Over-the-counter medication availability could augment self-management of male lower urinary tract symptoms.

In this review, we focus on current trends in the management of male lower urinary tract symptoms (LUTS), defined here as LUTS, namely, storage, voiding, and post-micturition symptoms presumed secondary to benign prostatic hyperplasia (BPH), and discuss possible novel approaches toward better care. According to results of a PubMed database search covering the last 10 years and using keywords pertaining to male LUTS, this condition continues to be globally undiagnosed or diagnosed late, partly because of men's hesitation to seek help for perceived embarrassing problems or problems considered a normal part of aging. In addition, the prevalence of male LUTS is continually increasing because of a constantly aging population. Male LUTS can be bothersome and affect the quality of life (QoL) and sexual function. Additional effective alternatives for managing this condition need to be identified and incorporated into the current care model. Considering that most male LUTS such as frequency, hesitancy, urgency, and intermittency are easy to self-identify, a self-management approach toward male LUTS is proposed. Limited evidence supports the efficacy of phytotherapies and herbals as self-management options for male LUTS. However, introducing over-the-counter (OTC) medication with proven efficacy, accompanied by lifestyle and behavioral modifications, may be a promising approach that will encourage more men to treat their symptoms in a timely manner. Formal guidelines, along with appropriate education programs for patients and support from the healthcare community, will be needed to ensure that the promise of this approach is fully materialized.

Incorporating Oxygen-Enhanced MRI into Multi-Parametric Assessment of Human Prostate Cancer.

Hypoxia is associated with prostate tumor aggressiveness, local recurrence, and biochemical failure. Magnetic resonance imaging (MRI) offers insight into tumor pathophysiology and recent reports have related transverse relaxation rate (R2*) and longitudinal relaxation rate (R1) measurements to tumor hypoxia. We have investigated the inclusion of oxygen-enhanced MRI for multi-parametric evaluation of tumor malignancy. Multi-parametric MRI sequences at 3 Tesla were evaluated in 10 patients to investigate hypoxia in prostate cancer prior to radical prostatectomy. Blood oxygen level dependent (BOLD), tissue oxygen level dependent (TOLD), dynamic contrast enhanced (DCE), and diffusion weighted imaging MRI were intercorrelated and compared with the Gleason score. The apparent diffusion coefficient (ADC) was significantly lower in tumor than normal prostate. Baseline R2* (BOLD-contrast) was significantly higher in tumor than normal prostate. Upon the oxygen breathing challenge, R2* decreased significantly in the tumor tissue, suggesting improved vascular oxygenation, however changes in R1 were minimal. R2* of contralateral normal prostate decreased in most cases upon oxygen challenge, although the differences were not significant. Moderate correlation was found between ADC and Gleason score. ADC and R2* were correlated and trends were found between Gleason score and R2*, as well as maximum-intensity-projection and area-under-the-curve calculated from DCE. Tumor ADC and R2* have been associated with tumor hypoxia, and thus the correlations are of particular interest. A multi-parametric approach including oxygen-enhanced MRI is feasible and promises further insights into the pathophysiological information of tumor microenvironment.

An Assessment of Patient Comfort and Morbidity After Robot-Assisted Radical Prostatectomy with Suprapubic Tube Versus Urethral Catheter Drainage.

OBJECTIVE: Robot-assisted laparoscopic prostatectomy (RALP) with suprapubic tube (SPT), compared to urethral catheter (UC) drainage, has been proposed to improve patient comfort and recovery. We sought to compare short-term outcomes for pain and morbidity after RALP with SPT vs UC drainage. METHODS: Between August 2012 and 2014, 159 men underwent a RALP and prospectively completed a questionnaire addressing postoperative pain and satisfaction. Group 1 (n = 94) underwent a RALP by one surgeon who placed a UC and removed it between postoperative day (POD) 7 and 10. Group 2 (n = 65) underwent a RALP by a different surgeon who placed an SPT and UC. On POD 1, the UC was removed. On POD 9, the SPT was capped and removed on POD 11 if the patient was voiding adequately. Preoperative and intraoperative data, complications, questionnaires, and patient-reported morbidity, including unplanned telephone calls and emergency department (ED) visits, were compared between groups. RESULTS: Patient characteristics were similar between groups. One week after surgery, the penile pain score was statistically significantly lower in Group 2 compared to Group 1 (56.9% and 79.8%, respectively, reported minimal-to-moderate pain, p = 0.003). Bladder spasms and overall pain were not significantly higher for Group 1 compared to Group 2 (p > 0.05). When asked "How big a problem has your urine storage device been?," 20.2% of patients in Group 1 reported it as a "moderate-to-big" problem compared to 10.8% in Group 2 (p > 0.05). The number of catheter-related unplanned telephone encounters did not differ between the two groups (p = 0.7), however, although not statistically significant, 4.6% of patients in Group 2 presented to the ED with catheter-related issues (p = 0.07). CONCLUSION: SPT after RALP was associated with less penile pain compared to UC drainage, and modestly better patient satisfaction. There were no significant differences in bladder spasms, overall pain, and patient-reported morbidity between groups.

Decision analysis model comparing cost of multiparametric magnetic resonance imaging vs. repeat biopsy for detection of prostate cancer in men with prior negative findings on biopsy.

PURPOSE: We compared cost of multiparametric magnetic resonance imaging (MP-MRI) vs. repeat biopsy in detection of prostate cancer (PCa) in men with prior negative findings on biopsy. METHODS: A decision tree model compared the strategy of office-based transrectal ultrasound-guided biopsy (TRUS) for men with prior negative findings on biopsy with a strategy of initial MP-MRI with TRUS performed only in cases of abnormal results on imaging. Study end points were cost, number of biopsies, and cancers detected. Cost was based on Medicare reimbursement. Cost of sepsis and minor complications were incorporated into analysis. Sensitivity analyses were performed by varying model assumptions. RESULTS: The baseline model with 24% PCa found that the overall cost for 100 men was $90,400 and $87,700 for TRUS and MP-MRI arms, respectively. The MP-MRI arm resulted in 73 fewer biopsies per 100 men but detected 4 fewer cancers (16 vs. 20.4) than the TRUS arm did. A lower risk of PCa resulted in lower costs for the MP-MRI arm and a small difference in detected cancers. At lower cancer rates, MP-MRI is superior to TRUS over a wide range of sensitivity and specificity of MRI. A lower sensitivity of MP-MRI decreases the cost of the MP-MRI, as fewer biopsies are performed, but this also reduces the number of cancers detected. CONCLUSIONS: The use of MP-MRI to select patients for repeat biopsy reduced the number of biopsies needed by 73% but resulted in a few cancers being missed at lower cost when compared with the TRUS arm. Further studies are required to determine whether cancers missed represent clinically significant tumors.

Actual medical management of lower urinary tract symptoms related to benign prostatic hyperplasia: temporal trends of prescription and hospitalization rates over 5 years in a large population of Italian men.

PURPOSE: The purpose of the study is to estimate the trends in drug prescriptions and the hospitalization rates for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) in real-life clinical practice, using information deriving from administrative databases of the Italian health care system. METHODS: Prescription data on approximately 1,500,000 men over 40 were examined, and prescribed boxes of alpha-blockers (ABs) and/or 5 alpha reductase inhibitors (5ARI) were calculated for 5 consecutive years, from 2004 to 2008. Annual use prevalence and incidence rates for each drug class and for the combination therapy (CT) were calculated according to age for the entire study period. Hospitalization rates for reasons related to LUTS/BPH were also evaluated for the same time period. RESULTS: The overall distribution of drugs for LUTS/BPH, in terms of number of boxes prescribed, increased by 43 %. This increase was accounted for by both classes of drugs although it was greater for 5ARI than for AB (+49 vs +41 %). The prevalence of CT showed a substantial increase to almost 25 % in patients aged ≥75. Hospitalization rate for BPH/LUTS-related reasons decreased during the study period (8 and 3 % per year for non-surgical and surgical reasons, respectively). CONCLUSIONS: The prevalence of the use of drugs prescribed for LUTS/BPH has steadily increased. An increase in terms of prescribed boxes was observed for both classes of drugs, even though the increase was greater for 5ARIs. The reduction in the hospitalization rates needs additional researches.

The economic burden of prostate cancer.

In the present review we discuss expenditure on prostate cancer diagnosis, treatment and follow-up and evaluate the cost of prostate cancer and its management in different countries. Prostate cancer costs were identified from published data and internet sources. To provide up-to-date comparisons, costs were inflated to 2010 levels and the most recent exchange rates were applied. A high proportion of the costs are incurred in the first year after diagnosis; in 2006, this amounted to 106.7-179.0 million euros (€) in the European countries where these data were available (UK, Germany, France, Italy, Spain and the Netherlands). In the USA, the total estimated expenditure on prostate cancer was 9.862 billion US dollars ($) in 2006. The mean annual costs per patient in the USA were $10,612 in the initial phase after diagnosis, $2134 for continuing care and $33,691 in the last year of life. In Canada, hospital and drug expenditure on prostate cancer totalled C$103.1 million in 1998. In Australia, annual costs for prostate cancer care in 1993-1994 were 101.1 million Australian dollars. Variations in costs between countries were attributed to differences in incidence and management practices. Per patient costs depend on cancer stage at diagnosis, survival and choice of treatment. Despite declining mortality rates, costs are expected to rise owing to increased diagnosis, diagnosis at an earlier stage and increased survival. Unless new strategies are devised to increase the efficiency of healthcare provision, the economic burden of prostate cancer will continue to rise.

Predictors of costs for robotic-assisted laparoscopic radical prostatectomy.

OBJECTIVES: Information on the association of perioperative parameters with costs for robotic-assisted laparoscopic radical prostatectomy (RALP) is lacking. Understanding factors that impact cost may allow reduction in cost of prostate cancer care. We identified factors associated with higher costs in a contemporary series of RALP. MATERIALS AND METHODS: Total direct cost and clinicopathologic data were available for 264 patients who underwent RALP at our institution between May 2005 and April 2008. We performed linear regression analyses to identify predictors of direct cost using preoperative, intraoperative, and postoperative variables. RESULTS: On univariable analyses, operating room (OR) time, placement of a pelvic drain (both P<0.001), complications during surgery (P=0.002) or hospitalization, blood transfusion, and length of stay (all P<0.001) were associated with higher direct costs. On multivariable analysis, none of the preoperative features were found to predict direct costs. Of the intraoperative factors, OR time (P<0.001) and pelvic drain placement (P=0.006) were associated with higher direct costs. A longer OR time, length of stay, and usage of transfusions (all P<0.001) during the postoperative course were independently associated with higher direct costs. CONCLUSIONS: Of factors that are available preoperatively, none seems to be useful to predict added costs for individual patients undergoing RALP. Higher costs for RALP are driven by events occurring during the procedure or postoperative hospital stay.

The influence of body mass index on the cost of radical prostatectomy for prostate cancer.

OBJECTIVE: to evaluate the impact of obesity on the costs of robotic-assisted (RALP), laparoscopic (LRP) and open retropubic radical prostatectomy (RRP). PATIENTS AND METHODS: the charts of 629 patients who underwent RP (262 RALP, 211 LRP and 156 RRP) between September 2003 and April 2008 at our institution were reviewed. Clinical and pathological data were collected, including age, American Society of Anesthesiologists score, body mass index (BMI), tumour stage, complications and length of stay. Direct and component costs (anaesthesia, laboratory, operating room service, radiology, room and board, pharmacy and surgical supplies) were obtained. Differences in costs were evaluated using three BMI categories (<25, normal weight; 25-<30, overweight; and ≥30 kg/m(2) , obese). RESULTS: of 629 patients, 136 (21.6%) had normal weight, 320 (50.9%) were overweight, and 173 (27.5%) were obese. Clinical and pathological characteristics were similar in the three BMI categories of the entire cohort. The median direct cost was higher for obese patients (P= 0.035). On further stratification by type of RP, costs were higher amongst obese than the other groups undergoing LRP (median US$5703 vs $5347; P= 0.002) and RRP (median $4885 vs $4377; P= 0.004). In patients who underwent RALP there were no significant differences in direct costs (median $6761 in obese vs $6745 in non-obese; P= 0.64). CONCLUSION: obesity influenced the costs in patients who underwent LRP and RRP, mainly due to increased operating room service and anaesthesia costs in obese patients. RALP can be performed with no additional financial burden in obese patients.

Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer.

BACKGROUND: Demand and utilization of minimally invasive approaches to radical prostatectomy have increased in recent years, but comparative studies on cost are lacking. OBJECTIVE: To compare costs associated with robotic-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and open retropubic radical prostatectomy (RRP). DESIGN, SETTING, AND PARTICIPANTS: The study included 643 consecutive patients who underwent radical prostatectomy (262 RALP, 220 LRP, and 161 RRP) between September 2003 and April 2008. MEASUREMENTS: Direct and component costs were compared. Costs were adjusted for changes over the time of the study. RESULTS AND LIMITATIONS: Disease characteristics (body mass index, preoperative prostate-specific antigen, prostate size, and Gleason sum score 8-10) were similar in the three groups. Nerve sparing was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of RRP procedures (p<0.001). Lymphadenectomy was more commonly performed in RRP (100%) compared to LRP (22%) and RALP (11%) (p<0.001). Mean length of hospital stay was higher for RRP than for LRP and RALP. The median direct cost was higher for RALP compared to LRP or RRP (RALP: $6752 [interquartile range (IQR): $6283-7369]; LRP: $5687 [IQR: $4941-5905]; RRP: $4437 [IQR: $3989-5141]; p<0.001). The main difference was in surgical supply cost (RALP: $2015; LRP: $725; RRP: $185) and operating room (OR) cost (RALP: $2798; LRP: $2453; RRP: $1611; p<0.001). When considering purchase and maintenance costs for the robot, the financial burden would increase by $2698 per patient, given an average of 126 cases per year. CONCLUSIONS: RALP is associated with higher cost, predominantly due to increased surgical supply and OR costs. These costs may have a significant impact on overall cost of prostate cancer care.

The effect of the approach to radical prostatectomy on the profitability of hospitals and surgeons.

OBJECTIVE: To evaluate the profit margins for radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic prostatectomy (RALP), and the effect on the reimbursement to the urologist, as there has been a dramatic increase in use of RALP, with the cost of the robot borne by hospitals. METHODS: Data on costs and payments to hospital and surgeon from 2003 to 2008 for RRP, LRP and RALP were obtained from the hospital and urology department. We determined the profit based on the difference between payments received and total cost. RESULTS: Between 2000 and 2008, 1279 RPs were performed at our private hospital. The introduction of RALP increased total number of RPs and replaced most RRPs. RRP represents the only procedure where payments exceed total costs. For RRP there was a significantly higher profit for patients with comorbidities. The type of payer had a large effect on profit. Medicare provides a small profit for RRP but a significant loss of >US$4000 for RALP. While all insurance companies resulted in losses for LRP and RALP, there was variability of almost $600/case for LRP and >$1400/case for RALP. RALP provided the highest reimbursement for the surgeon due to additional reimbursement for the S2900 code (use of robot). CONCLUSIONS: The introduction of RALP has increased the case volume at our hospital and improved profits for the surgeon. The hospital loses money on each LRP and RALP case compared with RRP, which provides a small profit.

Implications of recent epidemiology studies for the clinical management of lower urinary tract symptoms.

Lower urinary tract symptoms (LUTS) include storage, voiding, and postmicturition symptoms, and occur commonly in both men and women. Findings from two recent epidemiological studies, the Epidemiology of LUTS study and the Boston Area Community Health survey, further extend the understanding of the prevalence of individual LUTS, the overlap of LUTS in men and women, the associations of LUTS with other comorbid conditions, the impact of LUTS on health-related quality of life (HRQL), and the relationships between frequency and bother of LUTS and treatment-seeking behaviour. Examining the clinical implications of these findings might provide directions to physicians for managing their patients with LUTS. For example, common findings of separate patient groups spanning a spectrum from those with typically one urinary symptom of mild to moderate severity to those with multiple more severe LUTS and frequent comorbidities might further encourage the diagnosis and treatment of comorbid conditions as a standard part of the management of patients with LUTS. Likewise, understanding that the impact of LUTS on HRQL and the degree of bother, rather than the frequency of LUTS, are significant drivers for treatment seeking might aid in assisting patients to make decisions about treatment.

Are urologists fairly reimbursed for complex procedures: failure of 22 modifier?

OBJECTIVES: The 22 modifier was designed to provide surgeons with additional reimbursement for performing complex procedures. We evaluated whether urologists at a tertiary referral center are reimbursed when using the 22 modifier. METHODS: We evaluated the charts and billing data of all adult urology noncharity cases using the 22 modifier from January 2006 and September 2007. RESULTS: The 22 modifier was used in 317 of 7494 (4.2%) unique procedures performed. Of these 317 procedures, 99 (31%) were reimbursed at a greater rate than the contract level, with a mean increase greater than the contract of $388 (median $260, range $62-$3524), for a mean of 28% greater than the contract. Of the 317 cases, 114 were within $50 of the contract level and 104 were reimbursed at less than the contract level. Additionally, 56 cases were paid at the initial request and < or = 4 appeals were sent in 228 cases, with a successful result in 57 (25%). When analyzed by payor (n = 289), private insurance paid 81 of 187 (43.3%), Medicare paid 23 of 95 (24.2%), and Medicaid paid 1 of 7 (14.3%). Most payments took > 2 months to be paid. The reasons for using the 22 modifier code included extensive surgery, previous surgery, staghorn calculus, extended lymphadenectomy for bladder cancer, adhesions, difficult anatomy, complex dissection, morbid obesity, previous chemotherapy, scarring, previous radiotherapy, difficult debulking, and pregnancy. Of the 317 cases, > 121 had several confounding factors. CONCLUSIONS: The 22 modifier does not provide consistent reimbursement for urologists performing complex procedures. The long-term implications of financial disincentives to performing difficult surgeries need to be further evaluated.

Correlation of the International Prostate Symptom Score bother question with the Benign Prostatic Hyperplasia Impact Index in a clinical practice setting.

OBJECTIVE: To evaluate the association between the International Prostate Symptom Score (IPSS) bother question (BQ) and a validated disease-specific quality-of-life questionnaire, the Benign Prostatic Hyperplasia (BPH) Impact Index (BPH-II), using the BPH Registry and Patient Survey database. PATIENTS AND METHODS: The BPH Registry and Patient Survey is a multicentre, longitudinal, observational database of management practices and patient outcomes in a population of patients with BPH in the USA, managed with watchful waiting or pharmacotherapy. Men enrolled in the BPH Registry who completed the IPSS BQ and the four-item BPH-II at enrolment were identified. The association between the IPSS BQ score and the BPH Impact Index was assessed using Spearman rank correlation. RESULTS: At baseline (enrolment visit), 6439 men (mean age 66 years) completed the IPSS BQ and the BPH-II. The mean (sd) score of the IPSS BQ was 2.5 (1.4) and of the BPH-II was 2.8 (2.8). Based on responses to the BPH-II, at least half the men reported that their urinary symptoms were associated with physical discomfort, worry about their health, and bothersomeness. The IPSS BQ score was significantly correlated (P < 0.001) with the BPH-II (r = 0.68) and each of its four questions (physical discomfort, r = 0.52; worry about health, r = 0.53; bothersomeness of trouble with urination, r = 0.67; and time kept from usual activities, r = 0.44). CONCLUSIONS: The IPSS BQ score has a strong and positive correlation with the BPH-II among men enrolled in the BPH Registry. The IPSS BQ is a convenient tool for assessing disease-specific quality of life when determining treatment strategies and evaluating treatment outcomes in men with BPH.

Cost-effectiveness of prostate cancer chemoprevention: a quality of life-years analysis.

BACKGROUND: The Prostate Cancer Prevention Trial (PCPT) demonstrated that finasteride reduces the prevalence of prostate cancer by 24.8% (risk reduction) but questions remain regarding the cost-effectiveness of widespread utilization. The purpose of the current analysis was to evaluate the cost-effectiveness of chemoprevention utilizing a quality-of-life adjustment. METHODS: A Markov decision analysis model with probabilistic sensitivity analysis was designed to determine the lifetime prostate health-related costs, beginning at age 50 years, for men treated with finasteride compared with placebo. Model assumptions were based on data from the PCPT; Surveillance, Epidemiology, and End-Results program; literature review of costs, utilities, and transition rates among various prostate cancer health states; and local institutional cost data. RESULTS: The quality-adjusted cost-effectiveness ratio for finasteride compared with men not receiving chemoprevention was $122,747 (in U.S.$) per quality-adjusted life-years saved (QALYs). If finasteride is assumed to not increase the incidence of high-grade tumors, the quality-adjusted cost-effectiveness ratio was $112,062 per QALYs. Sensitivity analysis found that chemoprevention of prostate cancer with an agent that has no effect on the prevalence of benign prostatic hyperplasia can render a cost-effectiveness ratio of <$50,000 per QALYs saved when applied to a high-risk population associated with a 25% risk reduction, and a cost of $30 per month. CONCLUSIONS: Finasteride is unlikely to be cost-effective when considering the impact on survival differences among treated versus untreated groups. However, chemoprevention may be cost-effective in high-risk populations when taking into consideration adjustments for the impact on quality of life.

The cost of prostate cancer chemoprevention: a decision analysis model.

BACKGROUND: The Prostate Cancer Prevention Trial found reduced prostate cancer prevalence for men treated with finasteride. The public health cost of wide-scale chemoprevention is unclear. We developed a model to help clarify the cost effectiveness of public use of prostate cancer-preventive agents. METHODS: A Markov decision analysis model was designed to determine the lifetime prostate health-related costs, beginning at the age of 50 years, for men treated with finasteride compared with placebo. Model assumptions were based on data from the Prostate Cancer Prevention Trial, a literature review of survival and progression rates for patients treated with radical prostatectomy, and costs associated with prostate cancer disease states. RESULTS: Chemoprevention with finasteride resulted in a gain of 8.7 [corrected] life years per 1,000 men at a cost of $1.107 million [corrected] per life year saved (LYS). However, if finasteride is assumed to not increase the incidence of high-grade tumors, it renders a gain of 16.9 [corrected] life years per 1,000 men at a cost of $578,400 [corrected] per LYS; finasteride must cost $160 per year [corrected] to reach $100,000 [corrected] per LYS. When applied to a population at higher risk (lifetime prevalence >or=40%) [corrected]for developing prostate cancer, the cost of finasteride must be reduced from its current cost ($62/month) to <$15/month [corrected]for the cost effectiveness to fall below $50,000 [corrected] per LYS. CONCLUSIONS: Given the natural history of treated prostate cancer, implementation of chemoprevention would require an inexpensive medication with substantial cancer risk reduction to be cost effective. Targeting populations at higher risk for developing prostate cancer, however, allows for considerable flexibility in the medication cost to make prostate cancer chemoprevention a more attainable goal.

Implications of the prostate cancer prevention trial: a decision analysis model of survival outcomes.

PURPOSE: To assess the estimated effect of finasteride prevention of prostate cancer on overall survival. METHODS: Data for our decision tree model came from men in the two arms (finasteride or placebo) of the Prostate Cancer Prevention Trial (PCPT) and from clinically localized prostate cancer patients studied for long-term survival outcomes. Our model compared survival outcomes for men treated with finasteride or placebo. Prostate cancer rates were based on the 7-year period prevalence of prostate cancer detected in the PCPT; survival probabilities were abstracted from the long-term outcome studies. We assessed variability in the PCPT and long-term survival studies to test the variability of our model. RESULTS: Survival advantages for a finasteride-treated (v those not treated with finasteride) population include gains of 1.7 months in 15-year cause-specific survival (assuming finasteride-altered Gleason scores and prostate cancer prevalence rates in the PCPT), of up to 3 months for cancers treated conservatively or surgically (assuming finasteride does not alter Gleason scores), and of 0.35 months (assuming the rate of cancers detected by for-cause biopsies in the PCPT), which increased to 1.7 months when assuming a 30% rate of biopsy-detected cancer in the PCPT placebo group. Model-variability analyses support several survival benefits associated with finasteride (eg, the uniform benefits assuming finasteride does not alter Gleason scores) but question certain others (eg, in 15-year recurrence-free survivals assuming finasteride does alter Gleason scores). CONCLUSION: Finasteride can impart survival benefits according to our model, especially when we assume that finasteride does not alter Gleason scores.

The value of your time: evaluation of effects of changes in medicare reimbursement rates on the practice of urology.

PURPOSE: Several reforms to Medicare have changed the reimbursement of physicians from payment based on usual, customary or reasonable charges to a resource based relative value scale. We studied the effect of these changes on hourly reimbursement rates for various services provided by urologists. MATERIALS AND METHODS: We used a previously published national survey of urologists who provided information regarding physician time and work required before, during and after most frequently performed urological services, including during the global period. For comparison mean operative times during the last year at our private hospital for several common urological procedures were obtained. Medicare reimbursement rates for common urological procedures and evaluation and management (E&M) codes for 1995, 1999 and 2004 were acquired from our department's billing office and used to calculate reimbursement rate per hour. RESULTS: There was a steady increase in reimbursement for outpatient services and a decrease in reimbursement for surgical procedures. For E&M codes the reimbursement rates per hour for 2004 represent a mean 51% increase since 1995. However, surgical procedures have had a mean decrease of 28.5% in reimbursement rates per hour. There was remarkable consistency in rates with 7 of the 9 surgical procedures losing between 25.5% and 32% in reimbursement. In 1995 outpatient E&M services were the least profitable at less than half the hourly rate of operative procedures. In 2004 office cystoscopy and transrectal ultrasound biopsy of the prostate had the highest reimbursement and, with the exception of shock wave lithotripsy, there was a minimal difference in hourly reimbursement rates between common surgical procedures and E&M services. CONCLUSIONS: Changes in Medicare reimbursement during the last decade have resulted in significant changes in rates for different urological services. The near equity in reimbursement rates for E&M and surgical services will likely have an increasingly important role in the future practice of urology.

Distinguishing neurogenic from non-neurogenic detrusor overactivity: a urodynamic assessment of lower urinary tract symptoms in patients with and without Parkinson's disease.

OBJECTIVES: To examine the urodynamic (UDS) attributes of detrusor overactivity (DO) in patients with Parkinson's disease in comparison to DO in men without neurologic disease, in whom DO is presumably outlet obstruction induced. METHODS: The UDS database was reviewed for three groups of patients: group 1, men with lower urinary tract symptoms (LUTS) and no known neurologic condition with DO (n = 22); group 2, men with Parkinson's disease and LUTS (n = 39); and group 3, women with Parkinson's disease and LUTS (n = 18). Statistical analysis was used to compare the UDS parameters and diagnoses among the groups and to test for associations between Parkinson's disease duration, Hoehn and Yahr score, and UDS findings. RESULTS: Patients with Parkinson's disease had a significantly lower median volume at first detrusor contraction than those with non-neurogenic DO. The percentage of group 1 patients with urge incontinence was significantly lower than that found in the other two groups (9.1% versus 53.8% and 55.6%, P <0.001 and 0.002, respectively). No statistically significant correlation between the duration or severity of Parkinson's disease and UDS parameters was found. CONCLUSIONS: Men with non-neurogenic LUTS are less likely to have urge incontinence on UDS than either men or women with Parkinson's disease. DO owing to Parkinson's disease occurs earlier during filling compared with non-neurogenic DO, especially in women. The duration and severity of Parkinson's disease are not predictive of the nature or severity of UDS abnormalities.

Laparoscopic nephrectomy is cost effective compared with open nephrectomy in a large county hospital.

BACKGROUND AND OBJECTIVES: To evaluate the experience with laparoscopic nephrectomy in a large county hospital and perform a cost comparison between uncomplicated open and laparoscopic nephrectomy. METHODS: Eleven consecutive patients who underwent an uncomplicated laparoscopic nephrectomy in a large county hospital were compared with 8 patients who underwent uncomplicated open nephrectomy during the same period. Patient charts and corresponding billing records were reviewed to determine overall hospitalization cost and individual cost components. RESULTS: No perioperative complications occurred in either the laparoscopic or open group, and no statistically significant differences existed between groups with regard to patient demographics or operative parameters. The overall operating room costs favored the open nephrectomy group by dollars 1070 (P=0.003). However, the overall cost of hospitalization, surgeon professional fees, duration of hospitalization, room and board costs, laboratory, and radiology costs, pharmacy costs, intravenous solution and infusion pump costs all significantly favored the laparoscopic patient group. The mean difference in overall hospital cost between laparoscopic and open nephrectomy was dollars 1211 in favor of laparoscopy (P=0.037). CONCLUSIONS: Our experience with laparoscopic nephrectomy in a large county hospital demonstrates a clear economic advantage in favor of the laparoscopic approach. Given limited funding for public hospitals and a clear patient benefit, laparoscopic nephrectomy should constitute first-line therapy when nephrectomy is indicated.

Assessment of basic endoscopic performance using a virtual reality simulator.

BACKGROUND: The objective of this study was to evaluate the effect of supervised training using a state-of-the-art virtual reality (VR) genitourinary endoscopy simulator on the basic endoscopic skills of novice endoscopists. STUDY DESIGN: We evaluated 21 medical students performing an initial VR case scenario (pretest) requiring rigid cystoscopy, flexible ureteroscopy with laser lithotripsy, and basket retrieval of a proximal ureteral stone. All students were evaluated with objective parameters assessed by the VR simulator and by two experienced evaluators using a global rating scale. Students were then randomized to a control group receiving no further training or a training group, which received five supervised training sessions using the VR simulator. All students were then evaluated again in the same manner using the same case scenario (posttest). RESULTS: Comparing the results of pre- and posttests, no major differences were demonstrated for any variable in the control group. In the trained group, posttest results revealed statistically significant improvement from baseline in the following parameters: total procedure time (p = 0.002), time to introduce a ureteral guidewire (p = 0.039), self-evaluation (p < 0.001), and evaluator assessment (p < 0.001). Comparing the posttest results of the control and trained arms, we found significantly better posttest scores in the trained group for the following parameters: ability to perform the task (p = 0.035), overall performance (p = 0.004), and total evaluator score (p < or = 0.001). CONCLUSIONS: Students trained on the VR simulator demonstrated statistically significant improvement on repeat testing, but the control group showed no improvement. Endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the operating room.