Evaluation of microscopic hematuria and risk of urologic cancer in female patients.

BACKGROUND: Urologic cancer has a lower prevalence in women compared with men; however, there are no differences in the recommended evaluation for women and men with microscopic hematuria. OBJECTIVES: The purpose of this study was to identify risk factors that are associated with urologic cancer in women with microscopic hematuria and to determine the applicability of a hematuria risk score for women. STUDY DESIGN: We conducted a retrospective cohort study within an integrated healthcare system in Southern California. All urinalyses with microscopic hematuria (>3 red blood cells per high-power field) that were performed from 2009-2015 were identified. Women who were referred for urologic evaluation were entered into a prospective database. Clinical and demographic variables that included the presence of gross hematuria in the preceding 6 months were recorded. The cause of the hematuria, benign or malignant, was entered into the database. Cancer rates were compared with the use of chi-square and logistic regression models. Adjusted risk ratios of urologic cancer were estimated with the use of multivariate regression analysis. We also explored the applicability of a previously developed, gender nonspecific, hematuria risk score in this female cohort. RESULTS: A total of 2,705,696 urinalyses were performed in women during the study period, of which 552,119 revealed microscopic hematuria. Of these, 14,539 women were referred for urologic evaluation; clinical data for 3573 women were entered into the database. The overall rate of urologic cancer was 1.3% (47/3573). In women <60 years old, the rate of urologic cancer was 0.6% (13/2053) compared with 2.2% (34/1520) in women ≥60 years old (P<.01). In women who reported a history of gross hematuria, the rate of urologic cancer was 5.8% (20/346) compared with a 0.8% (27/3227) in women with no history of gross hematuria (P<.01). In multivariate analysis, > 60 years old (odds ratio, 3.1; 95% confidence interval, 1.6-5.9), a history of smoking (odds ratio, 3.2; 95% confidence interval, 1.8-5.9), and a history of gross hematuria in the previous 6 months (odds ratio, 6.2; 95% confidence interval, 3.4-11.5) were associated with urologic cancers. A higher microscopic hematuria risk score was associated with an increased risk of cancer in this test cohort (P<.01). Women in the highest risk group had a urologic cancer rate of 10.8% compared with a rate of 0.5% in the lowest risk group. CONCLUSIONS: In this female population, >60 years old and a history of smoking and/or gross hematuria were the strongest predictors of urologic cancer. Absent these risk factors, the rate of urologic cancer did not exceed 0.6%. A higher hematuria risk score correlated significantly with the risk of urologic cancer in this female test cohort.

Risk Factors for Microscopic Hematuria in Women.

OBJECTIVES: The objective of this study was to determine the risk factors that may contribute to the diagnosis of microscopic hematuria (MH) in women. METHODS: This multicenter case-control study reviewed cases of women presenting to Female Pelvic Medicine & Reconstructive Surgery sites with MH from 2010 to 2014. Microscopic hematuria was defined as 3 or more red blood cells per high power field in the absence of infection as indicated in the American Urologic Association guidelines. Controls were matched to cases in a 1:1 ratio and chart review of 10 risk factors was performed (urethral caruncle, pelvic organ prolapse, vaginal atrophy, personal or family history of nephrolithiasis, prior prolapse or incontinence surgery, past or current smoking, chemical exposure, family history of urologic malignancy, prior pelvic radiation, and prior alkylating chemotherapy). Odds ratios were performed to assess risk factors. RESULTS: There were 493 cases and 501 controls from 8 Female Pelvic Medicine & Reconstructive Surgery sites. Current smoking, a history of pelvic radiation, and a history of nephrolithiasis were all significant risk factors for MH (P < 0.05). Vaginal atrophy, menopausal status, and use of estrogen were not found to be risk factors for MH (P = 0.42, 0.83, and 0.80, respectively). When stratifying the quantity of MH, women with increased red blood cells per high power field were more likely to have significant findings on their imaging results. CONCLUSIONS: Our findings suggest that the risk factors for MH in women are current smoking, a history of pelvic radiation, and a history of nephrolithiasis.

Trends in urodynamics study utilization in a Southern California managed care population.

OBJECTIVE: We examined trends in overall and preoperative urodynamics utilization among women with stress urinary incontinence (SUI) to determine if practice patterns changed following publication of a 2012 randomized trial questioning the value of preoperative urodynamics in patients with uncomplicated SUI. STUDY DESIGN: We collected electronic medical record data on the number of female patient visits to Kaiser Permanente Southern California urology and urogynecology clinics with stress or mixed incontinence, urodynamic studies (UDS) performed, surgeries performed for stress incontinence, and the demographic and clinical characteristics of these patients during 2 discrete time periods before and after a potentially practice-changing publication. We used χ(2) tests and t tests as appropriate. A multivariate logistic regression model was used to estimate the odds of urodynamics performed during January 2013 through June 2014 (study period 2) compared to urodynamics performed during July 2010 through December 2011 (study period 1) after adjustment for demographic and clinical characteristics. RESULTS: In all, 33,775 women were diagnosed as having SUI or mixed urinary incontinence during study period 1 and 37,238 women were diagnosed with these conditions during study period 2. Among these women 12.8% underwent UDS in study period 1 compared to 8.4% in study period 2 (P < .01). The rate of UDS per patient visit decreased 27.0% between the 2 time periods (P < .01). In women undergoing surgery for stress incontinence, urodynamics were performed 56.5% of the time in study period 1 and 46.5% of the time in study period 2. After controlling for demographic, pelvic organ prolapse, and other bladder diagnoses, the odds of urodynamics performed in study period 2 was 0.54 times the odds of urodynamics performed in study period 1 (95% confidence interval, 0.52-0.57). Among women with only the diagnosis of stress incontinence, 1.78% underwent urodynamics in study period 1 compared with 0.84% in study period 2 (P < .01). Preoperative urodynamics decreased from 39% in study period 1 to 20% in study period 2 (P < .01). CONCLUSION: Significantly fewer UDS are being performed overall and prior to stress incontinence surgery in this population. This change may be due to recent studies suggesting low utility of urodynamics in patients with uncomplicated, stress-dominant incontinence.

Overlapping sphincteroplasty and posterior repair.

INTRODUCTION AND HYPOTHESIS: Knowledge of how to anatomically reconstruct extensive posterior-compartment defects is variable among gynecologists. The objective of this video is to demonstrate an effective technique of overlapping sphincteroplasty and posterior repair. METHODS: In this video, a scripted storyboard was constructed that outlines the key surgical steps of a comprehensive posterior compartment repair: (1) surgical incision that permits access to posterior compartment and perineal body, (2) dissection of the rectovaginal space up to the level of the cervix, (3) plication of the rectovaginal muscularis, (4) repair of internal and external anal sphincters, and (5) reconstruction of the perineal body. Using a combination of graphic illustrations and live video footage, tips on repair are highlighted. RESULTS: The goals at the end of repair are to: (1) have improved vaginal caliber, (2) increase rectal tone along the entire posterior vaginal wall, (3) have the posterior vaginal wall at a perpendicular plane to the perineal body, (4) reform the hymenal ring, and (5) not have an overly elongated perineal body. CONCLUSION: This video provides a step-by-step guide on how to perform an overlapping sphincteroplasty and posterior repair.

Topical 5-fluorouracil for treatment of cervical intraepithelial neoplasia 2: a randomized controlled trial.

OBJECTIVE: The objective of the study was to evaluate the efficacy of intravaginal application of 5% 5-fluorouracil (5-FU) for the treatment of cervical intraepithelial neoplasia (CIN) 2 in women. STUDY DESIGN: Women aged 18-29 years with CIN 2 were recruited for this randomized controlled trial of observation vs treatment with intravaginal 5-FU. Women in the observation group returned in 6 months for a Papanicolaou smear, colposcopy, and a human papillomavirus (HPV) deoxyribonucleic acid test. Women in the 5-FU group were treated with intravaginal 5-FU once every 2 weeks for a total of 16 weeks and were similarly evaluated at 6 months. All women who had a baseline visit were included in the intention-to-treat analysis. Values of P < .05 were considered statistically significant. RESULTS: Between August 2010 and June 2013, 60 women were randomized and had a baseline visit for intervention (n = 31) vs observation (n = 29). Of women who had cervical biopsy results at 6 months, regression of disease was demonstrated in 93% of women in the 5-FU group (26 of 28) and 56% of women in the observation group (15 of 27). Under the intention-to-treat analysis, a relative risk for cervical disease regression of 1.62 (95% confidence interval [CI], 1.10-2.56) was found between the 5-FU and observation arms (P = .01). When the cervical biopsy, Papanicolaou smear, and HPV results were combined for the 6 month follow-up visit, 50% of the 5-FU group (14 of 28) had a documented normal biopsy, normal Papanicolaou smear, and negative HPV test compared with 22% in the observation group (6 of 27) (relative risk, 2.25; 95% confidence interval, 1.05-5.09; P < .05). There were no moderate or severe side effects in the intervention group. CONCLUSION: Topical 5-FU appears to be an effective medical therapy for CIN 2 in young women. 5-FU is readily available and may be considered as an off-label treatment option for young women with CIN 2 who are interested in the treatment of disease but want to avoid excisional procedures.

Cornual placenta accreta managed by postpartum total laparoscopic hysterectomy.

The patient presented here delivered at 32 weeks' gestation after expectant management of spontaneous preterm membrane rupture. She had an unusually located placenta accreta at the left cornu that required a hysterectomy for treatment. The type of abnormal placentation and the laparoscopic approach to her surgery were unique features of her care.

Quality of life in GERD and Barrett's esophagus is related to gender and manifestation of disease.

OBJECTIVES: Gastroesophageal reflux disease (GERD) is a common condition that affects patients' health-related quality of life (HRQoL). The HRQoL of Barrett's esophagus (BE) has been less well studied. Furthermore, it is unknown to what extent BE patients suffer from psychological distress as a result of carrying a diagnosis of a premalignant condition. We sought to compare BE and GERD (stratified by erosive reflux disease (ERD) and non-erosive reflux disease (NERD)) with regard to HRQoL and psychological impact. METHODS: In this single-center study of subjects presenting for elective upper endoscopy, consecutive patients with BE and GERD were enrolled. Participants completed questionnaires assessing generic HRQoL (medical outcomes study short form-36 (SF-36)), disease-specific HRQoL (gastrointestinal quality of life index (GIQLI)), a measure of psychological distress (the Revised Hopkins Symptom Checklist: SCL-90R), and a patient-centered assessment of the impact of disease severity (the GERD health-related quality of life measure (GERD HRQL)). RESULTS: Patients with BE had the lowest symptom severity compared with those suffering from NERD or ERD (GERD HRQL: 13.7 vs. 18 and 15.9, respectively, P<0.01). Those with BE also had better disease-specific quality of life compared with NERD or ERD patients (GIQLI: 137.2 vs. 124.3 and 131.0, respectively, P<0.001). After adjusting for potential confounding variables including symptom severity and gender, BE patients continued to demonstrate better disease-specific HRQoL, scoring 12.2 points higher on the GIQLI than NERD patients (95% confidence interval (CI) 5.1-19.3) and 16.3 points higher than ERD patients (95% CI 5.4-27.3), as well as better generic HRQoL, scoring 4.8 points higher on the SF-36 physical component summary than NERD patients (95% CI 0.8-8.8) and 7.1 points higher than ERD patients (95% CI 1.2-13.1). There were no significant differences between groups in psychological distress, as demonstrated by the SCL-90R global severity index, although BE patients scored lower on the somatization domain compared with NERD and ERD patients. When stratified by gender, females with NERD and BE had worse disease-specific HRQoL than males. CONCLUSIONS: Patients with BE have better generic and disease-specific HRQoL when compared with patients suffering from NERD and ERD. This difference is only partially attributable to lower symptom severity amongs BE patients. Psychological distress did not differ significantly amongs groups. Female gender was associated with worsened HRQoL regardless of GERD disease manifestation. Though more precise instruments may aid in detecting any HRQoL decrements in BE patients because of perceived cancer risk or fear of developing or dying from cancer, we were unable to demonstrate an additional decrement in HRQoL because of cancer risk in subjects with BE.

Health-related quality of life in patients with Barrett's esophagus: a systematic review.

BACKGROUND & AIMS: Barrett's esophagus (BE) affects approximately 10% of patients with chronic gastroesophageal reflux disease (GERD). Patients with BE are at risk for reduced health-related quality of life (HRQoL) associated with GERD, in addition to the potential psychosocial stress of carrying a diagnosis of a premalignant condition with a risk of esophageal adenocarcinoma. We sought to systematically review the published literature on HRQoL of patients with BE. METHODS: We searched PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature for relevant clinical trials using a defined search strategy. We also manually searched relevant scientific meeting abstracts and related article bibliographies. Eligible articles were case series, cohort studies, or clinical trials that included one or more measures of HRQoL and/or quantitatively assessed burden of disease in patients with BE. Effect sizes were calculated when possible. RESULTS: Our initial search identified 95 articles. After 2 physician reviews, 25 articles met inclusion criteria. Data show that BE is associated with a significant decrement in HRQoL as measured by both generic and disease-targeted instruments. In addition, patients with BE are at risk for psychological consequences such as depression, anxiety, and stress, which may be related to their increased risk of esophageal adenocarcinoma. Compared with subjects with GERD alone or the general population, a diagnosis of BE also leads to increased health care use and spending. CONCLUSIONS: BE compromises multiple facets of patients' quality of life. Physicians and researchers should incorporate patient-reported outcomes data including HRQoL measures when treating or studying patients with BE.

Gastrointestinal endoscopy nurse experience and polyp detection during screening colonoscopy.

BACKGROUND & AIMS: The effect of gastrointestinal endoscopy nursing experience on polyp detection is unknown. The aim of this study was to determine whether nurse experience is associated with odds of polyp detection. METHODS: We performed a retrospective analysis of screening colonoscopies performed by attendings at University of North Carolina hospitals between August 2003 and 2005. Nurse experience was dichotomized at 6 months. The primary outcome was polyp detection, with secondary analysis by histologic type. Descriptive statistics, bivariate analysis, and multivariable logistic regression were performed. RESULTS: Any polyp was detected in 44% of the eligible 3631 colonoscopies. Multiple polyps were detected in 23%, adenomas in 25%, advanced lesions in 5%, and hyperplastic polyps in 11%. Twenty-nine nurses were employed during the study period, 19 of whom were new to endoscopy nursing. For nurses with 6 months of experience or less, any polyp was detected in 40.3% of procedures compared with 46.0% of procedures for nurses with more than 6 months of experience (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.09-1.46). Similar results were seen for multiple polyps (OR, 1.54; 95% CI, 1.29-1.84) and hyperplastic polyps (OR, 1.47; 95% CI, 1.22-1.76), but not for adenomas (OR, 1.10; 95% CI, 0.93-1.30) or advanced lesions (OR, 0.99; 95% CI, 0.71-1.36). These relationships were unchanged after adjusting for potential confounding patient and procedure variables. CONCLUSIONS: Procedures staffed by less-experienced gastrointestinal endoscopy nurses have increased odds of not detecting polyps. Subanalysis suggests that detection of hyperplastic polyps explains much of this relationship.