Pilot Study of a Novel Online Comprehensive Pelvic Floor Program for Urinary Incontinence in Women.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is common in women and has a vast impact on quality of life (QOL), financial health, and work disability. Robust evidence demonstrates the efficacy of comprehensive conservative therapy (pelvic floor muscle training [PFMT], and behavioral and dietary modification) in the treatment of UI. However, numerous barriers impede access to this care, including limited specialized therapists, financial barriers, and scheduling obstacles. To address these barriers, we developed a novel comprehensive online pelvic floor program (oPFP). METHODS: We performed a prospective study assessing continence and QOL outcomes in women with stress urinary incontinence (SUI), urge urinary incontinence (UUI), or mixed urinary incontinence (MUI) treated with oPFP between May 2019 and November 2022. Outcomes were assessed at baseline and following completion of the 2-month program using the validated International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms, Urgency Perception Scale (UPS), Incontinence Impact Questionnaire (IIQ-7) questionnaires, and 24-h bladder diary. Data were analyzed using linear, Poisson mixed models, or generalized estimating equations. RESULTS: Twenty-eight women (2 SUI, 3 UUI, 23 MUI) were enrolled and 19 (2 SUI, 2 UUI, 15 MUI) completed the study. Following oPFP, participants showed significantly improved SUI domain scores (3.04 ± 0.19 vs 1.81 ± 0.23, p < 0.001), UPS reason score (2.52 ± 0.18 vs 2.05 ± 0.14, p = 0.003), IIQ-7 sum scores (5.16 ± 0.88 vs 3.07 ± 0.70, p = 0.038), and daily incontinence episodes (2.96 ± 0.60 vs 1.06 ± 0.29, p < 0.001). Mean patient-reported improvement was 5.4 ± 2.5 (ten-point Likert scale). Of respondents, 89% reported program satisfaction, ease of use, and would recommend the program to others. CONCLUSION: The oPFP results in significant improvements to a variety of UI and QOL measures. This program provides an important UI treatment option and gives women greater access to effective conservative therapy.

Has the use of preoperative urodynamics for stress urinary incontinence surgery changed following the VALUE study?

AIMS: To assess whether routine urodynamic testing (UDT) in women undergoing slings for uncomplicated stress urinary incontinence (SUI) has decreased following publication of the landmark VALUE study, which recommended against routine UDT in uncomplicated SUI. METHODS: We identified women in the Virginia All Payers Claims Database diagnosed with SUI between 2011 and 2016 using International Classification of Disease (ICD) codes (N39.3, 625.6). Appropriate ICD/CPT (current procedural terminology) codes were used to exclude non-index patients (prior anti-incontinence/prolapse surgery, urge incontinence, neurogenic bladder). Beta regression was used to assess for changes in the monthly proportion of urethral slings with preoperative UDT. Interventional ARIMA modeling was used to assess for a relationship between the date of VALUE (The Value of Urodynamic Evaluation) publication and the incidence of slings with preoperative UDT. RESULTS: Analysis identified 6740 women with SUI undergoing sling placement, with 343 non-index patients excluded. Of 6397 remaining women, 4026 (62.9%) underwent preoperative UDT. The annual number of slings with preoperative UDT declined from 748 to 402 between 2011 and 2016. Beta regression analysis demonstrated a decrease in the proportion of slings with preoperative UDT over the study (68%, 2011; 58%, 2016), with a statistically significant decrease in the proportion of slings with UDT after May 2012 (ß coefficient, -.0093; P < .001). Interventional ARIMA models showed a trend toward decreasing slings with preoperative UDT after the VALUE trial (P = .057). CONCLUSIONS: Our analysis demonstrated a decrease in the proportion of women undergoing preoperative UDT in uncomplicated SUI patients following the VALUE study. Further research is needed to examine factors underlying UDT utilization trends and promote value-driven care.

Assessment of urinary tract dilation grading amongst pediatric urologists.

INTRODUCTION: The Urinary Tract Dilation (UTD) system was created to address variability in hydronephrosis grading. It is unknown if or how pediatric urologists are integrating this newer system into practice. OBJECTIVE: We sought to evaluate the current use of hydronephrosis grading systems, inter-rater reliability (IRR) for individual systems, and management preferences based on degree of hydronephrosis. STUDY DESIGN: A survey was emailed to the Societies for Pediatric Urology listserv. Questions addressed familiarity/preference for various grading systems and respondent confidence in interpretation of hydronephrosis. Three clinical vignettes asked respondents to grade hydronephrosis using their system of choice and report further imaging they would obtain. Descriptive statistics were calculated, and IRR was calculated using a linear-weighted modified Fleiss' kappa test. RESULTS: Response rate was 43% (n = 138). The majority of respondents used Society for Fetal Urology (SFU) (70%) or UTD (19%) systems. Most favored SFU (58%) or UTD (34%) systems for a unified system. Confidence in own interpretation was higher than confidence in radiologists' reads (median 4.4 vs 3.6, p < 0.001). IRR was substantial for UTD (κ0.68 [0.64-0.71]) and moderate for SFU (κ0.60 [0.52-0.76]). There was notable heterogeneity regarding follow-up imaging for cases. There was no difference in requested follow-up studies between SFU and UTD systems, except for fewer voiding cystourethrogram (VCUG) requests for Case 3 with UTD (28% vs 4%, p = 0.02). CONCLUSION: Most pediatric urologists still use SFU rather than the UTD system. There was slightly higher IRR with the UTD system. There was substantial variability in follow-up imaging not related to grading system, except with low grade hydronephrosis.

Tele-Urology During COVID-19: Rapid Implementation of Remote Video Visits.

INTRODUCTION: COVID-19 has brought unprecedented challenges to the delivery of urological care. Following rapid implementation of remote video visits at our tertiary academic medical center serving a large rural population we describe and assess our experience with planned video visits and ongoing scheduling efforts. METHODS: Patients scheduled for video visits between April 14 and April 27, 2020 were included. Prospective and retrospective data were collected on patient and clinical characteristics as well as telemedicine outcomes. Multivariable logistic regression was performed to evaluate factors influencing video visit success. Concurrently scheduling data were collected from a separate cohort regarding patient access to technology and willingness to participate in video visits. RESULTS: A total of 209 patients were included with an overall video visit success rate of 67%. Of video visits that failed (69) reasons included no-show (35%), inability to connect to the telemedicine platform (23%) and lack of Internet access (10%). Nearly half of failed video visits (46.4%) were completed as phone visits. After adjustment for patient demographics commercial insurance was significantly associated with video visit success. In assessment of scheduling outcomes 179 patients were contacted to offer video visits. Of these patients 6.7% reported not having Internet access. Of those with Internet access 87% agreed to proceed with a video visit in lieu of visiting in person. CONCLUSIONS: Our experience indicates that rapid implementation of video telemedicine is feasible and highly accepted by patients. Efforts focused on standardized pre-visit patient education may further optimize successful telemedicine visits.

Urinary Incontinence Research: Compliance With Research Standards for Clinical Studies.

OBJECTIVE: To perform an updated literature review to assess compliance with outcomes use and reporting guidelines. In 1997, the Urodynamics Society recommended standards of efficacy to be used for evaluation of treatment outcomes in urinary incontinence (UI). Studies published shortly after the release of these standards reported generally low rates of adherence. METHODS: We reviewed all 2017 articles related to UI in 3 urologic journals (Journal of Urology [JU], Neurourology and Urodynamics [NU], and Urology [UR]). Articles were assessed for compliance with 19 standards across 3 categories (methodology, pretreatment, and post-treatment). Analysis focused on overall and category specific compliance, as well as comparison of compliance between journals. RESULTS: A total of 78 articles met inclusion criteria for analysis. The mean overall compliance was 52% for all standards. JU demonstrated a higher compliance (63%) as compared to NU (50%) and UR (46%) (P <.01). No articles reviewed demonstrated 100% compliance with all standards. Only 23%, 6%, and 12% of JU, NU, and UR articles, respectively, demonstrated at least 75% compliance with all standards. In comparison of subcategory compliance, JU demonstrated a statistically higher methodology compliance (P <.01). In contrast, compliance with both pre- and post-treatment standards across all 3 journals demonstrated no statistically significant differences. CONCLUSION: Overall, we found that a significant percentage of recent study on UI fails to meet suggested standards for use and reporting of outcomes. These data suggest that continued efforts are needed to improve the quality and reporting of UI research.

Identifying and addressing training deficiencies in the examination of cryptorchidism-a quality improvement study.

BACKGROUND: Accurate and timely diagnosis of cryptorchidism by primary care providers (PCPs) is critical to oncologic and fertility outcomes. Physical exam is the mainstay of diagnosis, but little is known about PCPs' skills in examining cryptorchid patients. Patients referred to surgeons for cryptorchidism often have normal or retractile testes on exam, and delayed or missed diagnosis of cryptorchidism may contribute to advanced age at surgical intervention. Previous studies on cryptorchidism have not investigated the baseline training, confidence, and/or exam skills of providers. OBJECTIVE: The authors aimed to define baseline training and provider confidence in the exam of cryptorchid patients and to improve examiner confidence using bedside teaching with a pediatric urologist. Secondarily, baseline training and confidence were correlated to skill. STUDY DESIGN: Medical students, family medicine, pediatrics, and urology residents, and pediatric attendings completed surveys on baseline training and self-reported confidence in the examination of cryptorchid patients at an academic institution from 2017 to 2018. N.G.K. (pediatric urologist) proctored examinations of cryptorchid patients and provided standardized grades and individualized feedback. Surveys were readministered after 3 months. Non-parametric comparison tests were performed to determine intervention effect and compare subgroups. RESULTS: Ninety-two respondents participated. 62% reported little to no formal training on the scrotal exam, 50% were self-taught, and 20% defined undescended testis incorrectly. Confidence increased with level of training, comparing attendings to residents to students (P < 0.001). Those who learned from a mentor had higher baseline confidence than those who did not (P < 0.01). Baseline confidence and amount of formal training positively correlated with exam skill as graded during proctored sessions (n = 59, P < 0.01). Provider confidence was higher after proctored exams (Fig. 2, n = 32, P < 0.0001). DISCUSSION: Significant training deficiencies exist in the examination of cryptorchid patients. A single proctored exam with a pediatric urologist can improve provider confidence and may improve exam skills. A rotation with pediatric urology, including proctored exams of cryptorchid patients, has become standard practice for pediatric trainees at the authors institution as a result of this study. CONCLUSIONS: While further studies are required to assess the effectiveness of bedside teaching and its impact on accurate and timely diagnosis of cryptorchidism, implementation of the authors quality improvement recommendations at other teaching institutions would help address training deficiencies in the examination of cryptorchid patients.

Management of Penile Calciphylaxis: A Case Study.

BACKGROUND: Calciphylaxis, also called calcific uremic arteriolopathy, is a highly morbid syndrome characterized by calcium deposition and occlusion of small arterial vessels of the dermis and subdermal adipose tissue, leading to necrosis and gangrene. Penile involvement is rare and its management presents considerable challenges. CASE: We review the case of a 47-year-old man with end-stage renal disease managed with hemodialysis, diabetes mellitus, and urinary incontinence who presented with a painful necrotic lesion on his glans penis, and the second and third toes of his right foot. Following diagnosis of calciphylaxis of the toes and penis, he was conservatively managed with topical wound care, sodium thiosulfate adjustment of hemodialysis, and phosphate binder medications. Over the course of 2 months, his wound worsened in the setting of continued urinary incontinence, and before planned diversion with a suprapubic catheter, he progressed to gangrene and sepsis. After a goals-of-care discussion with the patient and family, he elected to forego debridement and was discharged on home-based palliative care. CONCLUSIONS: Penile calciphylaxis is a rare, life-threatening disease that portends a poor prognosis. Conservative principles for management include normalization of calcium phosphate levels and local wound care. Penectomy may not impact survival. Ultimately, each case is individualized, and we encourage establishing goals of care in collaborative discussion with an interdisciplinary care team, patient, and family.

Patient positioning during minimally invasive surgery: what is current best practice?

INTRODUCTION: Positioning injuries are a known surgical complication and can result in significant patient morbidity. Studies have shown a small but significant number of neurovascular injuries associated with minimally invasive surgery, due to both patient and case-specific factors. We sought to review the available literature in regards to pathophysiological and practical recommendations. METHODS: A literature search was conducted and categorized by level of evidence, with emphasis on prospective studies. The result comprised 14 studies, which were summarized and analyzed with respect to our study objectives. RESULTS: While incidence of positioning injury has been identified in up to one-third of prospective populations, its true prevalence after surgery is likely 2%-5%. The mechanism is thought to be intraneural disruption from stretching or pressure, which results in decreased perfusion. On a larger scale, this vascular compromise can lead to ischemia and rhabdomyolysis. Prevention hinges on addressing patient modifiable factors such as body mass index, judicious positioning with appropriate devices, and intraoperative team awareness consisting of recurrent extremity checks and time management. CONCLUSION: The risk for positioning injuries is underappreciated. Surgeons who perform minimally invasive surgery should discuss the potential for these complications with their patients, and operative teams should take steps to minimize risk factors.