Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy.

Objective: We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days. Methods: Records from 2008 to 2018 for "laparoscopy, surgical; partial nephrectomy" for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations. Results: Totally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations. Conclusion: Multiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.

Robot-Assisted Laparoscopic Ureteral Reconstruction for Malignant Pathology: Single-Center Experience with Analysis of Perioperative, Functional, and Oncologic Outcomes.

Introduction: Radical nephroureterectomy with bladder cuff excision (BCE) is the standard of care all high-risk upper tract urothelial carcinomas. With continued advancements, robot-assisted segmental ureteral resection can be employed for ureteral tumors for ipsilateral renal preservation. Herein, we are presenting our experience of different techniques classified by the affected ureteral segment, along with perioperative and intermediate to long-term functional and oncologic outcomes. Methods: From January 2008 to June 2021, a total of 17 patients underwent robot-assisted renal preserving excisional procedures for ureteral tumors. We collected and analyzed baseline, perioperative and follow-up outcomes parameters from our prospectively maintained institutional database. Eleven patients underwent segmental ureterectomy (SU) with BCE and ureteroneocystostomy with psoas hitch, five patients underwent SU with ureteroureteral anastomosis with/without psoas hitch, and one patient underwent ileal patch interposition after segmental ureteral excision. Results: Although majority of the patients had inconclusive or low-grade pathology on initial ureteroscopic biopsies, 73.33% of the patients were found to have high-grade tumors on final pathology report. Median tumor size was 2.7 cm (1-5.5 cm), and the median operative duration was 193 minutes (142-400 minutes). None of the procedures required conversion to open. Overall, only one patient (5.9%) had Clavien-Dindo grade ≥ III complication (pelvic abscess). At median follow-up of 41 months (7-156 months), four patients (26.67%) developed urothelial recurrences out of which only one patient required nephroureterectomy. Overall survival and nephroureterectomy-free survival were 86.67% and 92.31%, respectively. Conclusions: Our study provides a comprehensive review of various surgical approaches of robot-assisted renal sparing management for ureteral tumors. These procedures are surgically safe, feasible, and effective with satisfactory oncologic outcomes at intermediate to long-term follow-up. These procedures may be safely employed in select patients with a localized ureteral tumor to salvage the ipsilateral kidney and estimated glomerular filtration rate.

Effective Prevention of Recurrent UTIs With Vaginal Estrogen: Pearls for a Urological Approach to Genitourinary Syndrome of Menopause.

OBJECTIVE: To review the available data related to the prevention of recurrent urinary tract infection (rUTI) in postmenopausal women with vaginal estrogen preparations and provide the urologic community with the confidence to identify and treat genitourinary syndrome of menopause (GSM). MATERIALS AND METHODS: A literature search of MEDLINE and the Cochrane Central Register of Controlled Trials databases was performed to identify studies utilizing vaginal estrogen in the treatment of urological conditions related to rUTI and GSM. RESULTS: In the setting of untreated GSM, the etiology of rUTIs (at least 3 episodes of UTIs in 12 months or at least 2 episodes in 6 months) is not fully elucidated, but estrogen deficiency is a contributing factor. The diagnosis of GSM is primarily a clinical diagnosis supported by other objective findings including: a vaginal pH >5, decreased content of superficial cells, and/or increased proportion of parabasal cells on vaginal maturation index. Local vaginal estrogen, dehydroepiandrosterone (prasterone), and ospemifene are commonly used GSM treatments. Thirty-one trials were identified utilizing estrogen preparations for rUTI in postmenopausal women. CONCLUSION: Overall, multiple randomized clinical trials have successfully been completed to show the efficacy of local estrogen preparations for the treatment of rUTIs. This high yield review provides a framework for assessing GSM, prescribing recommendations for local vaginal hormone preparations, and a summary of the substantial evidence supporting the new 2019 American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Guidance for local vaginal estrogen use for rUTI.

MsFLASH network vaginal health trial: absence of evidence is NOT evidence of absence.

Approximately 50% of postmenopausal women experience vulvovaginal symptoms associated with genitourinary syndrome of menopause (GSM). GSM is a chronic and progressive condition with a well-defined treatment algorithm. Analysis of the MsFLASH Vaginal Health Trial data produced two main conclusions, which were that prescribed vaginal 10 µg estradiol tablet and over-the-counter (OTC) vaginal moisturizer did not provide additional benefit over placebo vaginal tablet and placebo gel in reducing postmenopausal vulvovaginal symptoms; or increasing the proportions of women reporting sexual activity or improving pain scores with sexual activity. These treatment conclusions are contrary to all prior robust clinical trial data for dyspareunia and vaginal dryness, and not in line with the good clinical practice for GSM management presented by the American College of Obstetricians and Gynecologists, The North American Menopause Society, and the Endocrine Society. Overall, the flaws of the MsFLASH Vaginal Health Trial were to incorrectly identify the therapeutic outcomes of most interest using metrics that exhibit high degrees of placebo bias; and to utilize low statistical power with which to appreciate any significant differences between groups.

Measurement of fat fraction in the human thymus by localized NMR and three-point Dixon MRI techniques.

PURPOSE: To develop a protocol to non-invasively measure and map fat fraction, fat/(fat+water), as a function of age in the adult thymus for future studies monitoring the effects of interventions aimed at promoting thymic rejuvenation and preservation of immunity in older adults. MATERIALS AND METHODS: Three-dimensional spoiled gradient echo 3T MRI with 3-point Dixon fat-water separation was performed at full inspiration for thymus conspicuity in 36 volunteers 19 to 56 years old. Reproducible breath-holding was facilitated by real-time pressure recording external to the console. The MRI method was validated against localized spectroscopy in vivo, with ECG triggering to compensate for stretching during the cardiac cycle. Fat fractions were corrected for T1 and T2 bias using relaxation times measured using inversion recovery-prepared PRESS with incremented echo time. RESULTS: In thymus at 3 T, T1water = 978 ±â€¯75 ms, T1fat = 323 ±â€¯37 ms, T2water = 43.4 ±â€¯9.7 ms and T2fat = 52.1 ±â€¯7.6 ms were measured. Mean T1-corrected MRI fat fractions varied from 0.2 to 0.8 and were positively correlated with age, weight and body mass index (BMI). In subjects with matching MRI and MRS fat fraction measurements, the difference between these measurements exhibited a mean of -0.008 with a 95% confidence interval of (0.123, -0.138). CONCLUSIONS: 3-point Dixon MRI of the thymus with T1 bias correction produces quantitative fat fraction maps that correlate with T2-corrected MRS measurements and show age trends consistent with thymic involution.

Distressing Sexual Function at Midlife: Unmet Needs, Practical Diagnoses, and Available Treatments.

Female sexual dysfunction (FSD) is characterized as chronic sexual symptoms that manifest with personal distress in the domains of desire, arousal, orgasm, and pain. Extensive epidemiologic evidence estimates that almost 50% of perimenopausal and postmenopausal women experience FSD. Screening for FSD is not readily conducted and patient-physician discussion of sexuality is limited by the lack of physician training on the topic and by the patient-held belief that sexual issues are not medical in nature. The purpose of this commentary is to provide clinicians with a framework to approach the discussion of FSD, to clinically identify FSD through patient symptoms and physical signs, and to manage FSD in perimenopausal and postmenopausal patients with the available U.S. Food and Drug Administration-approved and off-label treatments. Particular attention will be paid to FSD with common midlife onset including vulvovaginal atrophy, vulvodynia, and hypoactive sexual desire disorder. Although evaluating FSD can be a challenge, triaging symptoms by addressing pain before desire and arousal will improve patient outcomes and greatly simplify FSD management.

Classification of histologically scored human knee osteochondral plugs by quantitative analysis of magnetic resonance images at 3T.

This work evaluates the ability of quantitative MRI to discriminate between normal and pathological human osteochondral plugs characterized by the Osteoarthritis Research Society International (OARSI) histological system. Normal and osteoarthritic human osteochondral plugs were scored using the OARSI histological system and imaged at 3 T using MRI sequences producing T1 and T2 contrast and measuring T1, T2, and T2* relaxation times, magnetization transfer, and diffusion. The classification accuracies of quantitative MRI parameters and corresponding weighted image intensities were evaluated. Classification models based on the Mahalanobis distance metric for each MRI measurement were trained and validated using leave-one-out cross-validation with plugs grouped according to OARSI histological grade and score. MRI measurements used for classification were performed using a region-of-interest analysis which included superficial, deep, and full-thickness cartilage. The best classifiers based on OARSI grade and score were T1- and T2-weighted image intensities, which yielded accuracies of 0.68 and 0.75, respectively. Classification accuracies using OARSI score-based group membership were generally higher when compared with grade-based group membership. MRI-based classification--either using quantitative MRI parameters or weighted image intensities--is able to detect early osteoarthritic tissue changes as classified by the OARSI histological system. These findings suggest the benefit of incorporating quantitative MRI acquisitions in a comprehensive clinical evaluation of OA.

Sensitivity and specificity of univariate MRI analysis of experimentally degraded cartilage under clinical imaging conditions.

BACKGROUND: To evaluate the sensitivity and specificity of classification of pathomimetically degraded bovine nasal cartilage at 3 Tesla and 37°C using univariate MRI measurements of both pure parameter values and intensities of parameter-weighted images. METHODS: Pre- and posttrypsin degradation values of T1 , T2 , T2 *, magnetization transfer ratio (MTR), and apparent diffusion coefficient (ADC), and corresponding weighted images, were analyzed. Classification based on the Euclidean distance was performed and the quality of classification was assessed through sensitivity, specificity and accuracy (ACC). RESULTS: The classifiers with the highest accuracy values were ADC (ACC = 0.82 ± 0.06), MTR (ACC = 0.78 ± 0.06), T1 (ACC = 0.99 ± 0.01), T2 derived from a three-dimensional (3D) spin-echo sequence (ACC = 0.74 ± 0.05), and T2 derived from a 2D spin-echo sequence (ACC = 0.77 ± 0.06), along with two of the diffusion-weighted signal intensities (b = 333 s/mm(2) : ACC = 0.80 ± 0.05; b = 666 s/mm(2) : ACC = 0.85 ± 0.04). In particular, T1 values differed substantially between the groups, resulting in atypically high classification accuracy. The second-best classifier, diffusion weighting with b = 666 s/mm(2) , as well as all other parameters evaluated, exhibited substantial overlap between pre- and postdegradation groups, resulting in decreased accuracies. CONCLUSION: Classification according to T1 values showed excellent test characteristics (ACC = 0.99), with several other parameters also showing reasonable performance (ACC > 0.70). Of these, diffusion weighting is particularly promising as a potentially practical clinical modality. As in previous work, we again find that highly statistically significant group mean differences do not necessarily translate into accurate clinical classification rules.

Incorporation of Rician noise in the analysis of biexponential transverse relaxation in cartilage using a multiple gradient echo sequence at 3 and 7 Tesla.

PURPOSE: Previous work has evaluated the quality of different analytic methods for extracting relaxation times from magnitude imaging data exhibiting Rician noise. However, biexponential analysis of relaxation in tissue, including cartilage, and materials is of increasing interest. We, therefore, analyzed biexponential transverse relaxation decay in the presence of Rician noise and assessed the accuracy and precision of several approaches to determining component fractions and apparent transverse relaxation times. THEORY AND METHODS: Comparisons of four different voxel-by-voxel fitting methods were performed using Monte Carlo simulations, and phantom and ex vivo bovine nasal cartilage (BNC) experiments. In each case, preclinical and clinical imaging field strengths of 7 Tesla (T) and 3T, respectively, and parameters, were investigated across a range of signal-to-noise ratios (SNR). Results were compared with Cramér-Rao lower bound calculations. RESULTS: As expected, at high SNR, all methods performed well. At lower SNR, fits explicitly incorporating the analytic form of the Rician noise maintained performance. The much more efficient correction scheme of Gudbjartsson and Patz performed almost as well in many cases. Ex vivo experiments on phantoms and BNC were consistent with simulation results. CONCLUSION: Explicit incorporation of Rician noise greatly improves accuracy and precision in the analysis of biexponential transverse decay data.