A Rapid Method to Preoperatively Assess Frailty for Older Patients with Pelvic Floor Conditions.

PURPOSE: Assessment of frailty can help surgeons predict perioperative risk and guide preoperative counseling. However, current methods are often cumbersome in the clinical setting. We prospectively compared the effectiveness of a rapid picture based Clinical Frailty Scale (CFS-9) assessed by patient and surgeon against reference standard Fried Frailty Index in older patients with pelvic floor conditions. MATERIALS AND METHODS: We enrolled 71 patients between March 2018 and June 2019. Frailty assessment using CFS-9 (scale ranging from very fit to terminally ill) was performed followed by the Fried Frailty Index, a validated tool of 5 measures (shrinking, physical energy, activity, grip strength, walking speed). Correlations and agreement between Fried Frailty Index and CFS-9 scores from the treating surgeon, a second surgeon (surgeon 2) and patient were analyzed using sensitivity, specificity, area under the curve and Cohen's Kappa. RESULTS: The patient cohort was mostly female (97.2%), with a mean age (±SD) of 73.0 (±5.9) years and 23.9% were frail using the Fried Frailty Index. Compared to the Fried Frailty Index, CFS-9 scores of the treating surgeon, surgeon 2 and patient had AUC values (95% CI) of 0.86 (0.77-0.86), 0.91 (0.84-0.91) and 0.88 (0.79-0.88), respectively. As assessed by Cohen's Kappa the CFS-9 scores all had substantial (surgeon 2, Kappa 0.66, 95% CI 0.46-0.85 or moderate (all other CFS-9 measures, Kappa 0.44 to 0.58) agreement with the Fried Frailty Index scores. CONCLUSIONS: Rapid and effective validated tools to screen for frailty are needed in the clinical setting. CFS-9 is an excellent predictor of frailty compared to the Fried Frailty Index for patients with pelvic floor conditions.

I leaked, then I Reddit: experiences and insight shared on urinary incontinence by Reddit users.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is a highly prevalent condition, but is often not discussed owing to social stigma. Reddit is an internet platform for anonymous information sharing, expression, and discussion. We sought to qualitatively analyze people's behavioral, psychological, and illness experiences with UI expressed on Reddit to improve our understanding of patients' perceptions and ultimately the care we provide. METHODS: We used the Subreddit group "Incontinence" over 5 years and "BeyondtheBump" (postpartum forum) over 1 year as transcripts for qualitative analysis. Two independent researchers read and coded relevant threads (>100 posts and >400 comments). Charmaz's principles of grounded theory were applied. This included line-by-line coding of transcripts utilizing key phrases followed by grouping similarly coded phrases into preliminary themes. Emergent concepts were derived from these themes. RESULTS: A group of Reddit users with diverse UI etiologies were sampled. Qualitative analysis resulted in six preliminary themes. Users with UI were initially self-aware of their incontinence. They were interested in optimal product use. Users struggled with major life adjustments and relating to others. Nonetheless, they learned gradually to cope with their symptoms. Last, postpartum women specifically wanted additional immediate help for managing UI, often in the form of pelvic physiotherapy. Three emergent concepts were formed: the sense of isolation, acceptance over time, and self-drive to manage their UI. CONCLUSIONS: Internet forums such as Reddit may serve as a health resource for people with UI. Physicians can strive to better understand the patient perspective and their needs in order to provide optimal care.

Outcomes in a contemporary cohort undergoing sacral neuromodulation using optimized lead placement technique.

AIMS: To evaluate factors associated with progression to stage 2 sacral neuromodulation (SNM) for refractory overactive bladder, urinary retention, or fecal incontinence using optimal lead placement techniques with curved stylet. METHODS: This is a retrospective analysis of a prospectively collected database of all consecutive stage 1 SNM lead placements at our institution between August 2014 and May 2017 using optimal lead placement technique with curved stylet. Patients with refractory overactive bladder, urinary retention, or fecal incontinence were enrolled. Patients with 50% or more symptom improvement on voiding diaries were offered stage 2 implant. Demographics, clinical, and surgical characteristics were compared for patients who underwent successful stage 2 implants versus those who underwent lead removal at the end of the stage 1 trial period. RESULTS: 127 patients underwent SNM during the study period. Motor thresholds of ≤2 mA in all four electrodes were achieved in 74% of patients (94/127). A total of 89.0% (113/127) of patients received stage 2 implants. The main indication for implant, specifically urgency urinary incontinence, was positively associated with progression to stage 2 implant. Male gender, history of pelvic pain and previous SNM were negatively associated with progression to stage 2 implant. CONCLUSIONS: Our findings demonstrate that the contemporary optimized lead placement technique resulted in low motor thresholds and successful progression to stage 2 SNM implant in the majority of our cohort. Predictive factors associated with success or failure may potentially guide decision making for therapeutic interventions and counseling patient expectations.

Do Patients Discontinue Overactive Bladder Medications after Sacral Neuromodulation?

PURPOSE: Overactive bladder medications often have poor tolerability or lack of efficacy with many patients progressing to third line therapy such as sacral neuromodulation. Those treated with sacral neuromodulation may avoid the potential side effects of overactive bladder medications while achieving symptom improvement. We evaluated the postoperative rate of discontinuing overactive bladder medications in patients who underwent sacral neuromodulation of refractory overactive bladder. MATERIALS AND METHODS: We queried a prospectively collected, institutional review board approved database for patients who underwent sacral neuromodulation. Patients were excluded from analysis if the surgical indication was urinary retention or a sacral neuromodulation device was removed 1 year or less postoperatively. We assessed clinical characteristics, urodynamic parameters and filled overactive bladder medications using an external prescription database. Patient perceived postoperative outcomes were examined. Groups were compared by the Student t-test and the chi-square test. RESULTS: Of the 78 patients who met inclusion criteria 82.1% stopped and never restarted overactive bladder medications (the sacral neuromodulation only group). Of the patients 14.1% consecutively continued filling overactive bladder medications 1 year or more following surgery (the concurrent group). There was no difference between the groups in body mass index, gender, sacral neuromodulation revision, urodynamic parameters, the PGI-I (Patient Global Impression of Improvement) or patient perceived percent improvement. However, concurrent patients were significantly older than those who received sacral neuromodulation only (p = 0.002). CONCLUSIONS: More than 80% of patients who progressed to sacral neuromodulation discontinued overactive bladder medications and received sacral neuromodulation as the sole treatment. A small portion of patients concurrently used overactive bladder medications following sacral neuromodulation for 1 year or more. However, outcomes were similar in the 2 groups. Sacral neuromodulation is a strategy to provide a successful outcome in refractory cases and yet avoid the potentially detrimental side effects related to overactive bladder medications.

Opioid Prescription and Use in Sacral Neuromodulation, Mid Urethral Sling and Pelvic Organ Prolapse Surgery: An Educational Intervention to Avoid Over Prescribing.

PURPOSE: The opioid problem has reached epidemic proportions and the prescription of opioids after surgery can lead to chronic use. We explored prescribing patterns and opioid use after 3 pelvic floor surgeries (sacral neuromodulation, prolapse repair and mid urethral sling) before and after an educational intervention to reduce opioid prescriptions. MATERIALS AND METHODS: We retrospectively reviewed the amount of opioid medication prescribed to patients who underwent these 3 types of surgeries at our institution from June 2016 to May 2017. A telephone survey of patients was done to quantify opioid use after surgery and satisfaction with pain control. Prescribing recommendations were established based on these results and an educational intervention for clinicians was performed. We then evaluated changes in opioid prescription and use during the 6 months following the intervention. A multiple regression model was used to identify factors associated with variability in opioid use. RESULTS: Our retrospective review showed that the 122 patients were prescribed 149%, 165% and 136% more mean morphine mg equivalents than were actually used for sacral neuromodulation, mid urethral sling and prolapse repair, respectively. After the educational intervention there was a significant reduction in morphine mg equivalents prescribed for all 3 surgeries in 78 patients (p <0.001). Diabetes (p = 0.001), a chronic pain condition (p = 0.017) and rectocele repair (p = 0.001) were associated with increased opioid use. CONCLUSIONS: Our data demonstrate that over prescription of opioids after pelvic floor surgery and a provider educational intervention resulted in a significant reduction in opioid prescribing without changing patient satisfaction with pain control.

Practice patterns in the diagnosis and treatment of fecal incontinence with sacral neuromodulation: Can urologists impact this gap in care?

OBJECTIVE: The prevalence of fecal incontinence (FI) is 8% in the United States. Many patients will not seek treatment and the condition is underdiagnosed. Sacral neuromodulation (SNM) is effective in treating FI, and so urologists can play a key role in its treatment. We examine the practice patterns and treatment of FI with SNM in our institution. MATERIAL AND METHODS: The electronic medical record was queried for the proportion of patients seen for FI in the institution, the urology department, and among the female pelvic medicine and reconstructive surgery (FPMRS) urologists. The patients who underwent SNM for FI were evaluated for progression to second stage procedure. RESULTS: The proportion of patients seen for FI is 0.96% in the institution as a whole, 7.9% in the urology department, and 17.9% among FPMRS urologists. Fourteen patients underwent first stage SNM for FI or dual urinary/fecal incontinence, and they all progressed to a second stage procedure. Thirteen of these were performed by FPMRS urologists. CONCLUSION: In our institution, the proportion of patients seen for FI was lower than the prevalence of this condition. Because patients with urinary incontinence are more likely to have FI, urologists are in a unique position to identify these patients and offer treatment that can improve their quality of life. We acknowledge a gap in care of the patients with FI and an opportunity for urologists to help patients with this devastating yet treatable condition.

Analysis of the Completely Dry Rate Over Time After Mid-urethral Sling in a Real-world Clinical Setting.

OBJECTIVE: To improve patient counseling regarding mid-urethral slings (MUS), we performed an analysis of MUS patients dry at initial follow-up to evaluate probability of remaining dry over time, and analyzed clinical factors potentially influencing the probability of remaining dry. METHODS: A retrospective review of our prospectively-collected institutional database identified patients who underwent retropubic MUS (RMUS) or transobturator MUS (TMUS) between January 2001 and March 2016 and were completely dry, defined as an answer of "not at all" to UDI-6 question 3, at first follow-up within 1.5 years of surgery. Proportion remaining dry over time was estimated by Kaplan-Meier. Associated factors were evaluated using Cox proportional hazards modeling. Proportion with urge urinary incontinence at time of sling failure was assessed. RESULTS: Of 1102 patients undergoing MUS, 38.4% returned questionnaires and 47.5% of these were completely dry at initial follow-up (139 RMUS, 62 TMUS). Probability (95% CI, n = total patients) of remaining dry after RMUS at 3, 5, and 10 years was 72% (64%-81%, n = 70), 60% (51%-70%, n = 51), and 26% (18%-43%, n = 17). Probability estimates for TMUS at 3 and 5 years were 74% (62%-88%, n = 27) and 50% (35%-70%, n = 14). Obesity (Hazard ratio 2.22, P = .003) and age (Hazard ratio 1.043, P < .001) were associated with lower probability of remaining dry after RMUS. Of patients no longer completely dry at last follow-up, 72% RMUS and 75% TMUS had urge urinary incontinence. CONCLUSION: In our real-world cohort, patients who are dry within the first 1.5 years following MUS have ≥50% chance of remaining dry for 4 more years.

Patient Distress in Women with Recurrent Urinary Tract Infections: How Can Physicians Better Meet Patients Needs?

PURPOSE OF REVIEW: Recurrent urinary tract infections are a common condition that can impact patients' quality of life. The purpose of this review is to summarize and analyze the literature regarding the distress that these infections can cause to patients and provide guidance to clinicians on how to improve care of these patients. RECENT FINDINGS: The current literature on patient perspectives in urinary tract infections shows an emotional symptom experience that is not consistent with the typical symptoms expected by clinicians. The infections can impact all aspects of quality of life, including social, emotional, and financial domains. Women with recurrent urinary tract infections experience a significant amount of distress. They have a strong desire for validation of their experiences by their physicians. Clinicians can best serve these patients by understanding the true impact of their condition and creating treatment strategies that include shared decision making to meet patients' goals.

Reconstruction of Massive Localized Lymphedema of the Scrotum: Results, Complications, and Quality of Life Improvements.

OBJECTIVE: To review the surgical technique, outcomes, and complications of surgical excision of massive localized lymphedema (MLL) of the scrotum, and to determine changes in weight and quality of life (QOL) after excision. METHODS: A retrospective review was performed for all patients who have undergone excision of MLL of the scrotum at our institution between 2008 and 2014. Standard baseline characteristics, complications, pre- and postoperative weight, and QOL data were recorded. RESULTS: Eleven patients were included, with a mean follow-up of 26 months after surgery. The mean preoperative body mass index was 60, and the mean weight of resected tissue was 21 kg. No patient required an orchiectomy for completion of the resection. Skin grafting was performed in 1 patient, and the rest were closed primarily. Wound complications were common but generally managed successfully with local wound care. At the time of most recent follow-up, most patients had actually gained weight since surgery (mean weight change of +5.2 kg). However, QOL scores improved across all domains, and overall QOL improved from a mean of 1.3 preoperatively to 7.7 postoperatively (where 1 is poor, and 10 is excellent). CONCLUSION: Surgical treatment of MLL of the scrotum can be performed successfully for masses even up to 61 kg (134 lbs). Short-term wound complications are common, but subjective QOL scores improve dramatically. Despite expectations, most patients gained weight after mass removal, which indicates that they would benefit from a comprehensive weight loss plan that includes, but is not limited to, scrotal surgery.

Use of Third Line Therapy for Overactive Bladder in a Practice with Multiple Subspecialty Providers-Are We Doing Enough?

PURPOSE: Overactive bladder impacts more than 15% of the adult population. Compliance with medical treatment is low due to inadequate symptom control or intolerable side effects. Although third line therapies have improved the treatment of overactive bladder, many patients do not receive optimal treatment. We hypothesized that third line treatment use is higher among female pelvic medicine and reconstructive surgery urologists, and we examined its use at our tertiary referral center. MATERIALS AND METHODS: The electronic medical record was queried for patients with overactive bladder seen in 1 year. The number of visits associated with an overactive bladder prescription and the number of patients who received third line therapy were determined and subcategorized by department. Female pelvic medicine and reconstructive surgery providers were considered separately. RESULTS: A total of 5,445 patients (8,994 visits) were seen for overactive bladder. Of all patients seen for overactive bladder 3.5% received third line therapy compared with 10.0% and 14.1% of those seen by urology providers and female pelvic medicine and reconstructive surgery providers, respectively. CONCLUSIONS: The use of third line therapy was reported to be less than 5%. This rate is higher at our institution, which is likely due to multiple female pelvic medicine and reconstructive surgery providers. We also apply an algorithm that facilitates patient education on available options should first and second line treatments fail. Given the limited compliance with medical treatment for overactive bladder, we are likely missing a segment of the patient population who would benefit from third line treatment. Our data demonstrate an opportunity for urologists to improve the quality of overactive bladder treatment and subsequently improve patient quality of life.

Treatment for T1a Renal Cancer Substratified by Size: "Less is More".

PURPOSE: Due to the widespread use of computerized tomography, the diagnosis of small renal cancers (3 cm or less) within the T1a classification continues to increase. Current treatment of these tumors includes radical nephrectomy, partial nephrectomy and thermal ablation. We used the SEER (Surveillance, Epidemiology, and End Results) Program to compare treatment modalities for these cancers based on 1 cm increments in tumor size. We examined overall survival, cancer specific survival, survival from cardiovascular disease and race based treatment disparities. MATERIALS AND METHODS: In the SEER database we identified 17,716 renal cancers 3 cm or less diagnosed from 2005 to 2010 treated with radical nephrectomy, partial nephrectomy or thermal ablation. Overall survival, cancer specific survival and cardiovascular survival were determined for each treatment group, and then substratified by size in centimeters, tumor grade, age, geographical location and ethnicity. Survival was analyzed using Kaplan-Meier methods, multivariate proportional hazards models and a propensity score weighted approach. RESULTS: Overall survival, cancer specific survival and cardiovascular survival were better for partial nephrectomy than radical nephrectomy in all circumstances. Thermal ablation showed equivalent overall survival to partial nephrectomy for tumors 2 cm or less. Notably, radical nephrectomy for renal tumors 3 cm or less was applied in a disparately larger number of black patients (OR 1.63, 95% CI 1.47-1.81) and Hispanic patients (OR 1.28, 95% CI 1.14-1.44). CONCLUSIONS: Radical nephrectomy should be avoided for all tumors 3 cm or less. For renal cancers 2 cm or less partial nephrectomy and thermal ablation are equally effective. For tumors 2.1 to 3 cm partial nephrectomy is better than thermal ablation. We identified significant racial treatment disparities that negatively impact survival in black and Hispanic patients.

Comparative Effectiveness of Targeted vs Empirical Antibiotic Prophylaxis to Prevent Sepsis from Transrectal Prostate Biopsy: A Retrospective Analysis.

PURPOSE: We compared the effectiveness of targeted prophylaxis to the effectiveness of empirical prophylaxis for preventing sepsis after transrectal prostate biopsy using a retrospective multicenter quality improvement study. MATERIALS AND METHODS: A total of 13 Kaiser Permanente urology departments participated in a 1-year retrospective analysis of a quality improvement study. In the targeted prophylaxis group rectal cultures were performed before transrectal prostate biopsy and antibiotic sensitivities of Escherichia coli were used to guide the selection of a single agent antibiotic for prophylaxis. Cultures were plated on 10 µg/ml ciprofloxacin infused MacConkey agar at a central laboratory. Urologists using empirical prophylaxis continued the usual regimen of ciprofloxacin monotherapy prophylaxis but sometimes added an additional prophylactic antibiotic. The primary outcome of post-biopsy sepsis was compiled by a search of the electronic medical record for the appropriate ICD-9 codes. RESULTS: A total of 5,355 prostate biopsy procedures were performed between May 1, 2013 and April 30, 2014. Targeted prophylaxis was used in 1,802 procedures (34%) and empirical prophylaxis was used in 3,553 (66%). The overall incidence of post-biopsy sepsis was 0.52% (28 of 5,355 cases). The incidence of sepsis was 0.44% (8 of 1,802 cases) in the targeted prophylaxis group and 0.56% (20 of 3,553) in the empirical prophylaxis group (p = 0.568). The prevalence of ciprofloxacin resistant E. coli on rectal culture was 25% (444 of 1,802 cases). Seven of the 8 patients (88%) on targeted prophylaxis in whom sepsis developed used a prophylactic antibiotic to which the bacteria causing post-biopsy sepsis were sensitive. CONCLUSIONS: The targeted prophylaxis protocol enabled physicians to avoid using more than 1 broad-spectrum empirical antibiotic while simultaneously achieving an overall rate of sepsis similar to the rate seen with empirical prophylaxis.