Optimization of DNA extraction from human urinary samples for mycobiome community profiling.

INTRODUCTION: Recent data suggest the urinary tract hosts a microbial community of varying composition, even in the absence of infection. Culture-independent methodologies, such as next-generation sequencing of conserved ribosomal DNA sequences, provide an expansive look at these communities, identifying both common commensals and fastidious organisms. A fundamental challenge has been the isolation of DNA representative of the entire resident microbial community, including fungi. MATERIALS AND METHODS: We evaluated multiple modifications of commonly-used DNA extraction procedures using standardized male and female urine samples, comparing resulting overall, fungal and bacterial DNA yields by quantitative PCR. After identifying protocol modifications that increased DNA yields (lyticase/lysozyme digestion, bead beating, boil/freeze cycles, proteinase K treatment, and carrier DNA use), all modifications were combined for systematic confirmation of optimal protocol conditions. This optimized protocol was tested against commercially available methodologies to compare overall and microbial DNA yields, community representation and diversity by next-generation sequencing (NGS). RESULTS: Overall and fungal-specific DNA yields from standardized urine samples demonstrated that microbial abundances differed significantly among the eight methods used. Methodologies that included multiple disruption steps, including enzymatic, mechanical, and thermal disruption and proteinase digestion, particularly in combination with small volume processing and pooling steps, provided more comprehensive representation of the range of bacterial and fungal species. Concentration of larger volume urine specimens at low speed centrifugation proved highly effective, increasing resulting DNA levels and providing greater microbial representation and diversity. CONCLUSIONS: Alterations in the methodology of urine storage, preparation, and DNA processing improve microbial community profiling using culture-independent sequencing methods. Our optimized protocol for DNA extraction from urine samples provided improved fungal community representation. Use of this technique resulted in equivalent representation of the bacterial populations as well, making this a useful technique for the concurrent evaluation of bacterial and fungal populations by NGS.

The Truth Behind Transvaginal Mesh Litigation: Devices, Timelines, and Provider Characteristics.

OBJECTIVES: Following Food and Drug Administration communications about the safety of transvaginal prolapse, more than 73,000 patients with complications from treatment of pelvic organ prolapse (POP) or stress urinary incontinence (SUI) have filed product liability claims. This research analyzes the transvaginal mesh claims filed in the United States to identify key characteristics that may inform clinical decision-making. METHODS: We evaluated a 1% random sample from the Bloomberg Law Database: 2000 to 2014 and associated legal documents. Outcomes and measures used included annual rate of claim, mesh type, time interval between surgery and claim, defendants, and surgeon training. RESULTS: The search returned 76,865 results, and 2979 were excluded, leaving 73,915 claims. Of 739 claims (1%), 63.3% involved slings for SUI, 13.3% mesh for POP, and 165 (23.2%) involved both. The mesh named most often in claims was retropubic slings at 30.3% and transobturator slings at 27.1%. The number of cases filed increased significantly from 730 in 2011 to 11,798 in 2012, which then almost tripled in 2013 to 34,017. The interval from surgery to claim filing ranged from 4.8 to 5.3 years. Only 12% of implanting surgeons were or became board certified in Female Pelvic Medicine and Reconstructive Surgery. Only 4 cases named providers as codefendants. CONCLUSIONS: Most legal claims involved slings for SUI and began after the 2011 Food and Drug Administration communication about mesh for POP. The rise in lawsuits does not reflect the acceptably low complication rates for slings for SUI reported in the literature.

Health Care Disparities Among English-Speaking and Spanish-Speaking Women With Pelvic Organ Prolapse at Public and Private Hospitals: What Are the Barriers?

OBJECTIVES: The objective of this study was to compare perceptions and barriers between Spanish-speaking and English-speaking women in public and private hospitals being treated for pelvic organ prolapse (POP). METHODS: Eight focus groups, 4 in English and 4 in Spanish, were conducted at 3 institutions with care in female pelvic medicine and reconstructive surgery. Standardized questions were asked regarding patients' emotions to when they initially noticed the POP, if they sought family support, and their response to the diagnosis and treatment. Transcripts were analyzed using grounded theory qualitative methods. RESULTS: Thirty-three women were Spanish-speaking and 25 were English-speaking. Spanish speakers were younger (P = 0.0469) and less likely to have a high school diploma (P < 0.0001) than English speakers. Spanish-speaking women had more concerns that the bulge or treatments could lead to cancer, were more resistant to treatment options, and were less likely to be offered surgery. Women in the private hospital desired more information, were less embarrassed, and were more likely to be offered surgery as first-line treatment. The concept emerged that patient care for POP varied based on socioeconomic status and language and suggested the presence of disparities in care for underserved women with POP. CONCLUSIONS: The discrepancies in care for Spanish-speaking women and women being treated at public hospitals suggest that there are disparities in care for POP treatment for underserved women. These differences may be secondary to profit-driven pressures from private hospitals or language barriers, low socioeconomic status, low health literacy, and barriers to health care.

Communication between physicians and Spanish-speaking Latin American women with pelvic floor disorders: a cycle of misunderstanding?

OBJECTIVE: This study aimed to assess the effect of the initial visit with a specialist on disease understanding among Spanish-speaking women with pelvic floor disorders. METHODS: Spanish-speaking women with referrals suggestive of urinary incontinence (UI) and/or pelvic organ prolapse (POP) were recruited from public urogynecology clinics. Patients participated in a health literacy assessment and interview before and after their physician encounter. All interviews were analyzed using Grounded Theory qualitative methods. RESULTS: Twenty-seven women with POP (n = 6), UI (n = 11), and POP/UI (n = 10) were enrolled in this study. The mean age was 55.5 years, and most women had marginal levels of health literacy. From our qualitative analysis, 3 concepts emerged. First, was that patients had poor understanding of their diagnosis before and after the encounter regardless of how extensive the physician's explanation or level of Spanish-proficiency. Second, patients were overwhelmed with the amount of information given to them. Lastly, patients ultimately put their trust in the physician, relying on them for treatment recommendations. CONCLUSIONS: Our findings emphasize the difficulty Spanish-speaking women with low health literacy have in understanding information regarding pelvic floor disorders. In this specific population, the physician has a major role in influencing patients' treatment decisions and helping them overcome fears they may have about their condition.

The prevalence of urinary incontinence among community dwelling adult women: results from the National Health and Nutrition Examination Survey.

PURPOSE: Population based studies estimate that a large proportion of adult women report urinary incontinence. However, there is a wide range of estimates of the burden posed by UI. To measure the prevalence of incontinence in women in the community we analyzed data from women responding to the National Health and Nutrition Examination Survey. MATERIALS AND METHODS: NHANES is a series of health and nutrition surveys performed by the National Center for Health Statistics. From 1999 to 2000 NHANES asked a national sample of community dwelling women, "In the past 12 months, have you had difficulty controlling your bladder, including leaking small amounts of urine when you cough or sneeze (exclusive of pregnancy or recovery from childbirth)?" Questionnaire results were recorded and analyzed with respect to demographic data including age, race and level of education. RESULTS: The overall prevalence of urinary incontinence in women was 38%. The prevalence of daily incontinence increased with age, ranging from 12.2% in women 60 to 64 years old to 20.9% in women 85 years old or older. Of women reporting any incontinence, 13.7% reported daily incontinence, and an additional 10.3% reported weekly incontinence. Prevalence was higher in non-Hispanic white women (41%) than in non-Hispanic black (20%) or Mexican-American women (36%). Women with less than a high school education were less likely to report incontinence than were those with at least a high school education. CONCLUSIONS: Unlike many other studies the NHANES draws a nationally representative sample of subjects in the community and, thus, provides prevalence data for urinary incontinence for all women in the United States. Prevalence is high, and varies with age, race/ethnicity and socioeconomic variables.

Anastomotic contracture and incontinence after radical prostatectomy: a graded approach to management.

PURPOSE: We present a heterogeneous group of men presenting with varying degrees of anastomotic contracture (AC) and associated stress urinary incontinence (SUI) following radical prostatectomy. It is particularly important that AC should be resolved before artificial urinary sphincter (AUS) implantation, because instrumentation through the AUS can risk erosion. MATERIALS AND METHODS: The records of 54 consecutive men who were referred for the management of AC and associated SUI were reviewed. Patient treatment and outcomes were stratified according to their unique characteristics. RESULTS: A total of 54 patients underwent radical prostatectomy alone (48), or in combination with radiation therapy (7) or cryotherapy (1). In group 1, 35 patients had previously undiscovered AC, or 1 or more prior contracture incisions (CIs) with SUI. CI and AUS were performed simultaneously in 33 patients and sequentially in 2. In group 2, 7 patients with intractable AC following multiple CIs/dilations and self-calibration, or an indwelling urethral or suprapubic catheter underwent simultaneous (3) or sequential (2) CI/AUS or CI only (2). Five patients required temporary self-calibration. In group 3, in 12 patients with total outlet obliteration recanalization was accomplished with combined antegrade/retrograde endoscopy and CI. Ten patients had re-obliteration, of whom 1 underwent suprapubic diversion and 9 underwent repeat recanalization with placement of a UroLume stent (American Medical Systems, Minnetonka, Minnesota) across the anastomosis. Eight patients underwent artificial urinary sphincter (AUS) placement 4 to 6 weeks later and 1 awaits an AUS. Of those implanted with an AUS 2 required repeat endoscopic procedures because of recurrent but manageable stent ingrowth. CONCLUSIONS: Most ACs are treated successfully with simultaneous, aggressive CI/AUS. A history of many CIs or long, dense contractures suggest the need for staged management. In those with obliterated outlets we prefer to reestablish patency and if rapid recurrence develops, we place a UroLume stent. Regardless of a history of radiation therapy, continence is restored with an AUS.

Mixed incontinence: stressing about urge.

Urgency and urinary urge incontinence are troublesome and complex symptoms that can complicate the diagnosis and treatment of stress urinary incontinence. Despite this fact, first-line intervention frequently is directed toward the incompetent bladder neck using surgical approaches. Persistent urgency or detrusor instability following anti-incontinence surgery reduces patient satisfaction and overall continence in most series. This article discusses current theories explaining the etiology of mixed incontinence. It also reviews the results of anti-incontinence surgery for mixed incontinence and discusses management strategies. Possible predictors of outcome after sling surgery in this complex group of patients also are presented.

Cryopreservation of sperm: indications, methods and results.

PURPOSE: We review the history of the cryopreservation of human sperm. The current methods of cryopreservation and indications are highlighted, and the success rates of the various uses of cryopreserved sperm are reviewed. Potential adverse sequelae of human cryopreservation are also discussed. MATERIALS AND METHODS: Indications for cryopreservation include several applications, namely homologous and donor insemination, cryopreservation prior to surgical infertility treatment, intraoperative cryopreservation, postoperative cryopreservation, cryopreservation prior to treatment for malignancies and nonmalignant diseases, as well as premortem and postmortem cryopreservation. RESULTS: With the use of intracytoplasmic sperm injection, open microsurgical epididymal sperm aspiration and testicular sperm extraction with cryopreserved sperm in men with obstructive azoospermia yields pregnancy rates similar to those using fresh sperm. Intraoperative cryopreservation is recommended for complex reconstructive cases with lower patency rates, including vasoepididymostomy and vasoepididymostomy to the efferent ductule. In addition, sperm banking is strongly recommended for all patients with malignant disease who may wish to have children, since a small but significant percent of these men later use their banked semen. Although there is concern about the transfer of genetically damaged sperm after cryopreservation, no proven increase in genetic or phenotypic abnormalities in offspring has been identified. CONCLUSIONS: Sperm cryopreservation has revolutionized the field of assisted reproduction. Cryopreserving sperm avoids the need for additional surgery in couples undergoing repeated in vitro fertilization/intracytoplasmic sperm injection cycles. Moreover, it provides hope for men undergoing chemotherapy, radiation or radical surgery who once had no chance for future fertility.