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V332 HOLMIUM LASER INCISION OF BLADDER NECK FOR POST-PROSTATECTOMY BLADDER NECK STENOSIS
e132
THE JOURNAL OF UROLOGY姞
Vol. 183, No. 4, Supplement, Sunday, May 30, 2010
V332 HOLMIUM LASER INCISION OF BLADDER NECK FOR POSTPROSTATECTOMY BLADDER NECK STENOSIS. Hemendra Shah*, Mumbai, India INTRODUCTION AND OBJECTIVES: Bladder neck stenosis is an inherent long term complication of prostatectomy for bladder outlet obstruction. We present our experience with Holmium laser incision of post-prostatectomy bladder neck stenosis. To the best of our knowledge, there is no information on the outcome of this procedure in the literature. METHODS: Retrospective review of 11 patients with postprostatectomy bladder neck stenosis who underwent bladder neck incision with holmium laser at our institute from May 2003 to June 2008 was performed. All patients had an ascending urethrogram & cystoscopy to diagnose bladder neck stenosis. The procedure was performed using 550 laser fiber at 100 W holmium laser energy. Initially incision was taken at 5 and 7o clock position and deepened till all fibrous tissue is cut. Later on the fibrous tissue is resected using the holmium laser. An additional 12 o clock &/or 6o clock incision is take to completely release all the fibrous tissue. The remaining residual fibrous tissue is vaporized. All patients had a per urethral catheter for 1 day. Patients demographic and perioperative data was analyzed to know the safety and efficacy of the procedure. Follow-up data was obtained to know early outcome of surgery. Digital video clips from previously recorded Holmium laser incision of post-prostatectomy bladder neck stenosis were edited into a video describing the steps of procedures. RESULTS: The primary procedure for prostatectomy was open prostatectomy (1); TURP (7) and HoLEP (3). All patients presented with recurrent bladder outlet obstruction after initial prostatectomy. The mean interval between prior prostatectomy and presentation was 1.9 years (3 months – 9 years). The mean pre-prostatectomy prostate size (available in 8 patients) was 34.8 gm (11- 72 gm). The mean preoperative AUA symptom score, maximum uroflow rate and post-void residual urine were 24, 7.2 ml/sec and 112 ml respectively. There were no major intraoperative or post-operative complications. At mean follow-up of 21 months, no patients had recurrent bladder neck stenosis. The mean postoperative AUA symptom score, maximum uroflow rate and post-void residual urine during last available follow-up were 7, 19.8 ml/sec and 33 ml respectively. CONCLUSIONS: Holmium laser bladder neck incision is associated with favorable early postoperative outcome. Source of Funding: None
METHODS: We used the previously reported SEER-Medicare data and nationwide sample of employer provided estimates of costs of care for patients with diagnosis of prostate cancer. Resource allocation costs that include clinical service costs and test costs of PSA screening in the US were used to determine the costs of population based screening. The data from the ERSPC trial, in accordance with the study protocol, was used to determine the costs and cost-effectiveness of PSA screening. A model incorporating age at diagnosis, life expectancy and estimate of benefits from PSA screening was created that predicts cost effectiveness of screening intervention using alternative outcome scenarios. A sensitivity analysis was performed to test the robustness of results. RESULTS: The lifetime cost of screening with PSA, evaluation of abnormal PSA and treatment of identified prostate cancers to prevent one mortality from prostate cancer is $6,950,983 based on the findings from the ERSPC study and extrapolated to the US community patterns of care. If screening achieves similar decrease in overall mortality (by 0.6%) as the reduction in prostate cancer specific mortality observed in the ERSPC study, such intervention would cost $347,549 per life year saved. The screening as reported in the ERSPC study is not cost effective in the US based on the $50,000 per life-year saved cost-effectiveness threshold. The threshold for cost effectiveness of PSA screening is reached when the number needed to treat (NNT) is lowered to 7 or fewer men. The lifelong costs of screening protocols are determined by the cost of treatment with insignificant contribution from the costs of screening. PSA screening becomes cost effective if the average lifelong treatment costs are below $861 per year. CONCLUSIONS: PSA screening becomes cost-effective with NNT of 7 or fewer men with little dependence on life expectancy. This suggests that both older and younger men can be treated cost effectively with equally beneficial treatments. We established a model that predicts the minimal requirements including the NNT and improvement in mortality that would make PSA screening a cost-effective public health measure for population based implementation. Source of Funding: None
334 COST-EFFECTIVENESS OF CHEMOPREVENTION WITH FINASTERIDE FOR PROSTATE CANCER VARIES ACROSS SUBGROUPS DEFINED BY FAMILY HISTORY AND GENETIC POLYMORPHISMS Shelby Reed*, Charles Scales, Suzanne Stewart, Durham, NC; Jielin Sun, Winston-Salem, NC; Judd Moul, Kevin Schulman, Durham, NC; Jianfeng Xu, Winston-Salem, NC
General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I Moderated Poster 8 Sunday, May 30, 2010
1:00 PM-3:00 PM
333 COST EFFECTIVENESS OF PSA SCREENING IN THE US: EXTRAPOLATING FROM THE ERSPC TRIAL Alex Shteynshlyuger*, Gerald L. Andriole, St. Louis, MO INTRODUCTION AND OBJECTIVES: The objective of population screening for prostate cancer is to decrease morbidity, mortality and costs associated with prostate cancer. Preliminary results of the ERSPC study demonstrated decrease in prostate cancer specific mortality associated with PSA screening. We evaluated the cost effectiveness of PSA screening using data from the ERSPC study protocol when extrapolated to the US.
INTRODUCTION AND OBJECTIVES: The cost-effectiveness of chemoprevention with finasteride could improve if men at higher risk for developing prostate cancer were targeted. Xu et al. recently published a risk prediction model based on an individual’s family history of prostate cancer and presence of up to 14 inherited risk alleles. Our objective was to estimate the cost-effectiveness of chemoprevention strategies across risk groups defined by family history and the number of inherited risk alleles. METHODS: We constructed a probabilistic Markov model using data from 2000-2006 SEER 17 Incidence and Mortality data, on-line sources, and the published medical literature to estimate costs and quality-adjusted life-years (QALYs) across risk groups for men receiving or not receiving chemoprevention with finasteride. We assumed a risk reduction of 24.8% across all grades of prostate cancer. Costs were valued in 2009 US dollars. The base-case analysis represents men with a negative family history and 11 inherited risk alleles. To evaluate the cost-effectiveness of chemoprevention strategies, we incorporated the prevalence of family history and distribution of the number of risk alleles. RESULTS: The incremental cost-effectiveness of chemoprevention with finasteride in men 50 years of age for a duration of 25 years was estimated at $89,300 per QALY (95%CI: 58,800-149,800). The cost-effectiveness of finasteride varies from $128,600 per QALY
THE JOURNAL OF UROLOGY姞
Vol. 183, No. 4, Supplement, Sunday, May 30, 2010
V332 HOLMIUM LASER INCISION OF BLADDER NECK FOR POSTPROSTATECTOMY BLADDER NECK STENOSIS. Hemendra Shah*, Mumbai, India INTRODUCTION AND OBJECTIVES: Bladder neck stenosis is an inherent long term complication of prostatectomy for bladder outlet obstruction. We present our experience with Holmium laser incision of post-prostatectomy bladder neck stenosis. To the best of our knowledge, there is no information on the outcome of this procedure in the literature. METHODS: Retrospective review of 11 patients with postprostatectomy bladder neck stenosis who underwent bladder neck incision with holmium laser at our institute from May 2003 to June 2008 was performed. All patients had an ascending urethrogram & cystoscopy to diagnose bladder neck stenosis. The procedure was performed using 550 laser fiber at 100 W holmium laser energy. Initially incision was taken at 5 and 7o clock position and deepened till all fibrous tissue is cut. Later on the fibrous tissue is resected using the holmium laser. An additional 12 o clock &/or 6o clock incision is take to completely release all the fibrous tissue. The remaining residual fibrous tissue is vaporized. All patients had a per urethral catheter for 1 day. Patients demographic and perioperative data was analyzed to know the safety and efficacy of the procedure. Follow-up data was obtained to know early outcome of surgery. Digital video clips from previously recorded Holmium laser incision of post-prostatectomy bladder neck stenosis were edited into a video describing the steps of procedures. RESULTS: The primary procedure for prostatectomy was open prostatectomy (1); TURP (7) and HoLEP (3). All patients presented with recurrent bladder outlet obstruction after initial prostatectomy. The mean interval between prior prostatectomy and presentation was 1.9 years (3 months – 9 years). The mean pre-prostatectomy prostate size (available in 8 patients) was 34.8 gm (11- 72 gm). The mean preoperative AUA symptom score, maximum uroflow rate and post-void residual urine were 24, 7.2 ml/sec and 112 ml respectively. There were no major intraoperative or post-operative complications. At mean follow-up of 21 months, no patients had recurrent bladder neck stenosis. The mean postoperative AUA symptom score, maximum uroflow rate and post-void residual urine during last available follow-up were 7, 19.8 ml/sec and 33 ml respectively. CONCLUSIONS: Holmium laser bladder neck incision is associated with favorable early postoperative outcome. Source of Funding: None
METHODS: We used the previously reported SEER-Medicare data and nationwide sample of employer provided estimates of costs of care for patients with diagnosis of prostate cancer. Resource allocation costs that include clinical service costs and test costs of PSA screening in the US were used to determine the costs of population based screening. The data from the ERSPC trial, in accordance with the study protocol, was used to determine the costs and cost-effectiveness of PSA screening. A model incorporating age at diagnosis, life expectancy and estimate of benefits from PSA screening was created that predicts cost effectiveness of screening intervention using alternative outcome scenarios. A sensitivity analysis was performed to test the robustness of results. RESULTS: The lifetime cost of screening with PSA, evaluation of abnormal PSA and treatment of identified prostate cancers to prevent one mortality from prostate cancer is $6,950,983 based on the findings from the ERSPC study and extrapolated to the US community patterns of care. If screening achieves similar decrease in overall mortality (by 0.6%) as the reduction in prostate cancer specific mortality observed in the ERSPC study, such intervention would cost $347,549 per life year saved. The screening as reported in the ERSPC study is not cost effective in the US based on the $50,000 per life-year saved cost-effectiveness threshold. The threshold for cost effectiveness of PSA screening is reached when the number needed to treat (NNT) is lowered to 7 or fewer men. The lifelong costs of screening protocols are determined by the cost of treatment with insignificant contribution from the costs of screening. PSA screening becomes cost effective if the average lifelong treatment costs are below $861 per year. CONCLUSIONS: PSA screening becomes cost-effective with NNT of 7 or fewer men with little dependence on life expectancy. This suggests that both older and younger men can be treated cost effectively with equally beneficial treatments. We established a model that predicts the minimal requirements including the NNT and improvement in mortality that would make PSA screening a cost-effective public health measure for population based implementation. Source of Funding: None
334 COST-EFFECTIVENESS OF CHEMOPREVENTION WITH FINASTERIDE FOR PROSTATE CANCER VARIES ACROSS SUBGROUPS DEFINED BY FAMILY HISTORY AND GENETIC POLYMORPHISMS Shelby Reed*, Charles Scales, Suzanne Stewart, Durham, NC; Jielin Sun, Winston-Salem, NC; Judd Moul, Kevin Schulman, Durham, NC; Jianfeng Xu, Winston-Salem, NC
General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I Moderated Poster 8 Sunday, May 30, 2010
1:00 PM-3:00 PM
333 COST EFFECTIVENESS OF PSA SCREENING IN THE US: EXTRAPOLATING FROM THE ERSPC TRIAL Alex Shteynshlyuger*, Gerald L. Andriole, St. Louis, MO INTRODUCTION AND OBJECTIVES: The objective of population screening for prostate cancer is to decrease morbidity, mortality and costs associated with prostate cancer. Preliminary results of the ERSPC study demonstrated decrease in prostate cancer specific mortality associated with PSA screening. We evaluated the cost effectiveness of PSA screening using data from the ERSPC study protocol when extrapolated to the US.
INTRODUCTION AND OBJECTIVES: The cost-effectiveness of chemoprevention with finasteride could improve if men at higher risk for developing prostate cancer were targeted. Xu et al. recently published a risk prediction model based on an individual’s family history of prostate cancer and presence of up to 14 inherited risk alleles. Our objective was to estimate the cost-effectiveness of chemoprevention strategies across risk groups defined by family history and the number of inherited risk alleles. METHODS: We constructed a probabilistic Markov model using data from 2000-2006 SEER 17 Incidence and Mortality data, on-line sources, and the published medical literature to estimate costs and quality-adjusted life-years (QALYs) across risk groups for men receiving or not receiving chemoprevention with finasteride. We assumed a risk reduction of 24.8% across all grades of prostate cancer. Costs were valued in 2009 US dollars. The base-case analysis represents men with a negative family history and 11 inherited risk alleles. To evaluate the cost-effectiveness of chemoprevention strategies, we incorporated the prevalence of family history and distribution of the number of risk alleles. RESULTS: The incremental cost-effectiveness of chemoprevention with finasteride in men 50 years of age for a duration of 25 years was estimated at $89,300 per QALY (95%CI: 58,800-149,800). The cost-effectiveness of finasteride varies from $128,600 per QALY