- Email: [email protected]
MP19-13 WIDE VARIATION IN RADIATION DOSE DURING COMPUTERIZED TOMOGRAPHY
THE JOURNAL OF UROLOGYâ
e208
Group 1 (Cases): ?Included 30 patients, complaining of UUI diagnosed by history with or without positive urodynamics. They were evaluated and included in this study from May 2014 to september 2015. Group 2 (Control): -Included 38 healthy continent volunteers as a control group. Informed consent was obtained from all the volunteers. All patients were assessed by a detailed history, by clinical examination and by MRI examination (static and dynamic). RESULTS: MRI findings between both groups: 1. Comparison between the average length of the USLs In the control group: Mean length of rightUSL¼ 23.88 9 mms (range 9 to 40.5mms) while the left USL is 21.97 9 (range 9 to 45mms). In the cases group: Mean length of right USL is 35.11 11 mms (range 18 to 49.5mms) while the left USL is 34.03 11 mms (range 18 to 57mms). There is significant statistical difference between the length in both groups with longer length in the cases group (P<0.01). 2. Comparison between the average USL length in both groups classified according to uterine descent: We divided the UUI case group into 2 subgroups: (with uterine descent [n¼11] and without uterine descent [n¼19]) We did not find statistically significant difference between the 2 subgroups (p value>0.05¼non significant). We found that both subgroups have longer USLs length than the control group (ap< 0.01 relative to control group). 3. Comparison between the average USL length in both groups classified according to POP: We divided the UUI cases group into 2 subgroups (with POP and without POP). We found that the POP subgroup have longer USLs than the “no POP”subgroup (but no statistical significance) Both subgroups have longer USLs length than the control group. 4. Both USLs in 75-78% of controls originated from a more cranial level, while both USLs in 63.3% of cases originated from a more caudal level. This indicates a more caudal level for the ligament attachment to the female genital tract in the cases. CONCLUSIONS: We found that the average length of both USLs in the cases group is significantly longer than that of the control group. Moreover, we found a correlation between the increased length of the USLs and UUI. Source of Funding: none
MP19-12 CORRELATION BETWEEN SEMIQUANTITATIVE SONOELASTOGRAPHY AND IMMUNOHISTOCHEMISTRY IN THE EVALUATION OF TESTICULAR FOCAL (< 10 MM) LESIONS Antonio Luigi Pastore*, Giovanni Palleschi, Domenico Autieri, Antonino Leto, Andrea Ripoli, Andrea Fuschi, Yazan Al Salhi, Samer Al Rawashdah, Vincenzo Petrozza, Antonio Carbone, Latina, Italy INTRODUCTION AND OBJECTIVES: Sonoelastography is a novel and promising imaging tool, which has been applied to breast, thyroid, and prostate tissues. The aim of this study was to evaluate focal lesions of the testes with diameters of <10 mm using sonoelastography, B-mode sonography (US), and colour Doppler ultrasonography. METHODS: Thirty patients who were referred to our outpatient clinics for varicocoeles, scrotal pain, scrotal enlargements, epididymitis, palpable testicular nodules, or infertility, were prospectively enrolled. US evaluations had revealed that 27 subjects had focal testicular lesions with diameters of <10 mm and 3 subjects had 10-mm spherical nonhomogeneous testicular nodules. All lesions were evaluated using semi-quantitative sonoelastography, and the patients underwent orchifunicolectomies. The testicular lesions were examined histopathologically. The vascularization of the lesions and the surrounding testicular parenchyma was evaluated by analysing the immunohistochemical distribution of the cluster of differentiation 31 and by calculating the
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
vascular indices (VI). Potential associations between the strain ratios (stiffness of the lesions) and the VI were tested. RESULTS: Analyses of the strain fields obtained using semiquantitative sonoelastography yielded different values for the masses and the surrounding tissues, which led to significant increases in the strain ratios. Sonoelastography upheld all of the diagnoses that were suspected when the patients were physically examined, when the serum markers were analysed, and after the patients had undergone US and CDU. Histopathological examinations confirmed the neoplastic characteristics of these masses. A significant inverse correlation was determined between the sonoelastographic strain ratio and the VI (Pearson correlation coefficient, r¼-0.93; p<0.001). CONCLUSIONS: Our investigation shows that semiquantitative sonoelastography may provide additional objective information to support the algorithm used to diagnose testicular lesions. This might be of crucial diagnostic importance for lesions with diameters of <10 mm, particularly if they are not palpable, are negative for serum tumour markers, and if the findings from US are equivocal. The findings from semiquantitative sonoelastography might indicate the need for surgical exploration. Further investigations with larger numbers of patients are required to corroborate these data and to support the use of semiquantitative sonoelastography in the evaluation of testicular lesions. Source of Funding: NONE
MP19-13 WIDE VARIATION IN RADIATION DOSE DURING COMPUTERIZED TOMOGRAPHY Andrew Cohen*, Chicago, IL; Katie Hughes, Natalie Fahey, Brandon Caldwell, Chi-Hsiung Wang, Sangtae Park, Evanston, IL INTRODUCTION AND OBJECTIVES: We aim to minimize ionizing radiation without sacrificing diagnostic accuracy during computed tomography (CT), but radiation doses administered are ultimately at the discretion of radiology technicians and the CT scanner being used. Using dose-length product (DLP) to estimate radiation dose, we studied CT dose during scans for suspected urolithiasis (CT stone) and head CT performed during the same period, as controls. METHODS: We identified all patients who underwent CT stone (n¼1793) or head CT (n¼837) at our suburban four hospital health system in April, May, June of 2010 and the same months in 2014. Patient age, body mass index (BMI), and gender were recorded, along with hospital location, CT scanner model, year, and DLP of each scan. Age and organ appropriate k coefficients were used to calculate effective dose (ED). RESULTS: CT Stone: On univariate analysis, the youngest patients (<18 years) received over 30% less radiation than older ones (p<0.01). As expected, radiation dose monotonically increased from underweight to normal to obese categories (p<0.01). Unexpectedly, one specific hospital and its GE scanner was associated with up to 56% greater DLP (1134 vs. 728 mGy-cm, p<0.01), and there was no reduction in DLP from 2010 to 2014. CT Head: On univariate analysis, disturbingly, those aged < 18 received the same DLP as older patients, and one specific hospital was associated with up to 50% higher DLP (1238 vs. 821, p<0.01) compared to the other three. However, mean 2014 DLP improved significantly, compared to 2010 (p<0.01). On multivariate analysis adjusting for BMI, age, gender, scanner location, model and year, male gender, obesity and undergoing CT stone at hospital D using the GE machine were independent predictors of greater radiation dose (Table). The scatter plot demonstrates up to 6 fold variation in ED at a given BMI. CONCLUSIONS: Even after adjusting for age, gender and BMI, these data demonstrate large variations in CT radiation dose in our institution, despite the use of identical CT scanners and identical CT technicians. This suggests similar, or worse trends nationally, warranting more stringent dosage guidelines and regulations for diagnostic CT scans.
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
e209
Our study sought to identify and describe (1) urologist knowledge, attitudes, and practices related to use of imaging to stage prostate cancer (2) patient attitudes and behaviors related to use of imaging. METHODS: Modified grounded theory was used to conduct 39 semi-structured in-depth interviews with patients who have low risk prostate cancer and urologists caring for them to explore attitudes, norms and behaviors around prostate cancer imaging. Interviews were conducted between September 2014 and July 2015 at three VA hospitals. The hospitals were selected based on their levels of inappropriate imaging: low, middle and high. The goal was to elicit a range of opinions in regards to imaging for prostate cancer staging at the VA. After core theoretical concepts were identified, the Theoretical Domains Framework (TDF) was used to further explore linkages between emerging themes within the dataset and existing domains within the framework. Interviews were audio-recorded, transcribed and coded. NVivo 8 software was used for data organization and further analysis. RESULTS: Patients with prostate cancer have little interest in staging as compared to disease treatment. They tend to “trust their doctor” to make decisions about appropriate tests. While some patients “appreciated” that their physician took extra precautions to order imaging, none reported asking for a test. Physician interviews suggest that most reported knowing and trusting imaging guidelines but some are apt to follow their own intuition. Additionally, physicians feel that medico-legal concerns, fear of missing aggressive disease, and influence from colleagues who image frequently drive higher rates of imaging. CONCLUSIONS: These results suggest a physician-targeted intervention will be most effective. The information gathered from this study will inform the design of a physician-focused behavioral intervention to reduce unnecessary imaging. Source of Funding: Veterans Health Administration, Health Services Research & Development, The Edward Blank and Sharon Cosloy-Blank Family Foundation, and The Gertrude and Louis Feil Family.
MP19-15 RADIATION EXPOSURE OF THE SURGEON: BENEFIT AND PRACTICABILITY OF A LEAD-ACRYL SHIELD FOR URETEROSCOPY Thomas Knoll*, Jan Peter Jessen, Heiko Kohns, Roland Steiner, Roland Umbach, Gunnar Wendt-Nordahl, Sindelfingen, Germany
Source of Funding: none
MP19-14 A QUALITATIVE STUDY TO UNDERSTAND GUIDELINEDISCORDANT USE OF IMAGING TO STAGE INCIDENT PROSTATE CANCER Danil V. Makarov*, Erica Sedlander, Caitlin Curnyn, R. Scott Braithwaite, Heather T. Gold, Scott E. Sherman, New York, NY; Steven Zeliadt, Seattle, WA; Michele Shedlin, New York, NY INTRODUCTION AND OBJECTIVES: Reducing inappropriate use of imaging to stage incident prostate cancer is a challenge highlighted recently as a Physician Quality Reporting System quality measure and by the American Society of Clinical Oncology and the American Urological Association in the Choosing Wisely campaign.
INTRODUCTION AND OBJECTIVES: Patients with urolithiasis are exposed to significant radiation due to imaging for diagnosis, intraoperative management and follow-up. The need for repeated imaging is therefore weighted against potential hazards of radiation. However, radiation protection is as well a serious issue for endourologists. The purpose of this study was to evaluate the potential benefit and practicability of a lead-acryl shield during ureteroscopy (URS). METHODS: We performed a prospective evaluation of 30 consecutive rigid and flexible URS for ureteral and renal calculi. All procedures were done on a fluoroscopic working place (over-the-table fluoroscopy source, Primera 360, Storz Medical, Switzerland) under video-endoscopic control. The patients were divided into two groups with or without use of a ceiling-mounted, mobile lead-acryl shield (30x50cm, lead equivalent 0.5 mm, Mavig, Germany) placed at the level of the symphysis, protecting the head and chest of the surgeon. Dosearea product (mGy/m2, DAP) was assessed. The surgeon’s radiation exposure was measured with a thermoluminescent dosimeter (TLD) at the forehead and one at the ring finger (as control below the shield). RESULTS: Mean age of patients was in 48.1 yrs. in control and 49.5 yrs. in lead group (n.s.). BMI was 26.3 and 28.0 (n. s). OR time was slightly shorter in the control (39.2 vs. 53.9 min., p¼0.2) and a consecutively lower DAP of 390.0 vs. 642.7 mGy/m2 (p¼0.01). In contrast, the forehead exposure was lower in the acryl-lead group (13.9 vs. 33.7 mSv, p¼0.035). There was no difference for the ring dosimeter exposure (p¼0.6). The practicability rating was variable, mainly surgeon-specific. While one surgeon felt comfortable with the shield, others felt limited by it.
e208
Group 1 (Cases): ?Included 30 patients, complaining of UUI diagnosed by history with or without positive urodynamics. They were evaluated and included in this study from May 2014 to september 2015. Group 2 (Control): -Included 38 healthy continent volunteers as a control group. Informed consent was obtained from all the volunteers. All patients were assessed by a detailed history, by clinical examination and by MRI examination (static and dynamic). RESULTS: MRI findings between both groups: 1. Comparison between the average length of the USLs In the control group: Mean length of rightUSL¼ 23.88 9 mms (range 9 to 40.5mms) while the left USL is 21.97 9 (range 9 to 45mms). In the cases group: Mean length of right USL is 35.11 11 mms (range 18 to 49.5mms) while the left USL is 34.03 11 mms (range 18 to 57mms). There is significant statistical difference between the length in both groups with longer length in the cases group (P<0.01). 2. Comparison between the average USL length in both groups classified according to uterine descent: We divided the UUI case group into 2 subgroups: (with uterine descent [n¼11] and without uterine descent [n¼19]) We did not find statistically significant difference between the 2 subgroups (p value>0.05¼non significant). We found that both subgroups have longer USLs length than the control group (ap< 0.01 relative to control group). 3. Comparison between the average USL length in both groups classified according to POP: We divided the UUI cases group into 2 subgroups (with POP and without POP). We found that the POP subgroup have longer USLs than the “no POP”subgroup (but no statistical significance) Both subgroups have longer USLs length than the control group. 4. Both USLs in 75-78% of controls originated from a more cranial level, while both USLs in 63.3% of cases originated from a more caudal level. This indicates a more caudal level for the ligament attachment to the female genital tract in the cases. CONCLUSIONS: We found that the average length of both USLs in the cases group is significantly longer than that of the control group. Moreover, we found a correlation between the increased length of the USLs and UUI. Source of Funding: none
MP19-12 CORRELATION BETWEEN SEMIQUANTITATIVE SONOELASTOGRAPHY AND IMMUNOHISTOCHEMISTRY IN THE EVALUATION OF TESTICULAR FOCAL (< 10 MM) LESIONS Antonio Luigi Pastore*, Giovanni Palleschi, Domenico Autieri, Antonino Leto, Andrea Ripoli, Andrea Fuschi, Yazan Al Salhi, Samer Al Rawashdah, Vincenzo Petrozza, Antonio Carbone, Latina, Italy INTRODUCTION AND OBJECTIVES: Sonoelastography is a novel and promising imaging tool, which has been applied to breast, thyroid, and prostate tissues. The aim of this study was to evaluate focal lesions of the testes with diameters of <10 mm using sonoelastography, B-mode sonography (US), and colour Doppler ultrasonography. METHODS: Thirty patients who were referred to our outpatient clinics for varicocoeles, scrotal pain, scrotal enlargements, epididymitis, palpable testicular nodules, or infertility, were prospectively enrolled. US evaluations had revealed that 27 subjects had focal testicular lesions with diameters of <10 mm and 3 subjects had 10-mm spherical nonhomogeneous testicular nodules. All lesions were evaluated using semi-quantitative sonoelastography, and the patients underwent orchifunicolectomies. The testicular lesions were examined histopathologically. The vascularization of the lesions and the surrounding testicular parenchyma was evaluated by analysing the immunohistochemical distribution of the cluster of differentiation 31 and by calculating the
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
vascular indices (VI). Potential associations between the strain ratios (stiffness of the lesions) and the VI were tested. RESULTS: Analyses of the strain fields obtained using semiquantitative sonoelastography yielded different values for the masses and the surrounding tissues, which led to significant increases in the strain ratios. Sonoelastography upheld all of the diagnoses that were suspected when the patients were physically examined, when the serum markers were analysed, and after the patients had undergone US and CDU. Histopathological examinations confirmed the neoplastic characteristics of these masses. A significant inverse correlation was determined between the sonoelastographic strain ratio and the VI (Pearson correlation coefficient, r¼-0.93; p<0.001). CONCLUSIONS: Our investigation shows that semiquantitative sonoelastography may provide additional objective information to support the algorithm used to diagnose testicular lesions. This might be of crucial diagnostic importance for lesions with diameters of <10 mm, particularly if they are not palpable, are negative for serum tumour markers, and if the findings from US are equivocal. The findings from semiquantitative sonoelastography might indicate the need for surgical exploration. Further investigations with larger numbers of patients are required to corroborate these data and to support the use of semiquantitative sonoelastography in the evaluation of testicular lesions. Source of Funding: NONE
MP19-13 WIDE VARIATION IN RADIATION DOSE DURING COMPUTERIZED TOMOGRAPHY Andrew Cohen*, Chicago, IL; Katie Hughes, Natalie Fahey, Brandon Caldwell, Chi-Hsiung Wang, Sangtae Park, Evanston, IL INTRODUCTION AND OBJECTIVES: We aim to minimize ionizing radiation without sacrificing diagnostic accuracy during computed tomography (CT), but radiation doses administered are ultimately at the discretion of radiology technicians and the CT scanner being used. Using dose-length product (DLP) to estimate radiation dose, we studied CT dose during scans for suspected urolithiasis (CT stone) and head CT performed during the same period, as controls. METHODS: We identified all patients who underwent CT stone (n¼1793) or head CT (n¼837) at our suburban four hospital health system in April, May, June of 2010 and the same months in 2014. Patient age, body mass index (BMI), and gender were recorded, along with hospital location, CT scanner model, year, and DLP of each scan. Age and organ appropriate k coefficients were used to calculate effective dose (ED). RESULTS: CT Stone: On univariate analysis, the youngest patients (<18 years) received over 30% less radiation than older ones (p<0.01). As expected, radiation dose monotonically increased from underweight to normal to obese categories (p<0.01). Unexpectedly, one specific hospital and its GE scanner was associated with up to 56% greater DLP (1134 vs. 728 mGy-cm, p<0.01), and there was no reduction in DLP from 2010 to 2014. CT Head: On univariate analysis, disturbingly, those aged < 18 received the same DLP as older patients, and one specific hospital was associated with up to 50% higher DLP (1238 vs. 821, p<0.01) compared to the other three. However, mean 2014 DLP improved significantly, compared to 2010 (p<0.01). On multivariate analysis adjusting for BMI, age, gender, scanner location, model and year, male gender, obesity and undergoing CT stone at hospital D using the GE machine were independent predictors of greater radiation dose (Table). The scatter plot demonstrates up to 6 fold variation in ED at a given BMI. CONCLUSIONS: Even after adjusting for age, gender and BMI, these data demonstrate large variations in CT radiation dose in our institution, despite the use of identical CT scanners and identical CT technicians. This suggests similar, or worse trends nationally, warranting more stringent dosage guidelines and regulations for diagnostic CT scans.
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
e209
Our study sought to identify and describe (1) urologist knowledge, attitudes, and practices related to use of imaging to stage prostate cancer (2) patient attitudes and behaviors related to use of imaging. METHODS: Modified grounded theory was used to conduct 39 semi-structured in-depth interviews with patients who have low risk prostate cancer and urologists caring for them to explore attitudes, norms and behaviors around prostate cancer imaging. Interviews were conducted between September 2014 and July 2015 at three VA hospitals. The hospitals were selected based on their levels of inappropriate imaging: low, middle and high. The goal was to elicit a range of opinions in regards to imaging for prostate cancer staging at the VA. After core theoretical concepts were identified, the Theoretical Domains Framework (TDF) was used to further explore linkages between emerging themes within the dataset and existing domains within the framework. Interviews were audio-recorded, transcribed and coded. NVivo 8 software was used for data organization and further analysis. RESULTS: Patients with prostate cancer have little interest in staging as compared to disease treatment. They tend to “trust their doctor” to make decisions about appropriate tests. While some patients “appreciated” that their physician took extra precautions to order imaging, none reported asking for a test. Physician interviews suggest that most reported knowing and trusting imaging guidelines but some are apt to follow their own intuition. Additionally, physicians feel that medico-legal concerns, fear of missing aggressive disease, and influence from colleagues who image frequently drive higher rates of imaging. CONCLUSIONS: These results suggest a physician-targeted intervention will be most effective. The information gathered from this study will inform the design of a physician-focused behavioral intervention to reduce unnecessary imaging. Source of Funding: Veterans Health Administration, Health Services Research & Development, The Edward Blank and Sharon Cosloy-Blank Family Foundation, and The Gertrude and Louis Feil Family.
MP19-15 RADIATION EXPOSURE OF THE SURGEON: BENEFIT AND PRACTICABILITY OF A LEAD-ACRYL SHIELD FOR URETEROSCOPY Thomas Knoll*, Jan Peter Jessen, Heiko Kohns, Roland Steiner, Roland Umbach, Gunnar Wendt-Nordahl, Sindelfingen, Germany
Source of Funding: none
MP19-14 A QUALITATIVE STUDY TO UNDERSTAND GUIDELINEDISCORDANT USE OF IMAGING TO STAGE INCIDENT PROSTATE CANCER Danil V. Makarov*, Erica Sedlander, Caitlin Curnyn, R. Scott Braithwaite, Heather T. Gold, Scott E. Sherman, New York, NY; Steven Zeliadt, Seattle, WA; Michele Shedlin, New York, NY INTRODUCTION AND OBJECTIVES: Reducing inappropriate use of imaging to stage incident prostate cancer is a challenge highlighted recently as a Physician Quality Reporting System quality measure and by the American Society of Clinical Oncology and the American Urological Association in the Choosing Wisely campaign.
INTRODUCTION AND OBJECTIVES: Patients with urolithiasis are exposed to significant radiation due to imaging for diagnosis, intraoperative management and follow-up. The need for repeated imaging is therefore weighted against potential hazards of radiation. However, radiation protection is as well a serious issue for endourologists. The purpose of this study was to evaluate the potential benefit and practicability of a lead-acryl shield during ureteroscopy (URS). METHODS: We performed a prospective evaluation of 30 consecutive rigid and flexible URS for ureteral and renal calculi. All procedures were done on a fluoroscopic working place (over-the-table fluoroscopy source, Primera 360, Storz Medical, Switzerland) under video-endoscopic control. The patients were divided into two groups with or without use of a ceiling-mounted, mobile lead-acryl shield (30x50cm, lead equivalent 0.5 mm, Mavig, Germany) placed at the level of the symphysis, protecting the head and chest of the surgeon. Dosearea product (mGy/m2, DAP) was assessed. The surgeon’s radiation exposure was measured with a thermoluminescent dosimeter (TLD) at the forehead and one at the ring finger (as control below the shield). RESULTS: Mean age of patients was in 48.1 yrs. in control and 49.5 yrs. in lead group (n.s.). BMI was 26.3 and 28.0 (n. s). OR time was slightly shorter in the control (39.2 vs. 53.9 min., p¼0.2) and a consecutively lower DAP of 390.0 vs. 642.7 mGy/m2 (p¼0.01). In contrast, the forehead exposure was lower in the acryl-lead group (13.9 vs. 33.7 mSv, p¼0.035). There was no difference for the ring dosimeter exposure (p¼0.6). The practicability rating was variable, mainly surgeon-specific. While one surgeon felt comfortable with the shield, others felt limited by it.