Vol. 181, No. 4, Supplement, Sunday, April 26, 2009 194 THE JOURNAL OF UROLOGY ® Source of Funding: National Institute of Diabetes and Digestive and Kidney Diseases 544 OUTCOMES OF ELDERLY PATIENTS WITH UROTHELIAL CARCINOMA OF THE BLADDER AND CONSEQUENCES OF GUIDELINE-DISCORDANT TREATMENT Christian Bolenz*, Richard Ho, Geoffrey R Nuss, Nicolas Ortiz, Ganesh V Raj, Arthur I Sagalowsky, Yair Lotan, Dallas, TX INTRODUCTION AND OBJECTIVE: Treatment decisions in elderly patients diagnosed with urothelial carcinoma of the bladder (UCB) may not meet guideline recommendations (GR) due to presumed short lifespan, comorbidities, and psychosocial factors. We describe the management and clinical course of elderly patients following transurethral resection (TUR) of UCB. METHODS: The records of 116 consecutive patients with available data, over 75 yrs. [89 males, 27 females, median age 80 (range 75-94)], treated between 10/1998 and 08/2008 were reviewed. The AUA Treatment Recommendations were used as a reference when evaluating concordance with GR and clinical outcome. Median follow-up was 17.0 (0.3-111.5) months. RESULTS: Based on TUR pathology, 70 patients with non- muscle-invasive UCB had an indication for conservative treatment [TUR±intravesical therapy(IVT)]. 39 patients had an indication for BCG, 34 (87.2%) of which received at least a BCG induction cycle. 46 patients (39.7%) had an indication for radical cystectomy (RC), including muscle- invasive UCB, recurrent high-grade UCB and BCG failure. Of these, 29 patients (63%) underwent RC (n=24) or radio-chemotherapy (RCHT; n=5) in a curative attempt. The GR concordance rate was 87% and 63% in patients with and without indication for RC, respectively. Patients at higher age (p=0.006), lower Karnofsky performance status (KPS; p=0.008) and higher Charlson comorbidity index (p=0.025) were less likely to be treated following GR. 82 patients (70.7%) were eventually treated conservatively (TUR+/- IVT). Of 35 patients (42.7%) who recurred after IVT, 23 met indication for RC, but only 3 patients underwent RC. Overall, 42 deaths occurred (36.2%). Patients with indication for RC but considered unfit for this procedure showed significantly reduced OS, however, multivariable analysis revealed KPS as the sole independent predictor for reduced OS (p<0.001). In the subgroup of patients with a clear indication for RC, univariable analysis showed no difference in OS between treatment according to GR or not (p=0.976). Again, KPS at the time of TUR was the only parameter associated with reduced OS in this group (p=0.005). CONCLUSIONS: A vast majority of elderly patients appropriately received intravesical therapy. However, over one third of elderly patients did not undergo RC despite indication for the same. No difference in survival based on treatment with RC or not in this patient group was observed. KPS is a strong predictor for reduced OS and should be considered to optimize patient care. Source of Funding: None 545 THREE YEAR COST ANALYSIS OF SACRAL NEUROMODULATION, INTRA-DETRUSOR INJECTION OF BOTULINUM TOXIN TYPE A, AND AUGMENTATION CYSTOPLASTY FOR OVERACTIVE BLADDER WITH URINARY URGE INCONTINENCE Jonathan H Watanabe*, Jonathan D Campbell, Seattle, WA; Arliene Ravelo, Irvine, CA; Michael B Chancellor, Royal Oak, MI; Jonathan Kowalski, Irvine, CA; Sean D Sullivan, Seattle, WA INTRODUCTION AND OBJECTIVE: Three treatment options for oral antimuscarinic refractory patients are Sacral Neuromodulation (SNM), Intra-Detrusor injections of Botulinum Toxin Type A (BoNTA), and Augmentation Cystoplasty (AC). With U.S. OAB related costs estimated at $12.2 billion, decision makers are interested in understanding the cost of treatment options for antimuscarinic refractory patients. The objective was to estimate the average initial treatment costs, first year costs, and cumulative costs extending to three years of SNM, BoNTA, and AC in OAB patients. METHODS: SNM billing codes for procedures and surgical center costs were derived from commonly billed codes issued to providers by the SNM manufacturer. Intra-detrusor injection of BoNTA billing codes were based on recommended BoNTA-specific codes for OAB from a large health plan. AC codes were derived from literature review describing the surgical procedure. Procedure costs were based on the Center for Medicare and Medicaid Services (CMS) National Physician Fee Schedule. BoNTA drug cost was calculated using CMS Average Selling Price. SNM surgical center costs were based on CMS Ambulatory Payment Classification schedules. AC surgical center costs were determined from Diagnosis Related Group reimbursement files. One-way sensitivity analysis was performed to evaluate assumptions and uncertainty of results based on plausible variation in parameter estimates. All costs were reported in 2007 US dollars. RESULTS: Initial treatment costs were $22,226, $1,313, and $10,252 for SNM, Intra-Detrusor Injection of BoNTA, and AC respectively. The first-year costs were $23,614, $2,626, and $11,637 respectively. Three years after initiating treatment, the cumulative costs were $26,269, $7,651 , and $14,337 respectively. Sensitivity analysis revealed that SNM persisted as the most costly intervention in all modeled scenarios. The range of three year cumulative costs by intervention for SNM, BoNTA, and AC was $25,384-$27,357, $4,586-$11,476, and $12,315-$16,830 respectively. CONCLUSIONS: All estimates of cost endpoints for SNM were markedly greater than those for BoNTA and AC for OAB patients. These cost estimates, when combined with data on efficacy and safety outcomes, are important components of a robust health care technology assessment of treatment options for patients with OAB with urinary incontinence who fail or cannot tolerate oral antimuscarinic treatment. Source of Funding: University of Washington Post-Doctoral Fellowship sponsored by Allergan 546 PREOPERATIVE EXPENSES FOR PATIENTS UNDERGOING ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY: ARE COSTS JUSTIFIED? George Dakwar*, Ihor S Sawczuk, Jayant Uberoi, Ravi Munver, Hackensack, NJ INTRODUCTION AND OBJECTIVE: The number of patients with localized prostate cancer that elect for robotic-assisted laparoscopic radical prostatectomy (RLRP) is steadily increasing. We assessed individual and total costs for preoperative staging in patients that underwent RLRP in a major metropolitan area. METHODS: A retrospective review was performed of 249 patients that underwent RLRP over 12 consecutive months at a major referral institution. Preoperative parameters were analyzed, including PSA, biopsy Gleason score, cystoscopy, and radiographic imaging studies. Medicare reimbursement for cystoscopy and the various imaging modalities were used to estimate individual and total costs. The mean radiation dosage was calculated for the imaging modalities.