The introduction of novel bladder outlet therapies in a regional day-case unit in Northern Ireland

ContextNorthern Ireland has five health and social care trusts that provide a Urology service. COVID-19 resulted in the cessation of all but the most urgent elective urological cases. As a result there was an immediate need to enhance current facilities to improve care for our patients. Operations for bladder outlet obstruction, such as transurethral resection of the prostate (TURP), were largely on hold. Men with benign prostatic enlargement continued to suffer in terms of quality of life from symptoms and morbidity from their condition, with subsequent costly attendances through unscheduled care.Issue/ChallengeAs one trust, we had over 100 men active on a waiting list for TURP. We had over 100 patients awaiting a review to decide on surgical management. We had over 400 men awaiting routine assessment through our lower urinary tract symptom assessment clinic.Several surgical options now exist for bladder outlet obstruction. Until this project, TURP was the only option offered to men in Northern Ireland, which is out-with NICE guidance. A TURP has traditionally been an inpatient operation requiring a hospital stay of 2-3 days. During the pandemic and looking to the recovery of services, this was not a viable option.Assessment of issue and analysis of its causesA scoping exercise on where to best place any new service was performed. Key stakeholders included our clinical leaders, management colleagues in the trust and the Department of Health. With successful implementation of a traffic light system for COVID-19, a green pathway for elective surgery had been implemented with great success in our main inpatient Ulster Hospital site. Reflecting on what had been learned in this process, and with a clear need to advocate day-case as default for certain procedures, a regional centre out-with our main inpatient operating theatres was delivered – the Regional Day Procedure Centre (DPC), based at Lagan Valley Hospital.ImpactThe impact has been improved individual patient journeys and improved quality of life for men living with benign prostatic obstruction, with their treatment happening much more promptly, as well as increased staff satisfaction and a saving in theatre costs and bed days.InterventionWe learned and implemented novel bladder outlet techniques;namely Rezum steam ablation therapy to the prostate;green light laser treatment of the prostate (GLLP) and hoImium enucleation of the prostate (HoLEP). We arranged simulation-based training for our Consultant and Speciality Doctor team and mock theatre set up training with the theatre staff to include common pitfalls with equipment. We also arranged simulation-based training for postgraduate surgical trainees, enhancing training during the pandemic.Involvement of stakeholders, such as patients, carers or family members:We engaged and had the support of the clinical and managerial teams from the outset. We opened communication with the day-case unit pre-assessment and anaesthetic teams early. We introduced a new co-located outpatient prostate assessment clinic in conjunction with a nurse specialist.Key MessagesOver the last 6 months we have implemented an all options service for bladder outlet obstruction. We have performed more than 50 day-case Rezum cases, introduced day-case GLLP and inpatient HoLEP. All Rezum and GLLP cases have been day-case with the subsequent personal and institutional savings. We will report our clinical outcomes and reflect on lessons learned.Lessons learntThe introduction of novel bladder outlet therapies has led to improved quality of life for men living with bladder outlet obstruction. We have significantly reduced the waiting list and the waiting time for treatment. We have shown that service development and improvement for benign disease is possible even during a pandemic.Measurement of improvementWe are following up these men with validated symptoms and quality of life scores. We get objective measurement of improvement through repeat flow rate and measurement of post void residual urinary volumes. We have kept a database on key patien parameters and self-reported outcomes. Initial results are promising.Strategy for improvementAs an ongoing and ever evolving project, we use multiple PDSA cycles to improve our service. Weekly team briefs at the end of theatre lists allow feedback from all staff. In particular we have learned from our patients. We have introduced local anaesthetic treatment with Rezum in men unfit for other options. We have contacted other units to share their experience and there has been coverage of our work in our regional media.

IMPACT OF THE SARS-COV-2 VIRUS ON THE URINARY BLADDER

Introduction. There are publications about the impact of a new coronavirus infection (COVID) on the lower urinary tract, including the development of overactive bladder (OAB) or COVID-associated cystitis. The cause of dysuria in patients with COVID is not fully understood. Material and methods. A total of 14 consecutive patients after COVID with complaints of frequent urination with urgency were included in the study. The main inclusion criterion was the development or worsening of OAB symptoms after resolution of COVID, confirmed by the eradication of SARS-CoV-2 by a polymerase chain reaction. The severity of OAB was assessed using the International Scale of Symptoms (Overactive Bladder Symptom Score, OABSS). Results. Three (21.4%) out of fourteen patients had OAB symptoms prior to COVID, while in 11 (78.6%) patients OAB symptoms developed in post-COVID period. In 4 patients (28.6% of the entire cohort and 36.4% of patients in de novo group) urge urinary incontinence and urgency developed. The average score on the OABSS scale in patients with baseline OAB was 6.7±0.8, which corresponded to the moderate severity. In this group, one patient developed urge urinary incontinence and urgency, which were not present prior to COVID. In a retrospective evaluation of symptoms before the COVID, their average score on the OABSS scale was 5.2 ± 0.7, i.e., past COVID led to an increase in OAB symptoms by 1.5 points. In patients with OAB de novo, the symptoms were less pronounced, with a score of 5.1±0.6 points, that is between mild and moderate OAB. At the same time, urinalysis in 9 patients did not have signs of inflammation: in 5 cases, 5–7 white blood cells per field of view was seen only once. A follow-up urine test was normal, suggesting contamination. None of the cases revealed bacteriuria over 102 CFU/ml. All patients were prescribed trospium chloride at a dose of 30 mg per day. The choice of the drug was due to the absence of a negative effect on the central nervous system, which is very important both during COVID and in post-COVID period, since the neurotoxicity of SARS-CoV-2 has been proven. Conclusion. A past history of COVID led to an increase in OAB symptoms by 1.5 points in patients who had OAB prior to infection. In 11 patients, after the treatment of COVID, the moderate symptoms of OAB developed de novo. Our small study showed the importance of focusing the attention of internists and infectious disease doctors on urination disorders in patients with COVID and timely referral to a urologist. For the treatment of post-COVID OAB, trospium chloride is the drug of choice, as it does not aggravate the potential neurotoxicity of SARS-CoV-2. © 2023, Bionika Media Ltd.. All rights reserved.

Case study from Kosovo - repetitive COVID-19 infection and pregnancy

A 25-year-old woman, gravida 2, with no medical history of cardiovascular nor other chronic diseases, came to the gynaecologist and described symptoms of a flu-like disease, including very high fever. The gyneacologist prescribed her antibiotics and paracetamol to calm down the fever. At 37 week of gestation she was admitted to the provincial COVID-19 treatment center for isolation and health care in University Clinical Center of Kosovo in Gynecology/Obstetrics department. All bacteriological tests, including hemocultures and cultures of urines were negative. She received antipyretics (acetaminophen), antispasmodics trimethylphloroglucinol and antibiotics (oral azithromycin for 5 days and intravenous ceftriaxone). Despite this treatments, fever and uterine contractions persisted therefor the commission of doctors decided to deliver the baby via ceserean section. The peritoneal cavity and uterus were found to be very inflamed. Fetal appendages as well as the bladder were strewn with eruptive, vesicular lesions bleeding on contact. After few hours after the delivery her temperature (36.5 degreeC) and blood pressure (120/60 mmHg) were normal. The baby was healthy and tested negative on the COVD-19 tests performed. The patients after 2 weeks of treatment and a negative COVID-19 result she was released to go home and was counselled to eat healthy and prescribed multivitamins for her immune system and regular follow ups with the gynecologist. In a period of 8 months the patient became pregnant again and got infected with the COVID-19 again at 25 weeks pregnant. This time the symptoms were not severe and she was followed up at home. The delivery was planned with cesarean section and the baby was in healthy conditions. The patient got vaccinated with Astra Zeneca COVID-19 vaccine after the delivery. Because of their changed physiology, susceptibility to infections, and weakened mechanical and immunological processes, pregnant women are a particularly vulnerable group in any infectious disease outbreak. The requirement to protect the fetus adds to the difficulty of controlling their health. Keywords: COVID-19, pregnant women, cesarean section, Kosovo, astra-zeneca vaccineCopyright © 2023

COVID-19 vaccines in patients with solid tumor cancers receiving immune checkpoint inhibitors

Background: The interaction between checkpoint inhibitors (CPI) and Sars-COV-2 vaccines has been understudied. One potential complication in pts receiving CPI is immune-mediated adverse events (irAEs) resulting from overactivation of the immune system. It is unknown whether concurrent CPI and Sars-COV-2 vaccine administration increases the risk of irAEs. This retrospective study examined the incidence of severe irAEs in cancer patients receiving CPI therapy at the time of vaccination against Sars CoV-2. Method(s): Following IRB approval, pts with solid tumors who received any approved CPI since FDA authorization of the COVID-19 vaccine in December 2020 were identified via institutional electronic health record. Pts who received one or more doses of an authorized vaccine within 60 days of CPI treatment were included. The primary endpoint was to evaluate the incidence of severe irAE (one or more of the following: grade 3 AE or above, multi-system involvement, need for hospitalization). Secondary endpoints included time between CPI and vaccination, need for immunosuppressive therapy, and rate of discontinuation of CPI due to irAE. Data was analyzed using descriptive statistics. Result(s): 290 pts with bladder, head/neck, liver, skin (melanoma, SCC), renal, and gynecologic cancer were included in analysis. The median age was 67 years (IQR: 59.0-74.0) and 66% pts were male. At the time of vaccination, 201 pts (69.3%) received CPI monotherapy, 53 pts (18.3%) received combination (combo) CPI therapy, and 36 pts (12.4%) received other therapies (chemo, TKIs, etc.) with CPI. The vaccine manufacturer was Pfizer Bio-N-Tech in 162 pts (55.9%), Moderna in 122 pts (42.1%), and Johnson and Johnson in 6 pts (2.1%). The number of vaccinations received was >/= 3 in 214 pts, 2 in 64 pts, and 1 in 11 pts. 30 pts (11.5%) experienced severe irAEs following vaccination. The rate of severe irAEs was 10.3% (30/290) in the total population [6% (12/201) with CPI monotherapy, 19% (10/53) with combo CPI, and 22% (8/36) in the combo CPI-other group]. Severe irAEs occurred after the first vaccine dose in 5 pts (16.7%), second dose in 16 pts (53.3%), and third dose in 9 pts (30%) pts. The median time between CPI treatment and vaccination in pts who experienced irAE was15.5 days (IQR: 10.2-23.0). Hospitalization was required for 19 patients (63.3%). 24 pts (80.0%) required immunosuppressive therapy with a median therapy duration of 98.5 days (IQR 40.2-173.0). 16 pts (53.5%) discontinued CPI therapy following severe irAEs Conclusion(s): In this retrospective study, we observed a 10.3% rate of severe irAE in cancer pts receiving CPI concurrently with COVID-19 vaccines. Further investigation in pts with additional cancer types is warranted to help determine best practice guidelines for COVID-19 vaccination in cancer patients receiving CPI.

Resource Utilization in a Post-pandemic World

Extracorporeal Membrane Oxygenation is a resource intensive therapy;heavily reliant upon specialized equipment, unique disposables, and skilled staff. The Covid-19 pandemic and following events exposed flaws in multiple phases of the care delivery system. The combination of high patient census, acuity, manufacturing delays, and supply chain disruptions led to our center's reassessment of the way in which limited resources are utilized. As a combined pediatric and adult center, we possess the ability to share resources amongst all patient populations. Currently, the majority of our equipment and disposables support a heavier use of Centrimag. We adjusted our general weight guidelines in order to best serve the most patients. (<8kg Sorin Rollerhead, 8-20kg Sorin Revolution, >20kg Centrimag.) Presently, a major challenge is the cessation of production of the -inch Better Bladder. The ECMO Coordinator team collaborated with key physician stakeholders. It was decided that the fluid reservoir and air trap benefits of a bladder outweighed the risks of running without one on our Sorin Rollerhead circuit. We designed a circuit with a 3/8 Bigger Better Bladder. Recognizing the increased risk of clotting with the 3/8 segment, we added a post-oxygenator shunt. This allows for adequate blood flow to maintain circuit integrity, while limiting the amount of flow to the patient. The nationwide nursing shortage is well-known. Though our multidisciplinary ECMO Specialist Team supports nursing and respiratory therapy, the nursing shortage still impacts our staffing models, resulting in the inability to safely staff bedside nurses and ECMO specialists. At times of high census, ECMO patients are cohorted into one geographical location. This allows for a temporary 2:1 staffing model for Centrimag patients. Our goal remains to staff pediatric cases as a 1:1 ECMO Specialist assignment. The ability to obtain this is assessed shift to shift;factoring patient stability, experience of the ECMO specialist, and unit staffing. The collaboration with ICU Nurse Managers, Hospital Supervisors and Central Staffing Office is imperative to the success of staffing model alterations. Our ECMO department has increased its FTEs, implementing a core team to be preassigned to two ECMO beds. The objective is to alleviate the burden on ICU staffing, limiting the number of nurses pulled from staffing grids. In uncertain times, flexibility is vital. It is important to remain vigilant and proactive. Our ECMO program feels that continuous assessment of supplies, equipment, and open communication has been the key to successfully serving our patients.

Cool Your Jets Bro

History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be >107degreeF. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED;however, his temperatures subsequently spiked>103degreeF. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required. Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4degreeF Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities. Differential Diagnosis: 216. Septic Shock 217. Hypothalamic Stroke 218. Exertional Heat Stroke (EHS) 219. Neuroleptic Malignant Syndrome 220. Thyroid Storm Test Results: CBC: 18.2>14.5/40.6<167 CMP: 128/3.5 88/1831/2.7<104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl. Final Diagnosis: Exertional Heat Stroke. Discussion(s): No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/ pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS. Outcome(s): Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient's antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic. Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.

American College of Nuclear Medicine (ACNM) 2022 ACNM Annual Meeting Abstracts

The proceedings contain 91 papers. The topics discussed include: the new approach of COVID-19 patients with deteriorating respiratory functions using perfusion SPECT/CT imaging;increasing interest in nuclear medicine: evaluation of an educational workshop;cost-benefit analysis recommends further utilization of cardiac PET/MR for sarcoidosis evaluation;development of a nomogram model for predicting the recurrence of differentiated thyroid carcinoma patients based on a thyroid cancer database from a tertiary hospital in China;multi-center validation of radiomic models in new data using ComBat-based harmonization of features;bone scan with Tc99m-MDP, the missing link in the initial staging of muscle-invasive bladder carcinoma;and comparison of absorbed doses to kidneys calculated employing three time points and employing two time points in neuroendocrine patients undergoing Lu-177 DOTATATE therapy using planar images.

Abdominal imaging findings in patients with COVID-19 part 2: solid organs

Since Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) first appeared in China in December 2019, the globe has been dealing with an ever-increasing incidence of COVID-19 (Corona Virus Disease 2019). In addition to respiratory disorders, 40% of patients present with gastrointestinal (GI) involvement. Abdominal pain is the most common indication for computed tomography (CT) and ultrasonography. After GI tract involvement, solid visceral organ infarction is the most prevalent abdominal abnormality in COVID-19. This review aims to gather the available data in the literature about imaging features of solid abdominal organs in patients with COVID-19. Gallbladder wall thickening and distension, cholelithiasis, hyperdense biliary sludge, acalculous cholecystitis, periportal edema, heterogeneous liver enhancement, and liver hypodensity and infarction are among hepatobiliary imaging findings in CT, particularly in patients admitted to ICU. Pancreatic involvement can develop as a result of direct SARS-CoV2 invasion with signs of acute pancreatitis in abdominal CT, such as edema and inflammation of the pancreas. Infarction was the most prevalent renal and splenic involvement in patients with COVID-19 who underwent abdominal CT presenting with areas of parenchymal hypodensity. In conclusion, although solid abdominal organs are rarely affected by COVID-19, clinicians must be familiar with the manifestations since they are associated with the disease severity and poor outcome.

Study design of a phase 4, real-world study (COMPOSUR) to evaluate vibegron in patients with overactive bladder.

BACKGROUND: Overactive bladder (OAB) is defined as urinary urgency accompanied by frequency and nocturia, with or without urge urinary incontinence (UUI). Vibegron, a selective ß3-adrenergic receptor agonist approved in the US in December 2020, demonstrated efficacy in reducing symptoms of OAB and was safe and well tolerated in the 12-week EMPOWUR trial and its 40-week, double-blind extension trial. The goal of the COMPOSUR study is to evaluate vibegron in a real-world setting to assess patient treatment satisfaction, tolerability, safety, duration of treatment, and persistence. METHODS: This is a 12-month, prospective, observational, real-world study, with an optional 12-month extension to 24 months, in the US assessing adults ≥ 18 years old starting a new course of vibegron. Patients must be previously diagnosed with OAB with or without UUI, symptomatic for ≥ 3 months before enrollment, and receive prior treatment with an anticholinergic, with mirabegron, or with a combination of an anticholinergic and mirabegron. Enrollment is performed by the investigator following exclusion and inclusion criteria guided by US product labeling, reinforcing a real-world approach. Patients complete the OAB Satisfaction with Treatment Questionnaire (OAB-SAT-q) monthly and the OAB Questionnaire short form (OAB-q-SF) and Work Productivity and Activity Impairment Questionnaire (WPAI:US) at baseline and monthly for 12 months. Patients are followed up via phone call, in-person visits, or telehealth (ie, virtual) visits. The primary endpoint is patient treatment satisfaction as determined by the OAB-SAT-q satisfaction domain score. Secondary endpoints include percent positive responses to individual OAB-SAT-q questions, additional OAB-SAT-q domain scores, and safety. Exploratory endpoints include adherence and persistence. DISCUSSION: OAB leads to a significant decrease in quality of life, as well as impairment of work activities and productivity. Persistence with OAB treatments can be challenging, often due to lack of efficacy and adverse effects. COMPOSUR is the first study to provide long-term, prospective, pragmatic treatment data for vibegron in the US and the resultant effect on quality of life among patients with OAB in a real-world clinical setting. Trial registration ClinicalTrials.gov identifier: NCT05067478; registered: October 5, 2021.

Worse Arterial Stiffness, and Not Endothelial Dysfunction, Is Associated with Pasc

Background: COVID-19 survivors can experience lingering symptoms known as PASC that appear in different phenotypes. The etiology remains elusive and endothelial dysfunction has been postulated as a main driver of PASC. Method(s): Prospective cohort including COVID- and COVID+ with (COVID+PASC+) or without (COVID+PASC-) PASC. We measured endothelial function using Endopat, an FDA approved test, with derived reactive hyperemic index RHI (endothelial dysfunction<=1.67) and arterial elasticity (augmentation index standardized at 75 bpm or AI@75;(lower =better). PASC symptoms were categorized into three non-exclusive phenotypes: Cardiopulmonary CP (postexertional malaise, shortness of breath, cough, palpitations), Neurocognitive N (change in smell/taste, neuropathy, 'brain fog', headache), and General G (fatigue, gastrointestinal or bladder problems). Result(s): We included 491 participants with 109 of the 186 with confirmed COVID+ experiencing PASC. Median number of days between COVID diagnosis and study visit was 249 days (IQR: 144, 510). Among COVID+PASC+, the median number of symptoms was 7.0 (IQR: 3.0,13.0);97 experienced symptoms categorized as G, 90 as N, and 87 as CP. COVID+ PASC+ had the lowest RHI (1.77+/-0.47) and the largest proportion [46.79% (n=51)] with RHI<=1.67 (Figure). AI@75 was the lowest in COVID- (3.11+/-15.97) followed by COVID+PASC- (3.57 +/- 16.34). Within COVID+PASC+, the mean AI@75 among G was 10.11+/-14.85, 11.36+/-14.67 with N, and highest (12.01 +/- 14.48) with CP. Symptoms' number was positively associated with AI@75 (p=0.01). The estimated mean difference in AI@75 between COVID+ PASC+ with CP and COVID+ PASC- was 8.44+/-2.46 (p=0.001), between COVID+ PASC+ with CP phenotype and COVID- was 8.9+/-1.91 (p< .0001), and between COVID+ PASC+ with CP phenotype and COVID+ PASC without CP phenotype was 7.51+/-3.75 (p=0.04) Conclusion(s): PASC was associated with worse arterial elasticity and within PASC, the cardiopulmonary phenotype had the highest arterial stiffness. (Figure Presented).

Coronavirus infection and organizational changes in the clinical process in patients with non-muscle-invasive bladder carcinoma.

The spread of the aggressive disease caused by the novel respiratory syndrome coronavirus-2 (SARS-CoV-2) has had an impact not only on the health and psyche of people, but also on the state of health systems in different countries, by complicating the treatment and diagnostic process. These changes have affected patients with cancers to a greater extent. The diagnosis, treatment, and follow-up of patients are of particular scientific and practical interest when working in conditions of special anti-epidemic control. Objective. To assess the possibility of reducing the frequency of hospitalization of patients with non-muscle-invasive bladder carcinoma (NMIBC) during the Covid-19 period. Subjects and methods. Sixty-four patients with urinary tract malignancy, including 19 (29.7%) patients with low-and high-risk re-current NMIBC, were followed up in two clinics (Saint Petersburg, Russia) in March to October 2020. All the patients were oper-ated on;the patients at high risk for recurrence received a cycle of adjuvant BCG therapy. Methods for cytological examination of urine sediment and the biomarkers UBC and Cyfra 21-1 were used for special laboratory diagnosis;the server stations of both clinics were applied for telehealth consultations (TCs). Results. TCs were used to reduce hospitalization rates: after TCs, all the patients reported a reduction in transport costs and recovery time after hospitalization. TCs could protect the followed-up patients against COVID-19 infection, by observing the rules of clinical examination, and achieve maximum individualization of treatment. The authors refused to perform diagnostic operations for low-risk NMIBC and to use laboratory tests using urinary biomarkers. At the place of their residence, outpatients underwent urinalysis for several indicators, transmitting the result to the clinic's servers or through a monitoring system. Inpatient treatment was used only in cases of gross hematuria or after recording abnormal laboratory test results. Control cystoscopy detected no re-current tumor. Conclusion. During the spread of COVID-19, the periods of endoscopic examinations and control diagnostic operations can be post-poned, by replacing face-to-face consultations with TC monitoring. Outpatient laboratory and radiation examinations are indicat-ed in patients with new-onset gross hematuria or after combination treatment. Repeated operations, including diagnostic ones, should be performed in the case of multiple NMIBCs or after incomplete excision of the primary tumor.Copyright © 2021.

Understanding Patient Experiences with Overactive Bladder

INTRODUCTION AND OBJECTIVE: Overactive bladder (OAB) is highly prevalent, affecting millions of Americans, and poses a significant symptom burden. The purpose of this study was to understand patient experiences with OAB and the impact of these experiences on OAB treatment. METHOD(S): People with symptoms of OAB were recruited from a tertiary care clinic and from an online health research portal to complete semi-structured interviews regarding their OAB experiences. The interviews were recorded, transcribed, coded, and inductively analyzed to identify emerging themes. RESULT(S): We performed 19 interviews and identified several key themes central to the patient experience, including symptom impact and severity, knowledge, stigma, self-efficacy, and regret. We considered these themes along the following stages of the patient's OAB journey. Symptom Development and Awareness: The routine of self-care is insidious and normalized, making realization of a lifestyle that is centered around voiding less obvious to patients, leading to a delay of care-seeking. Participants noted restrictions on all aspects of life. Adjectives used to describe symptom impact included "annoyance, depression, humiliation and desperation." Care-Seeking: Participants expressed coping behaviors during onset and gradual worsening of symptoms, however many recounted a "sentinel event" that heightened their severity perception and served as a cue to action. Routine primary care visit screenings and friend recommendations were additional cues to action. Reasons for careseeking delay included lack of OAB knowledge, stigma, and embarrassment. Experiences with Therapy: Participants recognized that treatment outcomes depended on their engagement. Some individuals regretted their lack of self-advocacy and self-efficacy. Participants highlighted internal barriers (forgetfulness, doubting treatment effectiveness) and external barriers (comorbidities, COVID- 19) to therapy adherence. Among those with high self-efficacy, fear of treatment failure, calendar tools, and social support networks facilitated treatment compliance (Figure 1). CONCLUSION(S): Living with OAB affects patients physically, mentally, and socially. Gaining a better understanding of OAB experiences can help physicians tailor their practice to meet patients' needs.

Parietex Mini Male Sling for Stress Urinary Incontinence at the Time of Three Piece Penile Prosthesis: Technique and Outcomes

INTRODUCTION AND OBJECTIVE: Male stress urinary incontinence (SUI) and climacturia are often comorbid with erectile dysfunction (ED) post prostatectomy. While the inflatable penile prosthesis (IPP) is the gold standard surgical option for ED, there are many surgical options for male SUI as well as climacturia including bulking agents, Virtue male sling, AdVance>= male sling, mini Jupette with IPP, and artificial urinary sphincter (AUS). We present our technique and outcomes for mini male sling (MMS) with IPP insertion for mild SUI and climacturia using a hydrophilic monofilament polyester mesh. METHOD(S): After obtaining IRB approval, a retrospective review of all IPPs performed by a single high volume surgeon was performed. Those men who underwent IPP insertion with concomitant MMS were analyzed. The technique of MMS placement involves measurement of an approximately 5x3cm Parietex>= mesh (Covidien, MN) and overlying this ventrally over the bulbar urethra. The Parietex>= mesh includes a hydrophilic absorbable collagen film to minimize tissue reaction and risk of erosion. The lateral edges of the mesh are sutured to the 3- and 9 o'clock positions on the left and right corporal bodies, respectively, using a nonabsorbable, braided suture in an interrupted fashion. Mesh is sutured just proximal to the corporotomy sites. Tightness of mesh was measured using the proximal end of a Debakey forceps, with ease of passage when IPP deflated and inability to pass forceps when IPP inflated indicative of proper sizing. RESULT(S): A total of 63 men underwent IPP with MMS between January 2018 and October 2022. All patients had ED after radical prostatectomy. Average patient age was 67 years old, and average IPP size was 21cm with 1cm rear tip extender (RTE). A total of 59 men had SUI, with average pad per day (PPD) of 1.5. Twenty-five men with SUI had comorbid climacturia, and 4 men had preoperative climacturia without SUI. Average PPD post IPP with MMS was 0.1. Of the 29 men with preoperative climacturia, only one did not have resolution of his symptoms post MMS. There was only one reported complication of acute urinary retention requiring temporary foley catheter placement. Two patients required subsequent AUS insertion for persistent SUI. There were no reported cases of infection or mesh erosion. CONCLUSION(S): The hydrophilic Parietex>= mesh is a safe, easy to use, nonreactive, and effective material for mini male sling insertion at the time of IPP placement for men with ED and mild/moderate SUI or climacturia.

Progression of Overactive Bladder Symptoms in Patients with Prior Sars-Cov-2 Infection

INTRODUCTION AND OBJECTIVE: Infection with SARS-CoV- 2 can result in de novo or worsening genitourinary (GU) symptoms, such as frequency, urgency, nocturia, and pain/pressure, also referred to as COVID-19 associated cystitis (CAC). The aim of this study was to follow progression of OAB symptoms in patients that previously reported new or worsening OAB symptoms after COVID-19 diagnosis. METHOD(S): 19,128 individuals from a Beaumont COVID-19 serology study, were invited to participate in a follow-up study, with 2,137 subsequent respondents. Participants were divided into a COVID-, Ser+ (positive serology test only) or PCR+ (positive PCR test) groups. Initially, patients were asked to score their OAB symptoms retrospectively prior to the pandemic (baseline) and at present time (day 0). Participants were subsequently asked to score their symptoms at 2-, 4-, 8- and 12-months follow-up. Participants that obtained COVID-19 diagnosis during follow-up phase were excluded from the study. GU symptoms were assessed using the ICIQ-OAB. The minimal important difference (MID) of ICIQ-OAB of 1 is considered a significant change. Data was collected between May 2021 and July 2022. RESULT(S): Of 2,137 participants, 564 (26.4%) previously tested positive for COVID, and 1,573 (73.6%) were COVID naive (COVID-). Of these, 592 participants reported a >=1 unit increase in OAB score at study onset (Day 0) compared to pre-pandemic;243 (41%) were COVID-, 129 (21.8%) had positive serology test (Ser+), and 220 (37.2%) were COVID+ based on PCR test (PCR+). OAB score of these three cohorts were similar at pre-pandemic (2.71 vs 2.97 vs 2.53;p=0.193) but significantly higher at start of study (day 0) in PCR+ versus COVID- or Ser+ groups (5.83 vs 5.12 vs 5.33;p=0.019). In prospective follow-up, change in ICIQ-OAB scores from baseline were recorded at 2, 4, 8 and 12 months. At day 0, both Ser+ and PCR+ cohorts had significantly higher change in OAB score than COVID- group (2.8 and 3.11 vs 2.16;p=0.001). However, after 12 months follow-up, change in OAB score was similar between COVID- (1.86), Ser+ (2.15) and PCR+ (2.09). By 12 months, 74% of COVID-, 80.5% of Ser+ and 72.4% of PCR+ participants still reported significant increase in ICIQ-OAB scores from pre-pandemic levels. CONCLUSION(S): We previously demonstrated that COVID-19 infections increases the risk for developing CAC. COVID infected individuals with CAC take up to 12 months to reach levels of COVIDpatients with baseline elevated OAB Symptoms. Elevated ICIQ-OAB scores in COVID- participants may be contributed to other consequences of the pandemic such as elevated stress and depression.

Impact of Crystalloid Administration on Patients Receiving Haploidentical Allogeneic Stem Cell Transplant (Haplo SCT) with Post Transplant Cytoxan Prophylaxis (PtCy): a Quality Improvement Initiative

Background: Crystalloid fluid administration has traditionally played an important role in prevention of hemorrhagic cystitis with high dose cyclophosphamide. Cryopreservation of stem cells in the era of the COVID pandemic has further led to an increase in crystalloid use. Excess fluid administration over a short duration could lead to volume overload, respiratory failure and impact overall survival. Method(s): A retrospective chart review was conducted on patients receiving PtCy following Haplo SCT at UVA Medical Center from September 2016 through August 2022. Internal BMT quality audit in June 2021 identified increased rate of ICU transfers and respiratory failure amongst patient receiving PtCy due to fluid overload. Hence our PtCy hydration was reduced, with IV fluid administration decreasing from 200 mL/ hr over 62 hours to 100 mL/hr over 12 hours. Urine output parameters placed to administer Cytoxan were also removed. We present our quality improvement project demonstrating outcomes pre and post intervention. Result(s): All demographic patient and transplant-related data was collected during the period of hospitalization for Haplo SCT [Table 1]. Pre-intervention spanned 9/2016-8/2021. Our analysis identified higher than expected rates of respiratory (Table Presented) failure prompting intervention on 8/2021. Post-intervention spanned 8/2021-8/2022. Pre-intervention, 45% of patients receiving Haplo SCT developed respiratory failure (defined as a new hypoxia) in the 30 day post-transplant period. Of these, 93% had volume overload. Mechanical ventilation was required in 21%. Complication rates included ICU transfer - 30%, AKI - 39%, and renal replacement therapy - 18%. Three percent (1 pt) developed hemorrhagic cystitis requiring bladder irrigation. Median LOS was 31.0 days. Post-intervention, average IV crystalloid received was reduced by about 15L. Median diuretic use reduced by 40%. No instances of respiratory failure, mechanical ventilation, ICU transfer, AKI or renal replacement therapy occurred in this group. Median LOS was 26.5 days. There were no cases of hemorrhagic cystitis. Please refer Figure 1. (Figure Presented) (Figure Presented) Conclusion(s): This single center quality improvement initiative shows that reducing IV crystalloid administration with PtCy is associated with a reduction in respiratory failure and other adverse clinical outcomes, without observed increase in hemorrhagic cystitis. Larger multi-center studies are needed to validate this finding.Copyright © 2023 American Society for Transplantation and Cellular Therapy

Trends in Stress Urinary Incontinence Procedures from 2012 to 2020 from the Uda Project

INTRODUCTION AND OBJECTIVE: Stress urinary incontinence (SUI) is a major quality of life problem for many people. In women, SUI is associated with pelvic organ prolapse (POP) and in men after a radical prostatectomy. A safety review started in 2011 by the FDA of POP mesh resulted in the 2019 recall. This study reviews the prevalance and procedure trends for SUI between 2012 to 2020. METHOD(S): Using the 100% Optum Clinformatics Data Mart data and 100% national Medicare Fee-for-Service data, we identified subjects claims for urinary incontinence (UI) and any procedures performed for UI. Results reported as mean +/- standard deviation. RESULT(S): From 2012 - 2020, the mean prevalence of any UI in the 18-64 age group was 37,529 +/- 3292 or 0.62% of the population. In the Medicare population (aged 65+), it was 1,439,221 +/- 90507, or 5.7% of the group. The Female to Male ratio in the <65 yr group was 2.52:1 and in the 65+ was 5.31:1. The Medicare mean SUI prevalence was 212223 +/- 14292 (0.84% population), and the Optum group was 13,179 +/- 1,535 (0.22%).38,677 Medicare patients received procedures for UI in 2012. This increased to 54,122 by 2019, falling to 45,667 during COVID. In 2012, 12,286 patients received SUI procedures, which plateaued at 8,670/yr for 2015 to 2019. In 2020, 6508 patients had a SUI procedure. (Breakdown in Figure 1A). 4020 patients with UI aged 18-64 got a procedure in 2012, which decreased by 45% to 2635 in 2019 with a dip for COVID to 2020. The numbers plateaued from 2014 to 2019 at 2500 patients/yr approximately. The SUI patient numbers for this group decreased from 2501 in 2012 to 967 in 2020, plateaued between 2014 and 2019 at 1250 patients/yr approximately. (Breakdown in Figure 1B) There was a 50% decrease in patients getting sling procedures. Patients obtaining artificial urinary sphincter, and injectables remained constant. Men receiving artificial urinary sphincter, slings, and injectables has remained even in the 65+ age group. However, in the 18-64 age group, men obtaining slings decreased. CONCLUSION(S): The claims prevalence for UI has increased in older age and decreased in younger patients. Sling use has decreased in all female patients and younger men. The overall decrease in procedures for SUI, appears partly due to decreased reporting of incontinence claims in the younger population, together decreased Sling procedures in female patients.

Evaluation of Bladder Cancer Patients' Utilization of Urologic Telehealth Services

INTRODUCTION AND OBJECTIVE: Infection control practices and public policy in response to the COVID-19 pandemic shifted healthcare practices towards a telemedicine format. Even two years after peak onset of the pandemic, many clinics, including our own institution, maintain a working telehealth option for patient visits, with some patients even preferring this modality of care delivery. Our objective was to evaluate patient utilization of telehealth visits versus inperson visits at our institution and whether this was impacted by demographics, medical history, and socioeconomic factors. METHOD(S): Medical Record Numbers for all patients with bladder cancer were pulled via accessible billing-level data from the period 7/1/2019-2/28/2022. Chart review was conducted to pull clinical data on patients including telehealth versus in person visits, demographic data, clinical stage, comorbidities (diabetes, smoking status, BMI), rural/urban status by zip code (>50,000, <50,000 individuals) and income levels by zip code (25K-49.9K, 50K-99.9K, <100K), payor status, patient distance, and gas savings/carbon footprint. RESULT(S): 430 patients completed in person visits while 268 completed telehealth visits. There was no statistically significant difference for in person visits vs. telehealth visits regarding patients' race (p=0.541), ethnicity (p=0.394) age (p=0.862), urban/rural status (p=0.507), payor status (p=0.127), mean zip code income (p=0.175), and comorbidities (p=0.626 for diabetes, p=0.706 for smoking, p=0.459 for BMI), and clinical stage (p=0.07). There was a statistically significant difference in mean distance (14.85 miles versus 26.86 miles, p<0.01). CONCLUSION(S): Post-pandemic, telehealth usage and acceptability among patients with bladder cancer remains high. Patients' with bladder cancer receive care from their urologist via in person visits versus telehealth at similar rates irrespective of their urban/rural status, demographics, payor status, relevant comorbidities, or relative income. Patients are more likely to engage in care with their urologist via telehealth if they live farther from a large urban academic center, which produces an economical and environmental impact via gas/time savings and reduced carbon footprint.

Post-Operative Outcomes in 'Monti' Construction for Neurogenic Bladders in an Adult Population

INTRODUCTION AND OBJECTIVE: Various diversion techniques exist for the management of neurogenic bladders. In pediatrics, the appendicovesicostomy is a successful approach but may not be applicable for all patients. An alternative is the Yang-Monti ("Monti") catheterizable conduit, created using a section of small bowel. Although commonly used in pediatrics, there are very few series evaluating adults. This study aims to evaluate "Monti" outcomes in an adult population. METHOD(S): Between 1999 and 2022, "Monti" procedures at a single institution were identified using CPT codes, and the list was reviewed to select for adult patients with neurogenic bladder dysfunction. Preoperative data included indications for surgery and patient demographics. Perioperative (day 0 to end of hospital stay) data included time to return of bowel function, length of stay, and perioperative complications. Long-term complications included infections, hospital admissions, and reoperations. Data are presented as means or percentages. RESULT(S): 21 adult patients (male n=8;female n=13) with neurogenic bladder dysfunction were identified. 14 patients developed neurogenic bladder secondary to trauma, while other indications for surgery included idiopathic urinary retention (n=1), tumors (n=2), congenital abnormalities (n=2), multiple sclerosis (n=1), and autoimmune neuropathy (n=1). The mean follow-up time was 3.13 years and mean age at surgery was 35.5 years. The mean time to return of bowel function was 2.7 days (n=14) and postoperative hospital stay was 4.3 days (n=16). Perioperative complications occurred in 10 patients (47.6%) in the first 30 days including UTIs (n=3), surgical site infection (n=3), ileus (n=1), small bowel obstruction (n=1), and suprapubic tube related complications (n=3). Five emergency room admissions for urologic concerns occurred within this period with a total of 28 visits overall. At six month follow-up, a total of six (28.6%) patients had longer-term complications. These included a takedown, a scheduled revision, a hospitalization for complicated UTI, and three patients who were unable to catheterize. Overall, nine patients (42.9%) required reoperation, including three revisions and one cystectomy with conversion to ileal conduit. Two patients expired during the course of this study due to COVID pneumonia and suspected sepsis. CONCLUSION(S): "Monti" procedures are useful for adult patients with neurogenic bladder dysfunction. However, these procedures are associated with significant complications. This information should be used to aid in presurgical counseling.

The effect of the pandemic period on Bladder Pain Syndrome patients under amitriptyline treatment.

INTRODUCTION: COVID-19 is a disease that may cause anxiety, depression, and stress. Bladder pain syndrome (BPS) is a disease in which stress and psychological factors might negatively affect its course. In this study, we aimed to examine the possible clinical aggregation of the pandemic period on BPS patients. MATERIALS AND METHODS: A total of 35 BPS patients diagnosed between 2010 and 2018 were included. All patients were using medical treatment, and the follow-up period was at least 6 months. According to our clinical follow-up protocol, the BPS patients were given the King's Health Questionnaire (KHQ), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Overactive Bladder Form V8 (OAB-V8), and Visual Analog Score (VAS) in every visit. In the sixth month of the pandemic, the clinical course of the patients was questioned by telephone or video interview, and their treatment continuities were questioned. Information was received about the delays in their follow-up and the difficulties in accessing healthcare opportunities. The same questionnaires were filled out and compared with pre-pandemic scores. RESULTS: The mean age of the patients included in the study was 50.2 ± 13.32 (min:20, max:74), 11 were males and 24 were females. The mean follow-up periods were 71.8 ± 35.6 months. All questionnaire scores showed an increase compared to the pre-pandemic period. A statistically significant increase was detected during the pandemic in all sub-units of the KHQ. The VAS and OAB-V8 scores of 16 patients who requested hospital admission were significantly higher than before the pandemic. However, there was no statistically significant difference in the increase in VAS and OAB-V8 scores of the 19 patients who refused to come to the hospital. CONCLUSION: BPS patients have been negatively affected by the emotional effects of the COVID-19 pandemic. Due to the fear, stress, anxiety, and depression, the symptoms of BPS patients exacerbated, and the patients could not receive the necessary support due to a lack of regular follow-ups.

The use of ilioinguinal and iliohypogastric nerve block anesthesia in inguinal bladder hernia repair

Aim: There are data showing that the use of minimally invasive anesthesia methods (local anesthesia, nerve blocks) as an alternative to traditional anesthesia methods used in inguinal hernia repair surgery is safe and effective. During the COVID-19 pandemic, which affected the whole world, we aimed to evaluate the use of minimally invasive anesthesia methods in patients with inguinal bladder hernia, as well as their perioperative and postoperative results in our pilot study.Material and Methods: We evaluated the perioperative and postoperative data of five patients with inguinal bladder hernia, who underwent surgery with local anesthesia and ilioinguinal/iliohypogastric nerve blockade, four of which were performed during the COVID-19 pandemic.Results: It is possible to perform inguinal bladder hernia surgery with local anesthesia and ilioinguinal/iliohypogastric nerve block, including in secondary cases. Better hemodynamic stabilization in the intraoperative period reduces the need for narcotic analgesics by providing effective analgesia in the postoperative period, as well as reducing the risk of contamination in airway control.Discussions: Performing inguinal bladder hernia surgery using local anesthesia and ilioinguinal/iliohypogastric nerve block provides reliable and effective analgesia during the perioperative and postoperative periods.