological assessment were included in our analysis. Results of the AUA (American Urological Association) SI (Symptom Index) and the M‐ISI (Michigan Incontinence Symptom Index) completed at this visit were analyzed to assess the severity of lower urinary tract symptoms and incontinence. A chart review was performed to obtain information on demographics and documented urinary tract infections. Results: Between 2014 and 2017, 110 patients diagnosed with multiple sclerosis underwent post‐void residual volume measurement at our clinic. Average post‐void residual volume was 123.4 cc (range 0 to 650 cc). The mean AUA symptom score was 19.1 with an average bother score of 4.1. Analysis of post‐void residual volume as a continuous variable did not show an association between increasing post‐void residual volume and an increasing AUA SI or bother score (p = 0.53 and 0.44, respectively). When evaluated by post‐void residual volume tertile, no relationship was found between post‐void residual volume, and the AUA SI and the M‐ISI (p = 0.54 and 0.57, respectively). No correlation was also found between increasing post‐void residual volume and a recent history of recurrent urinary tract infections (p = 0.27). Conclusions: Post‐void residual volume was not associated with worsening obstructive lower urinary tract symptoms as assessed by the AUA SI, worsening incontinence as measured by the M‐ISI score or an increased risk of recurrent urinary tract infections in select patients with multiple sclerosis and lower urinary tract symptoms.

PD34-08 REAL-WORLD EFFECTIVENESS OUTCOMES FOR URETHROPLASTY

The use of cystoscopy and hydrodistention in the management of interstitial cystitis/bladder pain syndrome (IC/BPS) varies widely between providers. Current evidence regarding the risks and benefits of hydrodistention, as well as the long term effects of repeated hydrodistention are not well established. We sought to characterize the effects of hydrodistention on IC/BPS symptoms as well as bladder capacity.

PD58-05 CONTRIBUTING TO A CRISIS? DEFINING NATIONAL PATTERNS IN OPIOID PRESCRIBING AFTER OUTPATIENT VASECTOMY

INTRODUCTION AND OBJECTIVES: Urethral stricture disease is common condition with significant quality of life and economic implications. While endoscopic treatment with incision or dilation is the most common treatment approach, guidelines increasingly recommend urethroplasty based on its high success rates. Whether real world, community practice outcomes mirror those of large volume single center institutional series is unknown. For these reasons, we conducted a population-based study of patients treated with urethroplasty and their outcomes. METHODS: We identified male patients who underwent urethroplasty between 2001 and June 2015 based on ICD-9 codes and administrative claims from a large, national US health insurer (ClinformaticsTM Data Mart Database, OptumInsight, Eden Prairie, MN). We assessed utilization of endoscopic treatments (urethrotomy and dilation) prior to and after urethroplasty. We defined urethroplasty failure by any subsequent urethral dilation, urethrotomy, or urethroplasty after initial urethroplasty. We examined factors associated with failure using multivariable logistic regression and Cox proportional hazards models. RESULTS: We identified 1345 patients treated with urethroplasty. Urethroplasty failure occurred in 344 (26%) of patients. Repeat urethroplasty was performed in 139 (40%) of failures (range 28). Increased number of endoscopic treatments prior to first urethroplasty was associated with urethroplasty failure. The mean ( SD) time to failure was 270 42 days. CONCLUSIONS: Our population-based study demonstrated significantly lower success rates for urethroplasty than previously published reports. Strategies to achieve better outcomes for patients with urethral stricture disease include increasing referrals to reconstructive urologic surgeons, and knowledge and technique transfer to community urologists interested in providing this service rather than repeated, low-value endoscopic treatment.

PD60-11 POPULATION-BASED MANAGEMENT OF MALE URETHRAL STRICTURE DISEASE

INTRODUCTION AND OBJECTIVES: Surgical quality improvement literature has historically focused on strategies in cost reduction, outcome improvement, and increasing operating room (OR) efficiency. To this point, a vast majority of available literature on OR turnover has focused on institutional factors: role of the surgeon, leanthinking practices, and team perception of turnover. However, a paucity of research exists on patient-specific factors that may ultimately affect OR duration and turnover. Our objective was to determine the role of patient characteristics on urology OR turnover in both a hospital and ambulatory setting. METHODS: Patients undergoing urology procedures at our institution have routine prospective data collection, including preoperative ASA classification, as well as various time landmarks before, during, and between procedures (time patient enters the OR, time of intubation, etc). Retrospective collection of OR start and end times from an OR scheduling software was conducted. Emergency cases were excluded. Analysis of variance with effects of hospital vs. ambulatory location and ASA class (I-IV) was performed on logarithmically transformed times (to correct skew), followed by Tukeys test for multiple comparisons. RESULTS: A total of 1766 patients undergoing 1788 urology procedures over a 9 month period (January-September 2016) were stratified by ASA class I-IV. Both ASA class and location significantly affected time from OR start to procedure start, and time from procedure end to OR end; these times increased as ASA class increased. All OR times were significantly less in the ambulatory setting for any given ASA. CONCLUSIONS: Though patient characteristics have long been known to effect intra-operative duration, prior literature has not properly determined the role of patient factors in OR turnover times. Our data demonstrate that turnover times were shorter in our ambulatory setting and that, as ASA class increases, OR start and end times are prolonged. Future quality improvement studies should focus on patientspecific factors that may affect OR efficiency. Source of Funding: None.

Role of Post–Acute Care on Hospital Readmission After High-Risk Surgery

INTRODUCTION AND OBJECTIVES: Patient and disease characteristics influence ureteric stricture management with DJ stents, metallic stents, endoscopic, or reconstructive surgery. Memokaths are an option with reported 90-100% patency and 14-30% complication rates, but the published literature is limited by small sample size and short follow-up duration up to 22 months. Objective: To independently analyse 5-year Memokath stent outcomes, identifying variables associated with good outcomes to update clinical guidelines. METHODS: Management of obstructed ureteric stricture patients with Memokath stents was reviewed independently using electronic patient records. Outcomes included time to first complication, complications’ incidence and severity. Multiple linear regression was performed identifying variables linked with particular outcomes. RESULTS: 100 patients aged 23-87 years (mean 57) received Memokath stents for ureteric obstruction, 59% for malignant strictures, with 20% bilateral. Only 25 patients had no complications: either alive with, or dying of their primary malignancy with their original Memokath. Median time to complication in the remaining 75 patients was 12.5 months with Memokaths lasting longer in patients with malignancy (p1⁄40.02). Multiple linear regression analyses showed that increased eGFR (p1⁄40.005) and age (p1⁄40.0001) independently significantly predicted greater Memokath lifespan, while co-morbidities, stricture length and location, and underlying pathology, did not. 5 year outcomes: 25 patients had a Memokath in situ: 14 still alive with the original. 22 had other stents, while 12 required major surgery. 66% of patients with most severe complications (need for major surgery or dialysis) were in the benign group. CONCLUSIONS: Memokaths are a reasonable option for patients with malignant ureteric obstruction and life expectancy up to 1 year. Age and eGFR greater than 45 predicted longer Memokath duration. Patient and stricture variables other than aetiology did not affect Memokath durability, but should be considered for delivery of the most appropriate patient-centred individualised care. 5 year complication rates were significantly higher than previously reported (75 vs 25%). Updated practice guidelines would aid future patient selection and counselling, as well as encouraging protocolled follow-up and patient reported outcomes assessment, when considering metallic stent drainage for ureteric obstruction.