- Email: [email protected]
61 LONGTERM FOLLOW-UP OF MICROSOCOPIC MICROHEMATURIA AFTER NEGATIVE DIAGNOSTIC WORK-UP
Vol. 189, No. 4S, Supplement, Saturday, May 4, 2013
THE JOURNAL OF UROLOGY姞
studies conducted exclusively in the United States, enrollment of black men was associated with sample size (p⫽0.025), yet not with the use of public funding (p⫽0.534). We identified no study that enrolled black men exclusively or prospectively planned to stratify the analysis based on ethnic background. CONCLUSIONS: Enrollment of black men in RCTs of prostate cancer treatment appears low with no substantial improvement over time. Considering the high disease burden of prostate cancer in black men, increased effort to improve their participation in RCTs is essential.
e25
762 Paents Diagnosed with Prostate Ca Between 2000-2006
501 Paents (65.7%) Alive
261 Paents (34.3%) Died 75 Paents (28.7%) Lost to follow-up or Incomplete Data
Source of Funding: Prostate Cancer Research Program Collaborative Undergraduate HBCU Student Summer Training Program Award by the Department of Defense Office of the Congressionally Directed Medical Research Programs; Department of Urology, University of Florida; University of Florida Prostate Disease Center.
186 Paents (71.3%) Complete Data Available
145 Paents (71.0%) Other cause of death
41 Paents (22.0%) mCaP cause of death
60 PROSTATE CANCER MORTALITY IN AN EQUAL ACCESS HEALTHCARE SYSTEM
28 Paents (68.3%) Presented with mCaP
Figure 1. Diagram of paent populaon
Jane Cho*, Michael Liss, Douglas Skarecky, Thomas Ahlering, Atreya Dash, Orange, CA INTRODUCTION AND OBJECTIVES: Despite aggressive prostate cancer screening, men continue to die of advanced metastatic disease (mCaP). Recent literature suggests that some men dying are the healthy elderly (ⱖ75). In the contemporary PSA era, we characterize a cohort of men dying from mCaP in an equal access healthcare system. METHODS: We queried the Long Beach Veterans Hospital database for men diagnosed with prostate cancer from 1/2000-12/ 2006. Causes of death were identified (prostate cancer specific vs other). This cohort was characterized regarding demographics and clinical features. Prostate cancer death was confirmed with death certificate and chart review. The Mann-Whitney test for non-parametric values comparing those who presented with mCaP compared to those who eventually developed mCaP. Kaplan-Meier analysis with significance was determined by the Breslow test. RESULTS: We identified 762 men diagnosed with prostate cancer and of these, 34.3% (261/762) died at mean follow-up of 9 years. Complete follow up data was available on 71.3% (186/261) men. Of those men, 22% (41/186) died of mCaP and of these, 68.3% (28/41) presented with mCaP (See Figure 1). The median age was 69 yrs (49-90), Charlson score 1 (0-6), Gleason sum of 7 (6-10), PSA at diagnosis 22 (3-4662), first screening PSA 6 (1-2120). Six (14.6%) men received surgery and 9 (22.0%) had radiation therapy. Of men presenting with metastatic disease 28.6% (8/28) had no previous PSA recorded. There was a significant difference in age at diagnosis, smoking status, and time interval from biopsy to death (p⫽0.023, p⫽0.037, and p⫽0.007) between men who presented with mCaP and men who developed mCaP. Median survival of men who presented with mCaP was earlier than that of men who developed mCaP (595 days vs.1044 days; p⫽0.01). Among men older than 75 yrs who presented with mCaP, 91.7% (11/12) died of disease despite having higher cardiovascular risk factors by prior MI status [41.7%, (5/12) vs. 6.7% (2/29) (p⫽0.016)]. CONCLUSIONS: Prostate cancer mortality has a complex mix of men with mCaP and those men who died during long-term treatment. The majority of men who die of mCaP presented with metastatic disease. Especially at risk are men older than 75 yrs in which PSA screening was not recommended according to previous guidelines. Further investigation is warranted in this subset of men.
13 Paents (31.7%) Developed mCaP
Source of Funding: None
61 LONGTERM FOLLOW-UP OF MICROSOCOPIC MICROHEMATURIA AFTER NEGATIVE DIAGNOSTIC WORK-UP Nicolai Leonhartsberger*, Viktor Skradski, Renate Pichler, Brigitte Stöhr, Wolfgang Horninger, Hannes Steiner, Innsbruck, Austria INTRODUCTION AND OBJECTIVES: The objectives of this study were to determine the potential development of malignancies in the urinary tract or other diseases during the follow-up period after negative (no urological cancer) diagnostic work-up of microscopic hematuria. As the predictive value and the follow-up period for microscopic hematuria is not clear, patients were observed in a longterm follow-up period. METHODS: In this retrospective study charts of patients diagnosed with microscopic microhematuria in our department between July 1999 and March 2011 were searched and data corresponding to the inclusion criteria were collected. Criteria for inclusion in this study were a complete diagnostic assessment of microhematuria with ultrasonography, cystoscopy, upper urinary tract imaging and a follow-up period of at least 3.5 years after diagnostic microhematuria examination. The initial detection of malignancy was an exclusion criterion. The outcome of patients was evaluated across an average period of 8 years (3.7- 10.2 years). RESULTS: 87 patients, including 56 women and 31 men, with a mean age of 52.4 years (range 19-87 years) could be identified. AML (angiomyolipoma) was detected in three patients by diagnostic evaluation of microhaematuria but none during follow-up. Five patients developed kidney diseases during follow-up period. In one patient IgA nephritis was detected. This was the only finding of significant glomerular origin. One patient had papillary necrosis of the kidney, another patient polycystic nephropathy. Two patients revealed diseases affecting the renal vascular system. No bladder cancer and no cancer of the upper urinary tract has been detected in these 87 patients during follow-up. 6.4 years after diagnostic evaluation of microscopic hematuria one patient developed adenocarcinoma of the prostate (GII, Mostofi, Score 6, pT2a NX MX R0). At the time of diagnosis the patient was 71.7 years old. CONCLUSIONS: In most cases microscopic hematuria is harmless or not detectable. A thorough diagnostic evaluation is mandatory to rule out a possible malignancy. According to our findings, most patients with microscopic hematuria are unnecessarily re-evalu-
e26
THE JOURNAL OF UROLOGY姞
ated according to the AUA guidelines (i.e. reevaluation within three to five years), as the risk for developing urothelial malignancy is very low in the follow-up period. According to our data a modification of the appropriate follow-up management should be discussed in patients with negative work-up of microhematuria. Source of Funding: None
62 ASSESSING THE INTENDED EFFECTS OF AMBULATORY SURGERY CENTERS ON THE DELIVERY OF OUTPATIENT UROLOGIC PROCEDURES Anne M. Suskind*, Rodney L. Dunn, Zhang Yun, John M. Hollingsworth, Bruce L. Jacobs, Florian R. Schroeck, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Delivery settings for outpatient procedures have evolved over the past two decades to include various non-hospital based facilities, including ambulatory surgery centers (ASCs). The purpose of these facilities was to redistribute appropriate patients from the more expensive hospital setting without compromising quality. The objective of this study was to assess the impact of ASCs opening on rates of procedures performed in hospital-based outpatient facilities and on adverse events following these procedures. METHODS: This is a retrospective cohort study of Medicare beneficiaries undergoing ambulatory surgery between 2001 and 2009 at either hospital or freestanding ASCs. Ophthalmologic, gastrointestinal, musculoskeletal, and urologic procedures were evaluated. Difference-in-difference methods were used to estimate the effects of ASCs opening on outcomes at the level of the Hospital Service Area (HSA), including population-based rates of hospital-based outpatient surgery, mortality, and hospital admission within 30 days of an outpatient procedure. RESULTS: The number of freestanding ASCs in the US increased from 3,378 in 2001 to 4,573 in 2009. Rates of utilization of hospital-based outpatient surgery (overall) and outpatient urological surgery according to ASC capacity are shown in the figure. Markets where ASCs were added showed large declines in rates of hospitalbased urologic outpatient surgery, from 59.2 urologic procedures per HSA at baseline, to 45.5 and 39.1 at 2 and 4 years after ASC opening, respectively. Trends were similar for ophthalmologic, gastrointestinal, and musculoskeletal outpatient procedures. Mortality and hospital admission rates within 30 days of outpatient surgery remained stable for all specialties after ASC openings. CONCLUSIONS: The opening of an ASC in a healthcare market resulted in significant declines in corresponding hospital-based surgery without increasing population-based mortality or hospital admission. This suggests that ASCs can successfully offload procedures from the more expensive hospital setting without negatively impacting quality on a population level.
Vol. 189, No. 4S, Supplement, Saturday, May 4, 2013
63 INCREASING RATE OF FLUOROQUINOLONE RESISTANT ESCHERICHIA COLI AND INCIDENCE OF INFECTIOUS COMPLICATIONS FOLLOWING TRUS GUIDED PROSTATE NEEDLE BIOPSY IN CALGARY, ALBERTA, CANADA Jan Rudzinski*, Jun Kawakami, Calgary, Canada INTRODUCTION AND OBJECTIVES: Increasing risk of infectious complications following trans-rectal ultrasound guided prostate biopsy (TRUS-PNB) has been observed. Infectious complications are associated with colonic bacterial flora such as Escherichia coli (E.coli). Currently, fluoroquinolone antibiotics are the most commonly used antibacterial prophylaxis prior to TRUS-PNB. Our regional anti-biogram data suggests the rise in ciprofloxacin resistance in community strains of E.coli from 5% to 11% over the last 7 years. We sought to evaluate whether increasing E.coli resistance correlates with increased incidence in infectious complications following TRUS-PNB at our institution. METHODS: We conducted an electronic health record review of 927 patients who underwent TRUS-PNB between January and July 2012 in Calgary. The variables collected prospectively included patient age, pre-biopsy PSA, and date of biopsy. We then documented presentation to an emergency department (ER) within 30 days of TRUSPNB for infectious complications, specifically urinary tract infections (UTI), prostatitis, and sepsis/bacteremia. We analyzed the blood and urine cultures results as well as susceptibility and resistance rates to antibiotics for patients admitted to ER. RESULTS: Overall, 41 patients (4.4%) were admitted to the ER due to post TRUS-PNB infectious complications within 30 days postbiopsy. The most common infectious complication observed was sepsis/bacteremia in 22 patients (2.3%), followed by UTI in 9 (0.9%), and prostatitis in 4 (0.4%). Of the 22 patients with sepsis, the blood culture results showed fluoroquinolone resistance in 15 patients (68%). 15 patients had E. coli:13 were ciprofloxacin resistant while 2 strains were ciprofloxacin susceptible. Two of the 4 other blood culture postive patients had fluoroquinolone resistant organisms: Klebsiella pneumonia and Comanomas species. All of the patients admitted for UTI had ciprofloxacin resistant E.coli in their urine. 3 patients had negative cultures but were diagnosed with sepsis. Of those with positive blood cultures, 82% (15 of 19 patients) had fluoroquinolone resistance. CONCLUSIONS: Our results suggest increased incidence of sepsis due to fluoroquinolone resistant organisms following TRUS-PNB when compared to other centers. This finding could be attributed to increasing community resistance to ciprofloxacin. The current antimicrobial prophylactic regimen needs to be re-evaluated, and a novel approach may need to be considered. Source of Funding: None
64 HIGHER CASE VOLUME ASSOCIATED WITH LOWER COMPLICATION RATE FOR PERCUTANEOUS NEPHROLITHOTOMY (PCNL): RESULTS FROM THE NATIONWIDE INPATIENT SAMPLE (NIS) Adam Kadlec*, Chandy Ellimoottil, Kristin Greco, Maywood, IL; Maxine Sun, Quoc-Dien Trinh, Montreal, Canada; Thomas Turk, Maywood, IL
Source of Funding: AHRQ R01 HS018726-01A1.
INTRODUCTION AND OBJECTIVES: Prior studies have suggested that higher case volume is associated with a lower complication and higher in-hospital mortality rate for percutaneous nephrolithotomy (PCNL). Over the last 15 years, PCNL volume has shifted to tertiary high-volume centers practitioners closer to the end of training. Our objective was to contemporarily evaluate if volume-outcome relationships for PCNL exist in the United States. METHODS: Patients with a diagnosis of urinary calculus (diagnosis 592, 5920, 5921, and 5929) and primary procedure of percutaneous nephrolithotomy (procedure code 5504) were identified in NIS discharge records from 2010. Median annual case volume was 10 (IQR
THE JOURNAL OF UROLOGY姞
studies conducted exclusively in the United States, enrollment of black men was associated with sample size (p⫽0.025), yet not with the use of public funding (p⫽0.534). We identified no study that enrolled black men exclusively or prospectively planned to stratify the analysis based on ethnic background. CONCLUSIONS: Enrollment of black men in RCTs of prostate cancer treatment appears low with no substantial improvement over time. Considering the high disease burden of prostate cancer in black men, increased effort to improve their participation in RCTs is essential.
e25
762 Paents Diagnosed with Prostate Ca Between 2000-2006
501 Paents (65.7%) Alive
261 Paents (34.3%) Died 75 Paents (28.7%) Lost to follow-up or Incomplete Data
Source of Funding: Prostate Cancer Research Program Collaborative Undergraduate HBCU Student Summer Training Program Award by the Department of Defense Office of the Congressionally Directed Medical Research Programs; Department of Urology, University of Florida; University of Florida Prostate Disease Center.
186 Paents (71.3%) Complete Data Available
145 Paents (71.0%) Other cause of death
41 Paents (22.0%) mCaP cause of death
60 PROSTATE CANCER MORTALITY IN AN EQUAL ACCESS HEALTHCARE SYSTEM
28 Paents (68.3%) Presented with mCaP
Figure 1. Diagram of paent populaon
Jane Cho*, Michael Liss, Douglas Skarecky, Thomas Ahlering, Atreya Dash, Orange, CA INTRODUCTION AND OBJECTIVES: Despite aggressive prostate cancer screening, men continue to die of advanced metastatic disease (mCaP). Recent literature suggests that some men dying are the healthy elderly (ⱖ75). In the contemporary PSA era, we characterize a cohort of men dying from mCaP in an equal access healthcare system. METHODS: We queried the Long Beach Veterans Hospital database for men diagnosed with prostate cancer from 1/2000-12/ 2006. Causes of death were identified (prostate cancer specific vs other). This cohort was characterized regarding demographics and clinical features. Prostate cancer death was confirmed with death certificate and chart review. The Mann-Whitney test for non-parametric values comparing those who presented with mCaP compared to those who eventually developed mCaP. Kaplan-Meier analysis with significance was determined by the Breslow test. RESULTS: We identified 762 men diagnosed with prostate cancer and of these, 34.3% (261/762) died at mean follow-up of 9 years. Complete follow up data was available on 71.3% (186/261) men. Of those men, 22% (41/186) died of mCaP and of these, 68.3% (28/41) presented with mCaP (See Figure 1). The median age was 69 yrs (49-90), Charlson score 1 (0-6), Gleason sum of 7 (6-10), PSA at diagnosis 22 (3-4662), first screening PSA 6 (1-2120). Six (14.6%) men received surgery and 9 (22.0%) had radiation therapy. Of men presenting with metastatic disease 28.6% (8/28) had no previous PSA recorded. There was a significant difference in age at diagnosis, smoking status, and time interval from biopsy to death (p⫽0.023, p⫽0.037, and p⫽0.007) between men who presented with mCaP and men who developed mCaP. Median survival of men who presented with mCaP was earlier than that of men who developed mCaP (595 days vs.1044 days; p⫽0.01). Among men older than 75 yrs who presented with mCaP, 91.7% (11/12) died of disease despite having higher cardiovascular risk factors by prior MI status [41.7%, (5/12) vs. 6.7% (2/29) (p⫽0.016)]. CONCLUSIONS: Prostate cancer mortality has a complex mix of men with mCaP and those men who died during long-term treatment. The majority of men who die of mCaP presented with metastatic disease. Especially at risk are men older than 75 yrs in which PSA screening was not recommended according to previous guidelines. Further investigation is warranted in this subset of men.
13 Paents (31.7%) Developed mCaP
Source of Funding: None
61 LONGTERM FOLLOW-UP OF MICROSOCOPIC MICROHEMATURIA AFTER NEGATIVE DIAGNOSTIC WORK-UP Nicolai Leonhartsberger*, Viktor Skradski, Renate Pichler, Brigitte Stöhr, Wolfgang Horninger, Hannes Steiner, Innsbruck, Austria INTRODUCTION AND OBJECTIVES: The objectives of this study were to determine the potential development of malignancies in the urinary tract or other diseases during the follow-up period after negative (no urological cancer) diagnostic work-up of microscopic hematuria. As the predictive value and the follow-up period for microscopic hematuria is not clear, patients were observed in a longterm follow-up period. METHODS: In this retrospective study charts of patients diagnosed with microscopic microhematuria in our department between July 1999 and March 2011 were searched and data corresponding to the inclusion criteria were collected. Criteria for inclusion in this study were a complete diagnostic assessment of microhematuria with ultrasonography, cystoscopy, upper urinary tract imaging and a follow-up period of at least 3.5 years after diagnostic microhematuria examination. The initial detection of malignancy was an exclusion criterion. The outcome of patients was evaluated across an average period of 8 years (3.7- 10.2 years). RESULTS: 87 patients, including 56 women and 31 men, with a mean age of 52.4 years (range 19-87 years) could be identified. AML (angiomyolipoma) was detected in three patients by diagnostic evaluation of microhaematuria but none during follow-up. Five patients developed kidney diseases during follow-up period. In one patient IgA nephritis was detected. This was the only finding of significant glomerular origin. One patient had papillary necrosis of the kidney, another patient polycystic nephropathy. Two patients revealed diseases affecting the renal vascular system. No bladder cancer and no cancer of the upper urinary tract has been detected in these 87 patients during follow-up. 6.4 years after diagnostic evaluation of microscopic hematuria one patient developed adenocarcinoma of the prostate (GII, Mostofi, Score 6, pT2a NX MX R0). At the time of diagnosis the patient was 71.7 years old. CONCLUSIONS: In most cases microscopic hematuria is harmless or not detectable. A thorough diagnostic evaluation is mandatory to rule out a possible malignancy. According to our findings, most patients with microscopic hematuria are unnecessarily re-evalu-
e26
THE JOURNAL OF UROLOGY姞
ated according to the AUA guidelines (i.e. reevaluation within three to five years), as the risk for developing urothelial malignancy is very low in the follow-up period. According to our data a modification of the appropriate follow-up management should be discussed in patients with negative work-up of microhematuria. Source of Funding: None
62 ASSESSING THE INTENDED EFFECTS OF AMBULATORY SURGERY CENTERS ON THE DELIVERY OF OUTPATIENT UROLOGIC PROCEDURES Anne M. Suskind*, Rodney L. Dunn, Zhang Yun, John M. Hollingsworth, Bruce L. Jacobs, Florian R. Schroeck, Brent K. Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Delivery settings for outpatient procedures have evolved over the past two decades to include various non-hospital based facilities, including ambulatory surgery centers (ASCs). The purpose of these facilities was to redistribute appropriate patients from the more expensive hospital setting without compromising quality. The objective of this study was to assess the impact of ASCs opening on rates of procedures performed in hospital-based outpatient facilities and on adverse events following these procedures. METHODS: This is a retrospective cohort study of Medicare beneficiaries undergoing ambulatory surgery between 2001 and 2009 at either hospital or freestanding ASCs. Ophthalmologic, gastrointestinal, musculoskeletal, and urologic procedures were evaluated. Difference-in-difference methods were used to estimate the effects of ASCs opening on outcomes at the level of the Hospital Service Area (HSA), including population-based rates of hospital-based outpatient surgery, mortality, and hospital admission within 30 days of an outpatient procedure. RESULTS: The number of freestanding ASCs in the US increased from 3,378 in 2001 to 4,573 in 2009. Rates of utilization of hospital-based outpatient surgery (overall) and outpatient urological surgery according to ASC capacity are shown in the figure. Markets where ASCs were added showed large declines in rates of hospitalbased urologic outpatient surgery, from 59.2 urologic procedures per HSA at baseline, to 45.5 and 39.1 at 2 and 4 years after ASC opening, respectively. Trends were similar for ophthalmologic, gastrointestinal, and musculoskeletal outpatient procedures. Mortality and hospital admission rates within 30 days of outpatient surgery remained stable for all specialties after ASC openings. CONCLUSIONS: The opening of an ASC in a healthcare market resulted in significant declines in corresponding hospital-based surgery without increasing population-based mortality or hospital admission. This suggests that ASCs can successfully offload procedures from the more expensive hospital setting without negatively impacting quality on a population level.
Vol. 189, No. 4S, Supplement, Saturday, May 4, 2013
63 INCREASING RATE OF FLUOROQUINOLONE RESISTANT ESCHERICHIA COLI AND INCIDENCE OF INFECTIOUS COMPLICATIONS FOLLOWING TRUS GUIDED PROSTATE NEEDLE BIOPSY IN CALGARY, ALBERTA, CANADA Jan Rudzinski*, Jun Kawakami, Calgary, Canada INTRODUCTION AND OBJECTIVES: Increasing risk of infectious complications following trans-rectal ultrasound guided prostate biopsy (TRUS-PNB) has been observed. Infectious complications are associated with colonic bacterial flora such as Escherichia coli (E.coli). Currently, fluoroquinolone antibiotics are the most commonly used antibacterial prophylaxis prior to TRUS-PNB. Our regional anti-biogram data suggests the rise in ciprofloxacin resistance in community strains of E.coli from 5% to 11% over the last 7 years. We sought to evaluate whether increasing E.coli resistance correlates with increased incidence in infectious complications following TRUS-PNB at our institution. METHODS: We conducted an electronic health record review of 927 patients who underwent TRUS-PNB between January and July 2012 in Calgary. The variables collected prospectively included patient age, pre-biopsy PSA, and date of biopsy. We then documented presentation to an emergency department (ER) within 30 days of TRUSPNB for infectious complications, specifically urinary tract infections (UTI), prostatitis, and sepsis/bacteremia. We analyzed the blood and urine cultures results as well as susceptibility and resistance rates to antibiotics for patients admitted to ER. RESULTS: Overall, 41 patients (4.4%) were admitted to the ER due to post TRUS-PNB infectious complications within 30 days postbiopsy. The most common infectious complication observed was sepsis/bacteremia in 22 patients (2.3%), followed by UTI in 9 (0.9%), and prostatitis in 4 (0.4%). Of the 22 patients with sepsis, the blood culture results showed fluoroquinolone resistance in 15 patients (68%). 15 patients had E. coli:13 were ciprofloxacin resistant while 2 strains were ciprofloxacin susceptible. Two of the 4 other blood culture postive patients had fluoroquinolone resistant organisms: Klebsiella pneumonia and Comanomas species. All of the patients admitted for UTI had ciprofloxacin resistant E.coli in their urine. 3 patients had negative cultures but were diagnosed with sepsis. Of those with positive blood cultures, 82% (15 of 19 patients) had fluoroquinolone resistance. CONCLUSIONS: Our results suggest increased incidence of sepsis due to fluoroquinolone resistant organisms following TRUS-PNB when compared to other centers. This finding could be attributed to increasing community resistance to ciprofloxacin. The current antimicrobial prophylactic regimen needs to be re-evaluated, and a novel approach may need to be considered. Source of Funding: None
64 HIGHER CASE VOLUME ASSOCIATED WITH LOWER COMPLICATION RATE FOR PERCUTANEOUS NEPHROLITHOTOMY (PCNL): RESULTS FROM THE NATIONWIDE INPATIENT SAMPLE (NIS) Adam Kadlec*, Chandy Ellimoottil, Kristin Greco, Maywood, IL; Maxine Sun, Quoc-Dien Trinh, Montreal, Canada; Thomas Turk, Maywood, IL
Source of Funding: AHRQ R01 HS018726-01A1.
INTRODUCTION AND OBJECTIVES: Prior studies have suggested that higher case volume is associated with a lower complication and higher in-hospital mortality rate for percutaneous nephrolithotomy (PCNL). Over the last 15 years, PCNL volume has shifted to tertiary high-volume centers practitioners closer to the end of training. Our objective was to contemporarily evaluate if volume-outcome relationships for PCNL exist in the United States. METHODS: Patients with a diagnosis of urinary calculus (diagnosis 592, 5920, 5921, and 5929) and primary procedure of percutaneous nephrolithotomy (procedure code 5504) were identified in NIS discharge records from 2010. Median annual case volume was 10 (IQR