Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH ( p = 0.545, p = 0.637). Conclusion:The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.
IMPACT: We compare the cost-effectiveness of treatments for early prostate cancer, and propose how to maximize the value of care within an increasingly cost-constrained healthcare climate. OBJECTIVES/GOALS: Each year 192,000 men in the United States are diagnosed with prostate cancer. With various treatment options available, there is a growing role for cost-effectiveness analyses which may help maximize the value of care to the patient. In this review we compare the cost-effectiveness of primary treatments for clinically localized prostate cancer. METHODS/STUDY POPULATION: In this systematic review we aim to compare the cost-effectiveness or cost-utility of primary treatment strategies for clinically localized prostate cancer. This review, which adheres to 2009 PRISMA guidelines, included studies of men with clinically localized prostate cancer comparing at least two treatment strategies using the incremental cost-effectiveness ratio (ICER). We included analyses only of the United States healthcare system with at least 10 years of follow-up. These studies were published from 2006 to 2019 and generally included men with low or low to intermediate risk prostate cancer. Most studies reported outcomes for men age 65-70. All studies were prospective simulated trials and used a Markov model to simulate patient outcomes. RESULTS/ANTICIPATED RESULTS: Ten articles were included in the analysis. All studies used a Markov model to simulate a randomized trial. Six studies primarily compared radiation modalities, and four compared observation with immediate treatment. There was substantial heterogeneity in treatment protocols and the patients being simulated. Sensitivity analyses showed these models to be influenced by utility values and length of follow-up. A meta-analysis was not possible as no studies reported the variance of the primary outcome. Heterogeneity in study design limited comparisons of treatments across studies. However, these models were sensitive to patient-specific clinical factors, including life expectancy and the utility during and after each treatment. DISCUSSION/SIGNIFICANCE OF FINDINGS: These studies indicate collectively that the cost-effectiveness of prostate cancer treatment for similarly staged men may be heavily impacted by comorbidities and personal preferences. As the US moves towards value-based care, patient preferences may continue to drive the preferred treatment for newly diagnosed prostate cancer.
INTRODUCTION AND OBJECTIVE: Patients with kidney stones are counseled to eat a diet low in animal protein, sodium and oxalate, with a modest amount of calcium, usually from dairy. However, approximately 2/3 of the global population is lactose intolerant, and plant-based diets are becoming increasingly popular due to health and environmental benefits. Restriction of sodium, potassium and oxalate e90
Alpha-blocker medical expulsive therapy (MET) is widely utilized in the treatment of ureteral stones though its effectiveness is questionable. With increasing burden of urolithiasis on US healthcare, the utilization effects of a-blocker therapy have not been elucidated. We studied the effects of a-blocker MET in reducing surgical intervention, imaging, adverse events, ER visits, and cost up to 3 months.METHODS: Patients were selected from a US national commercial claims database between 2011 and 2016 based on prescription of a-blocker for a primary diagnosis of ureteral stone in an emergency room (ER), urgent care, outpatient, or inpatient hospital setting. We identified 58568 patients with and 78653 patients without prescription for alpha-blocker. Evaluation was performed at 30 days and 90 days after diagnosis of a ureteral stone event to determine rate of surgical intervention, number and type of follow-up imaging studies, adverse events, ER visits, and total medical claims cost. Multivariable linear and logistic regression models were used to test associations between outcome variables and the use of MET.RESULTS: a-blockers were prescribed to 43% of patients with ureteral stones for median length of 14 days. At 30-days after index stone event, 20.6% MET vs. 20.1% non-MET (p<0.001, OR[1.07) underwent a surgical procedure, 40% MET vs. 32% non-MET (p<0.001, OR[1.46) had a follow-up imaging study (KUB, CT or US scan) and 20% MET vs. 16% non- MET (p<0.001, OR[1.36) presented to the ER. Total medical claims cost at 30 days was $3860
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