Long-Term Cost Analysis of Third-Line Treatment Options for Overactive Bladder.

INTRODUCTION: We aimed to analyze the long-term cost of overactive bladder third-line treatments. METHODS: This insurance claims review analyzed the 2015 to 2020 MarketScan (MKS) claims data set subjects age ≥ 18, diagnosis of overactive bladder (OAB) using ICD-9/ICD-10 codes and receipt of treatment for percutaneous tibial nerve stimulation, sacral neuromodulation (SNM), or botulinum A. Age, gender, treatment types, and cost were extracted. Treatment costs were aggregated at the level of patient and treatment type for total payment and patient contribution by combining copay, coinsurance, and deductible. We used the Wilcoxon rank-sum test for continuous and chi-square test for categorical variables. SAS v9.4 was used for analyses. Significance was set at P < .05. RESULTS: We identified 17,755 patients from the commercial claims MKS and 10,912 patients from the Medicare supplemental (MDC) database with mean age 50.7±11.1 and 75.5±7.6 years, respectively, who underwent ≥ 1 third-line OAB treatment. Patients receiving third-line treatment were predominantly female (84.9%, MKS, 74.8%, MDC). Long-term costs over a 15-year period were estimated. Percutaneous tibial nerve stimulation is the most expensive in terms of total net payment ($105,337.50 MKS, $94,102.50 MDC) and patient contribution ($9177.60 MKS, $3921.00 MDC). Total net payment for botulinum A was $67,968 (MSK), $54,261 (MDC), and patient contribution cost was $2850 (MSK), $1110 (MDC). The most cost-effective option was SNM in terms of both total net payment ($5179.10 MKS, $6099.00 MDC) and patient contribution ($59.10 MKS, $60.00 MDC). CONCLUSIONS: SNM was the most cost-effective third-line treatment for OAB looking over a 15-year period in terms of both total net payment and patient contribution.

Microhematuria in Women: Prevalence of Malignancy and Risk Score Evaluation.

OBJECTIVES: To (1) determine the prevalence of urologic malignancy in women evaluated for microhematuria (MH) in a large university-based urology practice, (2) describe clinical features shared by women with MH, and (3) evaluate a risk score for urologic malignancy in women with MH. METHODS: A retrospective chart review identified women with MH evaluated by a large, university-based urology practice between 2010 and 2020. Clinical and demographic variables associated with their evaluation, referral pattern, appropriateness of referral and evaluation, workup completed, and resulting diagnoses were reported. Patterns of repeat evaluations were also described. Patients were stratified as low-, intermediate-, or high-risk according to AUA/SUFU recommended risk stratification. RESULTS: 4456 charts resulted from an initial query based on females with ICD-9 and ICD-10 codes for MH between 2010-2020. 1730 patients (95.5% referrals v. 4.5% established urology patients) met criteria for inclusion in the study, and 1350 underwent evaluation for MH at the practice. Over 30% of referrals were considered inappropriate. 13 patients were diagnosed with urologic malignancy, all of whom were classified as intermediate- or high-risk according to AUA/SUFU criteria. Over 10% of patients had at least 2 evaluations for MH, with only 1 malignancy discovered on repeat evaluation for persistent MH. CONCLUSIONS: Inappropriate referrals for MH are common. Incidence of urologic malignancy is incredibly low among women evaluated for MH, but especially among those classified as low- and intermediate-risk by new guidelines. Repeat evaluations for persistent, stable MH appear low yield in detecting malignancy.

Vaginal cuff pyoderma gangrenosum with associated ureteral stricture: A case report.

Pyoderma gangrenosum is a sterile inflammatory disease of unknown etiology characterized by recurrent cutaneous ulcers. It can occur in extracutaneous locations, especially at operative sites, and has been reported following gynecologic surgery. This report is the first case of pyoderma gangrenosum as a remote complication of pelvic surgery with associated ureteral stricture. It demonstrates the diagnostic challenge of this rare disease and the importance of broadening the differential diagnosis when apparent infections do not respond to treatment to minimize the morbidity of ineffective antibiotic and surgical interventions.

Contemporary Patterns of Third-line Treatments for Privately Insured Individuals With Overactive Bladder in the United States.

OBJECTIVE: To evaluate utilization of third-line overactive bladder (OAB) treatments including percutaneous tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS), and intradetrusor botulinum toxin A (BTX) among privately insured patients and examine factors associated with their use. MATERIALS AND METHODS: Using MarketScan claims (2015-2017), we identified patients who underwent third-line OAB treatments based on procedure codes. Factors of interest included location, age, health plan, among others. We fit multivariable logistic regression models to estimate associations between pertinent factors with receipt of PTNS and SNS relative to BTX and associations between provider type and practice location with each treatment modality. RESULTS: We identified 7383 patients (mean age 50.9) in our cohort. SNS was used most frequently (n = 3602, 48.8%), while PTNS was used least frequently (n = 955, 12.9%). PTNS patients were more likely to reside in metropolitan areas (vs BTX: OR 1.6, 95%CI 1.3-2.1; vs SNS: OR 2.2, 95%CI 1.7-2.8), be aged 55 years or older (vs BTX: 54% vs 47%, OR 1.6, 95%CI 1.2-2.1; vs SNS: 54% vs 45%, OR 1.6, 95%CI 1.2-2.0), and be covered under a health maintenance organization (vs BTX: 17% vs 10%; vs SNS: 17% vs 10%, P <.01). Urologists were most likely to perform SNS, and gynecologists were most likely to perform BTX. 91% of PTNS procedures were performed in office settings. CONCLUSION: Among patients receiving third-line OAB treatment, PTNS was used infrequently. PTNS utilization was concentrated within urban areas, and among older patients and those covered by cost-conscious health maintenance organizations.

Efficacy of Percutaneous Tibial Nerve Stimulation for Overactive Bladder in Women and Men at a Safety Net Hospital.

PURPOSE: We investigated efficacy and compliance related to percutaneous tibial nerve stimulation in patients treated for overactive bladder at a large, urban safety net hospital. MATERIALS AND METHODS: Consecutive patients who underwent percutaneous tibial nerve stimulation at Grady Memorial Hospital from May 2015 through January 2019 were included in our cohort and records were reviewed retrospectively. Primary outcomes of interest included self-reported urinary symptoms and episodes of urinary incontinence. Our secondary outcome of interest was patient compliance, defined as completion of 12 or more treatment sessions. Descriptive analysis and paired t-tests were performed. RESULTS: Of the 50 patients with a mean ± SD age of 59 ± 12 years 80% were black, 52% were male, 34% were uninsured and 54% subscribed to government insurance. Prior treatment included behavioral modification in 100% of cases, anticholinergics in 86% and mirabegron in 4%. Patients completed a mean of 10.7 ± 2.7 of the 12 planned weekly percutaneous tibial nerve stimulation treatments. Of the patients 70% completed all 12 weekly treatments and 77% of those who completed 12 treatments continued to maintenance treatment. After percutaneous tibial nerve stimulation treatment average symptoms improved across all metrics, including mean daytime frequency (from 11.0 to 6.6 episodes per day or -24.5%), nighttime frequency (from 4.8 to 2.5 episodes per night or -47.1%), urgency score (from 3.4 to 1.9 or -42.1%) and incontinence (from 1.6 to 0.4 episodes per day or -79.6%) (each p <0.001). A total of 43 patients (86%) reported symptom improvement. CONCLUSIONS: Percutaneous tibial nerve stimulation had favorable efficacy and compliance in a traditionally underserved patient population. This should be considered as a feasible modality to manage overactive bladder symptoms in patients in a similar demographic.

Variation in Practice Patterns and Reimbursements Between Female and Male Urologists for Medicare Beneficiaries.

Importance: Previous assessments of practice patterns and reimbursements for female urologists relied on surveys or board certification logs. A current evaluation of the geographic distribution and practice patterns by female urologists would reveal contemporary patterns of access for Medicare beneficiaries. Objective: To characterize the variation in practice patterns and reimbursements by urologist sex and the regional deficiencies in care provided by female urologists. Design, Setting, and Participants: This population-based cohort study used the publicly available Centers for Medicare & Medicaid Services Provider Payment database to evaluate payments for US urologists. The cohort (n = 8665) included urologists who provided and were paid for 11 or more services to Medicare beneficiaries in 2016. Data collection and analysis were performed from October 3, 2018, through June 19, 2019. Main Outcomes and Measures: Proportion of female-specific services, payments per beneficiary, and payments per work relative value unit (wRVU) by urologist sex were assessed. Density of female urologists across hospital markets was also identified. Results: Among the 8665 urologists who received payments in 2016, 7944 (91.7%) were men and 721 (8.3%) were women. Female urologists, compared with male urologists, saw a lower proportion of patients with cancer (mean [SD], 16.3% [9.2%] vs 22.7% [8.8%]; P < .001) and a greater proportion of female Medicare beneficiaries (mean [SD], 52.8% [23.2%] vs 24.4% [10.3%]; P < .001). Female urologists generated a greater proportion of wRVU from urodynamics (median [IQR], 2.88% [1.26%-4.84%] vs 1.07% [0.31%-2.26%]; P < .001) and gynecological operations (median [IQR], 0.68% [0.45%-1.07%] vs 0.41% [0.20%-0.81%]; P < .001) than male urologists. In addition, female urologists, compared with their male counterparts, received lower median payments per beneficiary seen ($70.12 [interquartile range (IQR), $60.00-$84.81] vs $72.37 [IQR, $59.63-$89.29]; P = .03) and lower payments per wRVU ($58.25 [IQR, $48.39-65.26] vs $60.04 [IQR, $51.93-$67.88]; P < .001). One-third (103 [33.7%]) of 306 hospital referral regions had 0 female urologists, and 80 (26.1%) had only 1 female urologist. Conclusions and Relevance: Female urologists were more likely to provide care for female Medicare beneficiaries, to receive lower payments per wRVU generated and beneficiaries seen, and to be difficult to access in certain geographic areas; these findings have policy-related implications and highlight the regional deficiencies in urological care and reimbursement discrepancies according to urologist sex.

Recurrent Urinary Tract Infection After Midurethral Sling: A Retrospective Study.

OBJECTIVES: Our primary objective was to estimate the proportion of patients with culture-proven urinary tract infection (UTI) and recurrent UTI after midurethral sling (MUS), as well as to evaluate their risk factors. Our secondary objective was to characterize the difference in the proportion of patients with recurrent UTI before and after MUS. METHODS: We conducted a retrospective study of patients who underwent MUS from 2009 to 2012 within a large health maintenance organization and subsequently had documentation of at least 1 positive urine culture (>100 K CFU/mL) within 1 year. Validated procedural and diagnostic codes were used to identify patients undergoing MUS and the diagnosis of UTI, respectively. RESULTS: Of the 7461 MUS performed, 883 (12%) patients had at least 1 culture-proven UTI and 258 (3.5%) patients met the definition of recurrent UTI postoperatively. Of those 883 patients, 89 (10%) patients met the definition of recurrent UTI before, and 258 (29%) patients after, MUS. McNemar χ test revealed that patients were more likely to have recurrent UTI after MUS compared with before (P < 0.0001). In multivariate logistic regression, Caucasian (odds ratio [OR], 1.60, 95% confidence interval [95% CI], 1.12-2.29; P = 0.01) and African-American (OR, 3.42; 95% CI, 1.42-8.29; P = 0.01) ethnicity, older age (OR, 1.02; 95% CI, 1.00-1.04; P = 0.03), and a history of recurrent UTI (OR 3.79, 95% CI 1.88-7.93, P = 0.0003) were risk factors for postoperative recurrent UTI. CONCLUSIONS: In this population, preoperative recurrent UTI was the only modifiable risk factor associated with an increased risk of postoperative recurrent UTI.

Female pelvic medicine and reconstructive surgery practice patterns: IUGA member survey.

INTRODUCTION AND HYPOTHESIS: The purpose of this study is to describe the current practice patterns of the International Urogynecological Association (IUGA) members regarding the diagnosis, evaluation, and surgical management of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). METHODS: A 30-item internet-based survey was sent to IUGA members. Response to the survey was voluntary, and subjects answered questions regarding demographics, the evaluation of POP and SUI, including urodynamics (UDS) testing, preferred management of POP and SUI, and the application of mesh in reconstructive surgery. RESULTS: Three hundred and thirty-four IUGA members responded to the survey; most of the responses were from Europe (40 %) and North America (23 %). After the FDA safety communication regarding serious complications of using transvaginal mesh, 45 % of responders reported decreased use of mesh, while 31 % reported that it had no effect or that they did not use mesh for transvaginal prolapse (23.6 %). Regarding the evaluation and treatment of SUI, 51 % of responders would perform urodynamics (UDS) before surgical correction of uncomplicated SUI and 78.5 % of responders would perform UDS if no urine leakage was demonstrated on examination. The preferred method of treatment for SUI is midurethral sling (MUS), regardless of prior treatments (65.1 %), concomitant surgeries (74.5 %), or examination findings (50.8-92.6 %). Regarding POP repair, the preferred approach for apical (61 %) and posterior (99.4 %) prolapse repair is vaginal. CONCLUSIONS: Most respondents use a vaginal approach for POP surgery. The FDA safety communication regarding serious complications related to the use of transvaginal mesh for prolapse surgery led to a global decrease in the employment of mesh for POP. Synthetic midurethral slings are predominant in the current treatment of SUI. Despite new recommendations, many responders still perform UDS for uncomplicated SUI.

Referral patterns for pelvic floor surgical prosthesis complications: from symptom onset and initial treatments to evaluation at a tertiary care center.

UNLABELLED: Although complications of prosthesis products used for pelvic organ prolapse and stress urinary incontinence have been extensively characterized, little is known about their referral patterns and the time lapse from symptom onset to evaluation and treatment. The aim of our study was to retrospectively describe the patterns and timing of referral of prosthesis-related complications and initial prereferral treatments. METHODS: We retrospectively identified patients referred to the University of Virginia from January 2002 to October 2012 with prosthesis complications related to previously placed devices for pelvic floor disorders. RESULTS: We identified 55 prosthesis-related complications in 51 patients. The types of prostheses used included mesh or permanent suture for pelvic organ prolapse (vaginal prolapse, n = 24), tapes for stress urinary incontinence (midurethral, n = 21), and materials for abdominal sacrocolpopexies and vaginal vault suspensions (intraperitoneal, n = 10). Original surgeons, who most frequently were general obstetric/gynecology providers, were the referring physicians for only 3.6% of the time. Vaginal and midurethral prosthesis complications occurred most commonly in the early postoperative period, whereas intraperitoneal were more commonly delayed. Patients reported to have experienced adverse symptoms on average from several months up to years while receiving conservative therapies by secondary providers and/or surgical treatments with their original surgeon before referral to our institution. CONCLUSIONS: Referral of prosthesis-related complications is often delayed, and most cases required evaluation by a secondary provider other than the original surgeon before a referral was initiated. Timing of symptom onset was dependent on the prosthesis type with up to 1 in 3 having a late presentation that may in part be delayed by prereferral treatments. Further education of original surgeons, primary care providers, and patients on the presentation, timing, and outcomes of potential prosthesis-related complications is needed to facilitate earlier management at tertiary care centers.

Short-term surgical outcomes and characteristics of patients with mesh complications from pelvic organ prolapse and stress urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: Surgical treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) can include the use of synthetic materials. Placement of synthetic materials into the vaginal wall, through either the vagina or the abdomen, includes the risk of complications such as vaginal wall extrusion or pain. There is little data regarding outcomes following treatment of mesh complications. METHODS: A retrospective chart review of patients who underwent excision of mesh placed for POP or SUI between 1 January 2001 and 31 October 2012 was performed at the University of Virginia. Chart abstraction queried patient demographics, clinical history, physical examination, pre- and post-excision symptoms, and operative findings. The International Continence Society (ICS) and International Urogynecological Association (IUGA) classification system was used to define the nature and location of mesh complications. RESULTS: A total of 57 patients (26 mid-urethral slings, 23 transvaginal prolapse, 9 intraperitoneal prolapse) with the diagnosis of mesh extrusion into the vaginal wall were analyzed. Twenty-five (average 2.8 cases/year) original mesh surgeries occurred between January 2001 and January 2010 and 41 (average 20.5 cases/year) occurred after January 2010. The most common presenting patient complaints were chronic pelvic pain (55.9 %), dyspareunia (54.4 %), and vaginal discharge (30.9 %). At a 6-week post-operative visit, 57.3 % of patient's symptoms were completely resolved and 14.6 % were improved. CONCLUSION: Clinicians should be cognizant of the variable presentations of post-operative vaginal mesh complications. Mesh excision by experienced pelvic surgeons is an effective and safe treatment for these complications; however, a significant number of patients may have persistent symptoms following surgery.

Patterns of care for renal surgery: Underutilization of nephron-sparing procedures.

BACKGROUND: Nephron-sparing procedures are well-described, provide similar oncologic outcomes to nephrectomy, and potentially decrease morbidity as compared to nephrectomy. METHODS: We analyzed academic and community health system data from Virginia and Kentucky to evaluate the utilization and cost of nephron-sparing procedures. Primary International Classification of Disease (ICD-9) diagnosis and procedure codes were employed to target subjects of interest. RESULTS: In total, we analyzed 3809 subjects from Virginia and 3163 subjects from Kentucky between 2004 and 2009 who underwent treatment of a malignant renal mass. There has been a 6.1% and 14.8% decrease in nephrectomy utilization in Virginia and Kentucky, respectively, since 2004. In 2009, 71.4% and 68.8% of all procedures for the treatment of renal masses were radical nephrectomies. The proportion of nephron-sparing procedures has increased in academic (20%) and community (15%) health systems since 2004. The difference in cost between nephrectomy, partial nephrectomy and ablative therapy in Virginia and Kentucky hospitals was negligible (p > 0.05). CONCLUSIONS: Nephron-sparing procedures have been increasingly employed over the last 6 years, but are still underutilized. There does not appear to be a significant cost difference in the treatment of renal masses with nephrectomy, partial nephrectomy or ablative therapies.

Adolescent pelvic pain: interstitial cystitis.

Interstitial cystitis (IC) is a syndrome characterized by urinary urgency and frequency, dysuria, nocturia, and suprapubic pain. Patients are often difficult to treat due to the phenotypic heterogeneity of the disease and the limited efficacy of the treatment options. Treatment regimens must be individualized and tailored through a process of trial and error. There is a paucity of information regarding the treatment of adolescent IC. Here we report a case of a 13-year-old girl with IC who required multiple management strategies prior to obtaining symptomatic relief. We outline our treatment protocols based on the American Urologic Association IC treatment algorithm.

Survival outcomes in men receiving androgen-deprivation therapy as primary or salvage treatment for localized or advanced prostate cancer: 20-year single-centre experience.

OBJECTIVES: To evaluate the overall survival (OS) and disease-specific survival (DSS) in men receiving primary androgen-deprivation therapy (PADT) or salvage medical ADT (SADT) for prostate cancer. PATIENTS AND METHODS: After Institutional Review Board approval, we retrospectively reviewed patients receiving ADT for prostate cancer between July 1987 and June 2007. Variables included age at diagnosis and ADT induction, race, PSA level before ADT, ADT schedule (continuous/intermittent), clinical/pathological stage, hormone-refractory prostate cancer (HRCP) status, PADT or SADT, and deaths. RESULTS: In all, 548 men were analysed. The mean age at diagnosis and ADT induction were 70.1 and 72.3 years, respectively, and 321 (58.6%) were African-American. The median PSA level before ADT was 16.3 ng/mL. ADT was administered continuously in 497 (90.7%) patients; 342 (62.4%) received PADT while 206 (37.6%) received SADT. At mean (range) follow-up of 81.8 (2.1-445) months, 98 (17.9%) deaths occurred; 31 (31.6%) were cancer-specific. The OS and DSS in the PADT and SADT groups were not significantly different (P = 0.36 and P = 0.81, respectively). Mortality rates/distributions were similar between groups (P = 0.68). Multivariate predictors of OS and DSS included age at diagnosis (P = 0.03) and ADT induction (P = 0.009), tumour stage (P < 0.001), and PSA level at ADT induction (P = 0.01). Progression to HRPC worsened OS and DSS (both P < 0.001). CONCLUSION: PADT and SADT prolong survival in men with prostate cancer. HRPC portends a poor DSS. Age at diagnosis and ADT induction, PSA level before ADT, and disease stage predict both OS and DSS in this population. However, most men died from causes unrelated to prostate cancer, thus questioning the true value of ADT in prolonging patient survival.

Prevalence and predictive factors for the development of de novo psychiatric illness in patients receiving androgen deprivation therapy for prostate cancer.

OBJECTIVE: Androgen deprivation therapy (ADT) remains a widely utilized modality for treatment of localized and advanced prostate cancer. While ADT-induced alterations in testosterone have demonstrated impacts on quality of life, the effects on mental health remain ill-defined. We investigated the prevalence of de novo psychiatric illness and predictive factors following ADT induction for prostate cancer. MATERIALS AND METHODS: We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between 1/1989-7/2005, excluding men receiving only neoadjuvant ADT. Variables included age, race, body mass index, prostate-specific antigen (PSA), Gleason sum, clinical stage, ADT type (medical/surgical) and schedule (continuous/intermittent), and presence of pre-ADT and newly diagnosed psychiatric illness. The cohort was divided into three groups for analysis: pre-ADT psychiatric illness, de novo psychiatric illness, and no psychiatric illness. Data analysis utilized statistical software with p < 0.05 considered significant. RESULTS: Three-hundred and ninety-five patients with a mean age of 71.7 years at ADT initiation were analyzed. Thirty-four men (8.6%) were diagnosed with pre-ADT psychiatric illness. At mean follow-up of 87.4 months, 101 (27.9%) men were diagnosed with de novo psychiatric illness, most commonly including: depression (n = 57; 56.4%), dementia (n = 14; 13.9%), and anxiety (n = 9; 8.9%). On multivariate analysis, increasing pre-ADT PSA was predictive of post-ADT anxiety (p = 0.01). Overall and disease-specific survival outcomes were similar between groups. CONCLUSIONS: De novo psychiatric illness was identified in 27.9% of men. While no predictive factors were identified for de novo psychiatric illness, increasing PSA was associated with de novo anxiety. Prospective investigation using validated instruments is requisite to further delineate the relationship between ADT and psychiatric health.