Reductions in anxiety, depression and insomnia in health care workers using a non-pharmaceutical intervention.

The COVID-19 pandemic has caused significant medical and psychological challenges worldwide, and not only exceeded the capacity of hospitals and intensive care units but also an individuals' ability to cope with life. Health-care workers have continued to provide care for patients despite exhaustion, fear of transmission to themselves and their family, illness or death of friends and colleagues, and losing many patients. They have also faced additional stress and anxiety due to long shifts combined with unprecedented population restrictions, including personal isolation. In this study, we study the effect of an app-based Yoga of Immortals (YOI) intervention on mental health of healthcare workers. In this study, the health care workers were digitally recruited, and their psychological parameters were measured using validated questionaries. The participants were randomly grouped into control and test groups. The validated psychological measures were the Patient Health Questionnaire-8 (PHQ-8), Insomnia Severity Index (ISI) and generalized anxiety disorder (GAD-7) scales. The digital YOI intervention significantly reduced the anxiety, depression symptoms, and insomnia in healthcare workers of all age groups. In contrast, there was no improvement in the control group. This study details the effectiveness of an app-based YOI intervention in healthcare workers.

Does deep brain stimulation improve Parkinson's disease-related lower urinary tract symptoms and voiding dysfunction?

Parkinson's disease (PD), caused by degeneration of dopaminergic neurons, leads to motor and autonomic symptoms. A large proportion of PD patients experience lower urinary tract symptoms (LUTS) and voiding dysfunction, associated with poor quality of life. Deep brain stimulation (DBS) is an adjunctive therapy used in combination with medication for Parkinsonian motor symptoms and is currently being explored to treat PD-related LUTS. This review discusses the current literature on the effects of DBS on lower urinary tract function and whether this modality can be used to modulate PD-related LUTS and voiding dysfunction.

Yoga of Immortals Intervention Reduces Symptoms of Depression, Insomnia and Anxiety.

Background: Depression, anxiety, and disordered sleep are some common symptoms associated with sub-optimal mental health. During the COVID-19 pandemic, mental health issues have grown increasingly more prevalent in the population. Due to social distancing and other limitations during the pandemic, there is a need for home-based, flexible interventions that can improve mental health. The Yoga of Immortals (YOI) mobile application provides a structured intervention that can be used on any mobile device and applied from the user's home. Methods: A total of 1,505 participants were enrolled in the study and used the YOI app for an 8-week period. Participants were asked to fill out three questionnaires: The Patient Health Questionnaire, 8 items (PHQ-8), the Generalized Anxiety Disorder questionnaire (GAD-7) and the Insomnia Severity Index (ISI). These three items were completed by 1,297 participants a total of four times: before starting YOI, two more times during use, and a fourth time after the 8-week usage period. Changes in PHQ8, GAD7 and ISI in participants were compared to a control group, who did not use the YOI app but completed all questionnaires (590 controls finished all questionnaires). Results: Participants reported significant decreases in depression and anxiety-related symptoms. Compared to baseline, PHQ-8 scores decreased 50% on average after the 8-week period. GAD-7 scores also decreased by 40-50% on average, and ISI scores decreased by 50%. These changes were significantly greater (p < 0.05) than that observed in the control group. Participants who reported a previous diagnosis of depression and generalized anxiety reported significantly larger decreases in PHQ-8 and GAD-7 as compared to participants with no prior diagnosis (p < 0.05). Conclusions: Regular use of the YOI intervention over an 8-week period led to significant decreases in symptoms of both depression and anxiety, as well as alleviation of insomnia.

Yearly Trends of Overactive Bladder Medication Usage.

INTRODUCTION: Anticholinergics are associated with cognitive side effects and dementia. Agents such as trospium, fesoterodine and darifenacin have been shown to be less likely to cross the blood-brain barrier. Furthermore, in 2012, mirabegron was approved by the U.S. Food and Drug Administration as the first beta-3 adrenoreceptor agonist to treat overactive bladder (OAB). This study aims to examine prescribing patterns of OAB medications in the United States over time. METHODS: The 2013-2017 Medicare Part D Public Use File was used to identify prescribers of OAB medications including oxybutynin, tolterodine, trospium, darifenacin, solifenacin, fesoterodine and mirabegron. The number of claims and total annual expenditure for each medication for all prescribers, nonurologists and urologists were analyzed from 2013 to 2017. RESULTS: Oxybutynin was consistently the most prescribed OAB medication each year, comprising 53.9% of all OAB medication prescriptions in 2017. From 2013 to 2017, mirabegron claims increased from 140,401 to 1,617,439, making it the second most prescribed OAB medication. Solifenacin usage decreased each year. Trospium, darifenacin and fesoterodine were the least prescribed agents each year. These trends were similar for those ≥65 years old. Total annual expenditure for mirabegron increased yearly, and it had the highest total expenditure of OAB medications, with $658.6 million in 2017. CONCLUSIONS: Oxybutynin was consistently the most prescribed OAB medication every year. Mirabegron utilization steadily increased each year. Anticholinergic medications associated with fewer cognitive adverse effects, such as trospium, darifenacin and fesoterodine, were among the least prescribed.

Management of Postradical Prostatectomy Urinary Incontinence: A Review.

Postprostatectomy urinary incontinence has a significant impact on the quality of life of patients who undergo radical prostatectomy. Stress and overflow incontinence may result from the procedure, with sphincteric incompetence and detrusor hypocontractility implicating their development, respectively. In many cases, treatment begins with conservative approaches, including pelvic floor muscle training or biofeedback. Pharmacotherapy can be used to treat overactive bladder. For stress incontinence, transurethral bulking agents are utilized in select patients; however, artificial urinary sphincter and male slings are the most efficacious options with good success rates. In this review, the various treatment modalities are critically discussed with special emphasis on safety and efficacy.

Role of chemokines in renal cell carcinoma.

With new frontiers of pharmaceutical therapies focusing on tumor growth and angiogenesis, understanding the interaction between immune system and tumor microenvironment has become ever more important. Chemokines and chemokine receptors appear to play an integral role in tumor characteristics. Evidence suggests CXCR4, CXCL5, CXCR7, and stromal derived factor-1 appear to be crucial in survival, growth, and metastasis of renal cell carcinoma. As the role of chemokines in renal cancer is becoming more evident, further research will lead to a better understanding of tumor biology and the development of new therapeutic targets to help improve survival.

Surgery for pelvic organ prolapse: a historical perspective.

Surgical treatment of pelvic organ prolapse has evolved from the use of pomegranates as pessary devices to contemporary robot-assisted laparoscopic sacral colpopexy. Symptomatic pelvic organ prolapse requires correction of all the defects to achieve optimal outcomes. Factors to consider in selecting the appropriate repair include patient's age; stage of prolapse; vaginal length; hormonal status; desire for uterine preservation and coitus; symptoms of sexual, urinary, or bowel dysfunction; and any comorbidities that influence her eligibility for anesthesia or chronically increase intra-abdominal pressure. There is currently no consensus as to the best surgical approach for advanced pelvic organ prolapse. Reconstructive surgery for pelvic organ prolapse is currently performed by vaginal or abdominal (open, laparoscopic, and robotic approaches) approaches or a combination. It is important to maintain skills in proven procedures such as abdominal sacrocolpopexy and sacrospinous ligament suspension. This paper discusses the historical evolution of surgery for pelvic organ prolapse from antiquity to date.

Construction-related differences seen in ureteral access sheaths: comparison of reinforced versus nonreinforced ureteral access sheaths.

OBJECTIVES: Ureteral access sheaths (UASs) are used to facilitate ureteroscopic procedures. Difficulties with use have been reported. Manufacturers have redesigned these devices to ameliorate these problems, including reinforcement of the sheath wall. This study compared reinforced (RUASs) and nonreinforced UASs (NRUASs) of the same manufacturer to determine whether RUASs expedite ureteroscopy and how relevant the reinforced structure is in terms of overall success. METHODS: We prospectively followed up patients undergoing ureteroscopy for urolithiasis with 1 of 2 UASs; the Applied NRUAS and the Applied RUAS. The demographics, operative parameters, and outcomes were assessed. Statistical analysis was performed. RESULTS: A total of 98 UASs were used in 68 male and 30 female patients (47 NRUASs and 51 RUASs). No significant differences were found between the groups in terms of demographic parameters, operative parameters, or successful sheath deployment. The overall success rate for sheath deployment was 95%. A pre-existing stent was significantly associated with successful deployment (P = .004). The sheath-specific limitations included kinking (NRUASs, 10%) and sheath angulation/deformity (RUASs, 21%). The mean follow-up time was 43.4 months; and 93.9% of the patients had radiologic follow-up. No ureteral strictures were noted. CONCLUSIONS: No significant difference was found in the overall success rates between the use of Applied NRUASs and RUASs. The presence of a pre-existing stent was significantly associated with successful sheath deployment. Each UAS design had its own unique limitations, seen with low frequency. Successful sheath use might relate to both the sheath itself and the patient/operative parameters.

Diagnostic and prognostic molecular markers in renal cell carcinoma.

PURPOSE: We reviewed the contemporary literature on molecular biomarkers in renal cell carcinoma and their prognostic significance. MATERIALS AND METHODS: Articles published during 1981 to 2007 in English on renal cell carcinoma were surveyed using the MEDLINE/PubMed database. The subject headings included were genetics, biomarkers, prognosis and risk models of renal cell carcinoma. We present a synthesis of currently known renal cell carcinoma biomarkers at various stages of development and their clinical significance, and prognostic nomograms incorporating biomarkers. RESULTS: The beneficiary role of biomarkers in renal cell carcinoma is challenged by the relatively low prevalence of the disease. Even if a biomarker for renal cell carcinoma had 100% sensitivity and 99.4% specificity, the positive predictive value of the marker in men older than 65 years would be only 10%. Several biomarkers are being investigated in renal cell carcinoma, of which many relate to pathogenic molecular changes that are currently therapeutic targets. Carbonic anhydrase IX is a von Hippel-Lindau mediated enzyme that is expressed in most renal cell carcinoma cases. High (greater than 85%) expression of this marker indicates favorable prognosis and may predict the response to interleukin-2 therapy. B7-H1 expression in renal cell carcinoma cells/lymphocytes may indicate worse survival, possibly through impaired host antitumor immunity. Prognostic nomograms incorporating clinical variables and molecular markers to refine the prediction of treatment outcomes are in active development and await prospective clinical validation. CONCLUSIONS: Several renal cell carcinoma molecular markers appear promising to refine the prognosis and prediction of localized, advanced or metastatic renal cell carcinoma. Currently carbonic anhydrase IX is the best studied and promising marker. Prospective, multicenter clinical validation aimed at the practical clinical usefulness of renal cell carcinoma biomarkers is warranted.

Predictors of success for first stage neuromodulation: motor versus sensory response.

PURPOSE: We investigated whether intraoperative motor or sensory response is more predictive of successful sacral neuromodulation using the InterStim system. MATERIALS AND METHODS: A total of 35 patients with medically refractory frequency, urgency and urge incontinence were enrolled in the study. All patients underwent lead placement for quadripolar test stimulation under local anesthesia with intravenous sedation. Confirmation of correct lead placement was by observation of known motor and sensory responses that result from third sacral nerve stimulation. Motor and sensory responses were documented intraoperatively. Patients had a 1-week trial of stimulation, and those who had greater than 50% improvement in symptoms had placement of the implantable pulse generator. Those without at least 50% improvement in their symptoms had the quadripolar lead removed. RESULTS: Of the 35 patients enrolled 21 had successful quadripolar test stimulation and went on to permanent implantable pulse generator placement. Of the patients who had successful quadripolar test stimulation 95% demonstrated positive intraoperative motor response whereas only 21.4% of patients with unsuccessful quadripolar test stimulation demonstrated positive motor response. If only a positive sensory response was elicited, patients had only a 4.7% chance of having a positive quadripolar test stimulation. CONCLUSIONS: A positive quadripolar test stimulation (greater than 50% improvement in symptoms) with InterStim sacral neuromodulation is more likely when intraoperative lead placement results in positive motor response vs only sensory response.

Female sexual dysfunction following vaginal surgery: a review.

PURPOSE: Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. In this review we address the etiologies and incidence, evaluation and treatment of female sexual dysfunction following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior colporrhaphy, perineoplasty and vaginal vault prolapse. MATERIALS AND METHODS: Literature on the mechanisms by which vaginal surgery affects female sexual function are discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunction following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair were also discussed. RESULTS: Current literature does not support an association between vaginal length following vaginal surgery and sexual function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence CONCLUSIONS: Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.

Management of neobladder-vaginal fistula and stress incontinence following radical cystectomy in women: a review.

Contemporary literature regarding the management of neobladder-vaginal fistula and stress urinary incontinence following radical cystectomy and neobladder reconstruction in women is reviewed in this article. Neobladder-vaginal fistula is uncommon but mandates meticulous repair. Compared to the native bladder, the wall of the neobladder is much thinner that may render it vulnerable to fistulization. Preservation of the anterior vaginal wall during radical cystectomy decreases the likelihood of pouch-vaginal fistula. Omental flap interposition between the vaginal stump and neobladder at cystectomy may not always prevent fistulization if anterior vaginal wall is violated or overlapping suture lines are not avoided. Surgery for intractable stress incontinence following neobladder reconstruction is fraught with severe complications and requires judicious use of allograft pubovaginal slingplasty possibly with bone anchors. Martius flap interposition appears to play a crucial role in improving the outcome following transvaginal repair of the neobladder-vaginal fistula in multiple non-overlapping layers.

Two-stage management of severe postprostatectomy bladder neck contracture associated with stress incontinence.

OBJECTIVES: To report our experience using a two-stage, rather than a synchronous, approach in the management of bladder neck contracture (BNC). Anastomotic BNC associated with urinary incontinence is a major complication after radical prostatectomy. Patients may present with a decreased force of stream, urinary retention, or stress, urge, or overflow urinary incontinence. METHODS: The pertinent data of 15 patients (age range 52 to 78 years, mean 62) with postradical prostatectomy BNC associated with stress urinary incontinence (mean pad use 3 per day) were retrospectively reviewed. Video-urodynamic evaluation in 10 of 15 patients revealed a Valsalva leak point pressure of less than 80 cm H2O in all 10 patients. Bladder outlet obstruction was noted in 4 of 10 patients. Of the 15 patients, 2 declined an artificial urinary sphincter (AUS), the other 13 proceeded with our two-stage management. Step one consisted of deep transurethral incision of the BNC (TUIBNC) with Collin's knife electrocautery. Step two consisted of implantation of an AUS (AMS-800) 6 to 8 weeks after TUIBNC once bladder neck patency had been demonstrated cystoscopically. RESULTS: During a mean follow-up of 15 months, 3 patients developed early recurrence of BNC: 2 at the 5-week cystoscopy, 1 at 8 weeks discovered at the scheduled AUS placement. All 3 patients underwent repeat TUIBNC and remained clinically patent at a mean follow-up of 9 months. The remaining 10 patients were clinically patent after a single TUIBNC, with good subjective flow and postvoid residual volume of less than 30 mL at a mean follow-up of 11 months. Of the 13 patients who underwent AUS placement, 12 were socially continent (wearing 0 to 1 thin pad daily). The thirteenth patient remained incontinent after AUS placement. One of the 12 continent patients developed an infection at the device 8 months postoperatively and required explantation. CONCLUSIONS: We recommend a two-stage approach (TUIBNC followed by AUS insertion) rather than synchronous management for postprostatectomy BNC associated with stress urinary incontinence. Such an approach allows identification of BNC recurrence and its safe management before AUS implantation.

Female sexual dysfunction following vaginal surgery: myth or reality?

This article reviews the mechanisms by which vaginal surgery affects female sexual function and related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as they apply to vaginal surgery. Methods to avoid neurovascular damage during pelvic floor surgery have been corroborated by supporting literature. The incidence of female sexual dysfunction after various transvaginal procedures for indications such as stress urinary incontinence and pelvic organ prolapse, anterior/posterior colporrhaphy, perineoplasty, and vaginal vault prolapse has been discussed. Current literature regarding female sexual dysfunction following other procedures such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair also are reviewed.

Does retroperitoneal lymphadenectomy for testicular germ cell tumor require a different approach in the presence of horseshoe kidney?

PURPOSE: We report our management of stage II testicular nonseminomatous germ cell tumor in 2 patients with horseshoe kidney and discuss the technical challenges posed by this renal fusion anomaly. The embryology and clinical anatomy of horseshoe kidney are discussed with particular reference to the anomalous vascular pattern and routes of testicular lymphatic drainage in this setting. Modifications and innovations of the standard technique of retroperitoneal lymphadenectomy in the presence of horseshoe kidney are discussed in light of our experience with these patients at 2 major tertiary care cancer centers. The significance of contemporary advanced noninvasive radiological techniques, such as helical computerized tomographic angiography with digital 3-dimensional reconstruction and magnetic resonance angiography, in the surgical planning and safe performance of surgery is emphasized. MATERIALS AND METHODS: Two young male patients treated at 2 major American teaching hospitals who had coexistent stage II testicular nonseminomatous germ cell tumor and horseshoe kidney underwent salvage retroperitoneal lymph node dissection. RESULTS: There was no evidence of recurrence in these 2 patients 12 and 15 months after surgery, respectively. CONCLUSIONS: Horseshoe kidney poses special technical problems during retroperitoneal lymphadenectomy for testicular tumors due to anomalous renal and intra-abdominal vascular patterns. Helical computerized tomography angiography is useful for meticulous surgical planning and the safe performance of surgery in this setting.

Initial report of bladder carcinoma following combined bladder-drained pancreas and kidney transplantation.

Although long-term survival of a functional allograft requiring long-term immunosuppressive therapy is responsible for higher incidence of non-urothelial cancers in renal allograft recipients than in normal population, the incidence of bladder cancer is uncommon and carcinoma of the bladder in the setting of combined kidney-pancreas transplantation has not been reported to date. We herein report a case of poorly differentiated invasive adeno-squamous cell carcinoma of the bladder following renal and bladder-drained pancreatic transplantation in a 44-yr-old lady with long-standing insulin dependent diabetes mellitus, which necessitated radical extirpation. Management implications are reviewed.