Neoadjuvant Leuprolide Therapy with Radical Prostatectomy: Long-term Effects on Health-related Quality of Life.

BACKGROUND: Neoadjuvant androgen ablation (neoadjuvant androgen deprivation therapy [NADT]) is used prior to radical prostatectomy, contrary to guidelines, but its long-term effects on quality of life is unknown. OBJECTIVE: To determine the effect of NADT on patient's long-term recovery following surgery. DESIGN, SETTING, AND PARTICIPANTS: From March 2011 to August 2013, 5808 men with newly diagnosed prostate were followed up to 24 mo. A cohort of men who received NADT prior to robotic-assisted laparoscopic prostatectomy (RALP; n=51) was compared 1:3 with a matched group that underwent RALP only (n=153). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients were matched on Charlson comorbidities, biopsy Gleason score, and node status on final pathology. The Kruskall-Wallis test was used to compare the groups on their bowel, urinary, sexual, and hormonal domains of the 26-item Expanded Prostate Cancer Index Composite at baseline and at 1, 3, 6, 12, 18, and 24 mo postoperatively. RESULTS AND LIMITATIONS: The urinary irritative, urinary incontinence, and bowel domains were similar in the two groups during the 24 mo (p=0.832, 0.901, and 0.732, respectively). In the hormonal domain, the NADT group did worse (p<0.001). The sexual domain was also worse for the NADT group. However, when accounting for nerve sparing, there was no significant difference in sexual outcomes between the two groups (p=0.069). CONCLUSIONS: Patients who received NADT prior to RALP do not have worse sexual function, but have worse hormonal scores for up to 2yr after surgery. PATIENT SUMMARY: Neoadjuvant androgen deprivation therapy (NADT) is administered prior to robotic-assisted laparoscopic prostatectomy (RALP), contrary to clinical guidelines. NADT may not have worse sexual function outcomes up to 2yr after RALP.

Physician Compliance to Choosing Wisely® Initiative in Radiographic Imaging of Low Risk Prostate Cancer in an Integrated Health Care System.

INTRODUCTION: We evaluated the adherence of urologists within an integrated health care system to Choosing Wisely®, an initiative aimed at avoiding unnecessary medical tests. In urology, 2 of the guidelines state bone scans and pelvic computerized tomography scans are unnecessary in low risk prostate cancer. METHODS: We performed a retrospective study on patients diagnosed with low risk prostate cancer between January 1, 2010 and December 31, 2017 at Kaiser Permanente Southern California. All demographics and imaging data were obtained. Patients with symptoms concerning for metastatic disease or with other malignancies were excluded by chart review. Statistical analysis was employed to compare the use of bone scans and computerized tomography scans in this population before and after the Choosing Wisely guidelines were published. RESULTS: Of the 6,996 patients, 121 (1.7%) and 96 (1.4%) underwent a bone scan and computerized tomography scan, respectively. A Cochran-Armitage test showed no change after implementation of the statements. Logistic regression analysis revealed that for every point increase in prostate specific antigen, the odds ratio was 1.09 for ordering both a bone scan and computerized tomography scan. When compared to Whites, the odds ratio of having a bone scan and computerized tomography scan were 0.35 and 0.37 for Blacks, 0.30 and 0.38 for Hispanics, and 0.47 and 0.61 for Asians, respectively. CONCLUSIONS: Over the study period, there were low rates of inappropriate imaging for low risk prostate cancer. There was no change in trend after publication of the Choosing Wisely. Higher prostate specific antigen levels and White ethnicity were predictors for ordering inappropriate imaging.

Single Institutional Experience with Single Stage Sacral Neuromodulation: Cost Savings and Outcomes in a Contemporary Case Series.

PURPOSE: Sacral neuromodulation is traditionally performed in 2 stages. Studies have projected that 1-stage sacral neuromodulation is cost-effective if the conversion rate is 61.3% or greater. To our knowledge we present the first case series in the literature to evaluate the cost of 1-stage sacral neuromodulation. The objective of our study was to evaluate outcomes and analyze cost using our institutional experience with 1-stage sacral neuromodulation. MATERIALS AND METHODS: A total of 15 consecutive 1-stage sacral neuromodulation procedures were performed at a self-insured, integrated health care institution. Cost data were determined using 2019 Medicare reimbursement rates for CPT codes 64581, 64585, 64590 and 64595. Median operative time was derived from actual institutional data. RESULTS: One-stage sacral neuromodulation implantation was performed in 15 patients. Median followup was 14.6 months (IQR 6.9-22.5). Of the 15 cases 14 (93.3%) were successful, defined as a 50% or greater improvement from baseline. Total reimbursement for the 15 patients who underwent 1-stage implantation was $329,430. If these patients had undergone traditional 2-stage implantation with equivalent outcomes, the overall reimbursement was determined to be $414,796. Single-stage sacral neuromodulation implantation provided a calculated total cost savings of $85,366 (p <0.01). Moreover, a projected 233 minutes in operative time was saved by performing 1-stage sacral neuromodulation (p <0.01). CONCLUSIONS: This study demonstrates the potential health care savings of a 1-stage sacral neuromodulation procedure. Moreover, 1-stage sacral neuromodulation may have other added benefits, such as reduced infection rates, patient satisfaction and other indirect cost savings, including reduced time off from work.

Postvasectomy Scrotal Pain and Hematospermia, a Possible Harbinger for Vasectomy Failure and Recanalization: A Case Report.

INTRODUCTION: Vasectomy is the most common and most effective method of achieving permanent male sterility. However, there is a low risk of vasectomy failure. To our knowledge, there is no symptom complex that has been identified and described that is predictive of early recanalization and vasectomy failure. CASE PRESENTATION: A 44-year-old man underwent a routine bilateral vasectomy without complication. Two months after the procedure, the patient experienced an acute onset of scrotal pain and hematospermia. Several semen analyses were performed during the following months, the results of which demonstrated progressively rising numbers of motile sperm and were indicative of vasal recanalization. The patient underwent repeated vasectomy, during which he was found to have right vasal recanalization leading to vasectomy failure. DISCUSSION: Delayed postvasectomy scrotal pain associated with hematospermia may be a sign of vasal recanalization. We propose that this symptom complex should prompt an investigation for vasal recanalization, during which the patient should be instructed to refrain from intercourse without the use of an additional method of contraception.

Breast reconstruction satisfaction rates at a large county hospital.

BACKGROUND: It has been previously reported that the indigent patient population is less likely to seek breast reconstruction. It has also been reported that lower income women who do chose to undergo reconstruction are less satisfied with the results. This study assesses the level of breast reconstruction satisfaction in women treated at Los Angeles County Medical Center (LAC). For those women with lower satisfaction, we seek to identify the root source of this dissatisfaction. METHODS: Patients who underwent breast reconstruction at LAC from 2007 to 2012 were identified by Current Procedural Terminology codes. Eligible participants were administered the BREAST-Q postreconstruction module. Demographic data were obtained from the patient and/or their medical records. RESULTS: A total of 65 patients completed the surveys. The satisfaction scores for the appearance of the breast were 61 (24) and satisfaction with overall outcome was 80 (26). The occurrence of major complications was associated with lower satisfaction scores with respect to the appearance of the breast (P<0.0001) and overall outcome (P=0.02). In addition, patients with delayed reconstruction were also noted to be more satisfied with respect to appearance of the breast (P=0.03). CONCLUSIONS: Despite suggestions that the indigent and the underserved patient population are less satisfied with the results of their breast reconstruction procedures, patients at LAC demonstrated comparable satisfaction levels to other published reports. The occurrence of major complications and immediate reconstruction were significantly associated with lower levels of satisfaction.