Active surveillance, radiofrequency ablation, or cryoablation for the nonsurgical management of a small renal mass: a cost-utility analysis.

BACKGROUND: Patients with a cortical small (≤4 cm) renal mass often are not candidates for or choose not to undergo surgery. The optimal management strategy for such patients is unclear. METHODS: A decision-analytic Markov model was developed from the perspective of a third party payer to compare the quality-adjusted life expectancy and lifetime costs for 67-year-old patients with a small renal mass undergoing premanagement decision biopsy, immediate percutaneous radiofrequency ablation or percutaneous cryoablation (without premanagement biopsy), or active surveillance with serial imaging and subsequent ablation if needed. RESULTS: The dominant strategy (most effective and least costly) was active surveillance with subsequent cryoablation if needed. On a quality-adjusted and discounted basis, immediate cryoablation resulted in a similar life expectancy (3 days fewer) but cost $3,010 more. This result was sensitive to the relative rate of progression to metastatic disease. Strategies that employed radiofrequency ablation had decreased quality-adjusted life expectancies (82-87 days fewer than the dominant strategy) and higher costs ($3,231-$6,398 more). CONCLUSIONS: Active surveillance with delayed percutaneous cryoablation, if needed, may be a safe and cost-effective alternative to immediate cryoablation. The uncertainty in the relative long-term rate of progression to metastatic disease in patients managed with active surveillance versus immediate cryoablation needs to be weighed against the higher cost of immediate cryoablation. A randomized trial is needed directly to evaluate the nonsurgical management of patients with a small renal mass, and could be limited to the most promising strategies identified in this analysis.

MRI for pelvic floor dysfunction: can the strain phase be eliminated?

PURPOSE: The purpose of the study was to determine if the strain phase of an MR defecography (MRD) protocol is redundant and can be eliminated without a loss of diagnostic information. MATERIALS AND METHODS: Institutional review board approval was obtained and the requirement for informed consent was waived. A retrospective single-center review of 80 MRD examinations (68 female, 12 male, mean age 55 years old) was conducted. Two radiologists blinded to patient information evaluated in consensus the strain and evacuation phases separately and in a random order. Each phase was assessed for the presence and degree of posterior compartment descent, cystocele, urethral hypermobility, uterovaginal prolapse, rectocele, rectal intussusception, and enterocele. The degree of pelvic floor descent was compared using a paired t test and McNemar's test was used to compare the proportion of abnormal findings. RESULTS: The evacuation phase identified all abnormalities identified on the strain phase and also identified both additional and more pronounced abnormalities, including an additional 34 cystoceles, 20 cases of urethral hypermobility, 13 uterovaginal prolapses, 36 rectoceles, 5 rectal intussusceptions, and 6 enteroceles (all p < 0.02). The mean posterior compartment descent was 24.1 mm greater on the evacuation phase than the strain phase (p < 0.0001). CONCLUSION: The strain phase is redundant and we propose that it can be eliminated from a routine MRD protocol. This will help streamline the examination, simplify patient instructions, and reduce both imaging and reporting time.

Effect of voice recognition on radiologist reporting time.

OBJECTIVE: To study the effect that voice recognition (VR) has on radiologist reporting efficiency in a clinical setting and to identify variables associated with faster reporting time. METHODS: Five radiologists were observed during the routine reporting of 402 plain radiograph studies using either VR (n = 217)or conventional dictation (CD) (n = 185). Two radiologists were observed reporting 66 computed tomography (CT) studies using either VR (n = 39) or CD (n = 27). The time spent per reporting cycle, defined as the radiologist's time spent on a study from report finalization to the subsequent report finalization, was compared. As well, characteristics about the radiologist and their reporting style were collected and correlated against reporting time. RESULTS: For plain radiographs, radiologists took 13.4% (P= 0.048) more time to produce reports using VR, but there was significant variability between radiologists. Significant association with faster reporting times using VR included: English as a first language (r = -0.24), use of a template (r = -0.34), use of a headset microphone (r = -0.46), and increased experience with VR (r= -0.43). Experience as a staff radiologist and having a previous study for comparison did not correlate with reporting time. For CT, there was no significant difference in reporting time identified between VR and CD (P = 0.61). CONCLUSIONS: Overall, VR slightly decreases the reporting efficiency of radiologists. However, efficiency may be improved if English is a first language, a headset microphone, and macros and templates are used.