Utility estimation for neurogenic bowel dysfunction in the general population.

BACKGROUND: Neurogenic bowel dysfunction (NBD) affects over 80% of individuals with spina bifida causing bowel incontinence and/or constipation. NBD is also associated with decreased quality of life, depression, anxiety, and decreased employment/educational attainment. Because NBD is a life-altering condition without a cure, understanding the utility of different health states related to NBD would aid clinicians as they try to counsel families regarding management options and to better understand the quality of life associated with disease management. OBJECTIVE: To elicit utility scores for NBD using an online community sample. STUDY DESIGN: A cross-sectional anonymous survey was completed by 1534 voluntary participants via an online platform (Amazon Mechanical Turk (MTurk, http://www.mturk.com/)), representing an 87% response rate. The survey presented hypothetical scenarios that asked respondents to imagine themselves as an individual living with NBD or as the caretaker of a child with NBD. The time trade-off (TTO) method was used to estimate a utility score, and outcomes for each scenario were calculated using median and IQR. Univariate comparisons of distributions of TTO for demographic data were made using Kruskal-Wallis tests. RESULTS: The median utility score for NBD was 0.84 [0.70-0.92]. Participants reported that they would give up a median of 5 years of their own life, to prevent NBD in themselves of their child. Utility values for child scenarios were significantly different when stratified by age, gender, race, parental status, marital status, and income. Stratification by current health status did not yield significantly different utility values. DISCUSSION: Study findings are comparable with other TTO-determined utility values of moderately severe disease states, including severe persistent asthma (0.83), moderate seizure disorder (0.84) and mild mental retardation (0.84). The significant variations in utility values based on age, gender, race, parent status, partner/marital status and income variables existed in our study, which is similar to findings in other health fields. Study limitations include lack of unanimous agreement about TTO's validity in measuring utility values, and MTurk participant reports can be generalized to greater population. CONCLUSION: NBD is perceived by the community as having a substantial impact on the lives of children with spina bifida, representing a 16% reduction from perfect health. In general, health state utilities have been increasingly used in healthcare systems to understand how burdensome a population perceives a disease is and to evaluate whether interventions improve quality of life years.

Comparison of Penile Prosthesis Cultures Within Individual Patients After Removal/Replacement and Subsequent Salvage.

INTRODUCTION: Infection rates for virgin inflatable penile prostheses (IPPs) range from 1 to 3%; however, this can increase to 7-18% after IPP revision or removal/replacement (RR) for mechanical malfunction. Although studies have reported various RR and salvage cultures, limited data are available that directly compare microorganisms after each of these procedures within the same patient. Comparison of these cultures may determine if the infection is due to a persistent microorganism or new inoculation. AIM: Our aim is to characterize prosthesis cultures within individual patients who develop infection after RR. METHODS: We retrospectively reviewed patients undergoing various IPP procedures at our institution from September 2002 to August 2018. RR procedures were determined by current procedural terminology codes 54,410 or 54,416. Infection, defined as salvage or explantation without replacement for infectious reasons, was described by current procedural terminology codes 54406, 54411, 54415, or 54417. Inclusion criteria consisted of IPP infection after RR and the presence of both RR and salvage cultures within the same patient. Owing to the small cohort size, only descriptive statistics were used. MAIN OUTCOME MEASURES: Characterization of removal/replacement and salvage cultures is the main outcome measure of this study. RESULTS: A total of 202 non-infected RR procedures were performed with 9 cases (4%) of IPP infection after RR identified. Four (44%) of the RR cultures were positive and contained gram-positive (44%) and gram-negative (11%) organisms. In comparison, salvage cultures grew gram-positive bacteria (66%), gram-negative bacteria (33%), and/or fungal elements (33%). A direct comparison of the RR and salvage cultures indicated that only 2 patients (22%) grew similar organisms. CONCLUSIONS: The risk of IPP infection after RR and modified washout is low. In this small series, gram-positive bacteria were most common at the time of RR and salvage. The increased incidence of fungal infections may indicate a need to modify RR protocols. Larger multi-institutional studies are needed to further investigate this relationship. Chandrapal J, Harper S, Davis LG, et al. Comparison of Penile Prosthesis Cultures Within Individual Patients After Removal/Replacement and Subsequent Salvage. Sex Med 2020;8:783-787.

Penile Implant Infection: Experience With Expanded Salvage Criteria and a Shortened Course of Postoperative Antibiotics.

INTRODUCTION: The preferred treatment for inflatable penile prosthesis (IPP) infection includes antibiotic therapy, device removal, and immediate replacement. While this is an accepted procedure, the delivery and length of postoperative antibiotics are not standardized. Furthermore, historical salvage criteria may be overly restrictive given the new salvage techniques. AIM: Our aim is to determine if an expanded salvage criteria and shorter course of antibiotics demonstrate acceptable IPP infection rates. METHODS: We retrospectively reviewed 466 consecutive IPP cases from a single surgeon between March 2014 and March 2019. Salvage and reinfection were determined by current procedural terminology codes, and the final cohort was individually reviewed for integrity. Demographic, operative, and culture data from each patient were obtained. All patients were discharged on oral antibiotics after initial salvage. Patients were not excluded for exposed hardware, immunosuppression, tissue necrosis, severe diabetes, or corporal purulence. Owing to the small sample size, only descriptive statistics were used to describe the final cohort. MAIN OUTCOME MEASURES: The main outcome measures were classification of microorganisms cultured at the time of salvage and salvage failure rate. RESULTS: A total of 26 cases of IPP infections (6%) were identified. The median (interquartile ratio) age and body mass index were 62 (58-66) and 32 (28-34), respectively. During initial salvage, gross purulence was noted in 9 patients (35%), and 22 patients (84%) had a malleable prosthesis placed. The most prescribed postoperative antibiotic was Bactrim/Augmentin with a median (interquartile ratio) antibiotic duration of 14 days (11-14). After IPP salvage, 2 patients (8%) developed a reinfection while on oral antibiotics. One of those patients was immunosuppressed, and the other was infected with Candida glabrata. CONCLUSION: Expanded salvage criteria and postoperative oral antibiotic duration of at least 14 days demonstrated an acceptable infection rate. This suggests that a longer antibiotic therapy may not be necessary. Chandrapal J, Harper S, Davis LG, et al. Penile Implant Infection: Experience With Expanded Salvage Criteria and a Shortened Course of Postoperative Antibiotics. Sex Med 2020;8:383-387.

Cadaveric Laboratory Simulation Training of Male Stress Urinary Incontinence Treatment Improves Trainee Knowledge and Confidence.

OBJECTIVE: To assess whether a focused, simulation training course can improve trainee surgical knowledge and confidence in the treatment of male stress urinary incontinence. MATERIALS AND METHODS: Urology residents participated in a prosthetic education course as part of the 2018 SUPS and SMSNA annual meeting. The course included didactic lectures and a hands-on cadaveric laboratory. Participants completed questionnaires before and after the lab (2 weeks and 6 months) to assess procedural knowledge and confidence. Analysis of lab responses was performed using the Wilcoxon signed rank test for matched pairs. RESULTS: Thirty-two residents (median age 29, range 27-34) participated in the course. The majority were postgraduate year 4 (63%) or postgraduate year 5 (20%). Most participants reported minimal AUS or sling experience with 50% and 94% reporting less than 5 cases, respectively. Overall score from the knowledge assessment improved significantly between the pre-lab versus 2-week post-lab (P = .02) and pre-lab versus 6-month post-lab (P = .01). Similarly, procedural confidence improved between pre-lab vs 2-week post-lab (P < .001) and pre-lab versus 6-month post-lab (P < .001). Knowledge and confidence assessments were not different between year of residency training or pre-lab experience. CONCLUSIONS: Simulation training improves knowledge and confidence in prosthetic surgery for male stress incontinence. In the current climate of reduced exposure and limited availability of prosthetic educators, simulation courses can provide much needed educational value.

Assessment of conservative dietary management as a method for normalization of 24-h urine pH in stone formers.

Low urine pH is a metabolic risk factor for stone formation. While medical therapy is typically prescribed (as urinary alkalinization), patients typically prefer dietary modifications. We aimed to assess capacity to alter urine pH with dietary management alone. We analyzed a retrospective cohort of stone formers seen between 2000 and 2015 with multiple 24-h urine collections (24hUC). Patients ≥ 18 years old with low urine pH (< 6.0) were included; those prescribed alkalinizing agents or thiazides were excluded. Demographic data, 24hUC parameters, and medications were abstracted. 24hUC was utilized to calculate gastrointestinal alkali absorption (GIAA). The primary outcome was urine pH ≥ 6.0 on second 24hUC. Predictors were selected utilizing multivariable logistic regression. The database consisted of 2197 stone formers; 224 of these met inclusion criteria. On second 24hUC, 124 (55.4%) achieved a favorable pH ≥ 6.0. On univariable analysis, a second pH ≥ 6.0 was associated with high initial pH, low initial sulfate, younger age, increase in citrate/GIAA/urine volume, and decrease in ammonium (P < 0.02). On multivariable analysis, high initial pH (OR = 23.64, P < 0.001), high initial GIAA (OR = 1.03, P = 0.001), lower initial sulfate (OR = 0.95, P < 0.001), increase in urine volume (OR = 2.19, P = 0.001), increase in GIAA (OR = 8.6, P < 0.001), increase in citrate (OR = 2.7, P = 0.014), decrease in ammonium (OR = 0.18, P < 0.001), and younger age (OR = 0.97, P = 0.025) were associated with a second pH ≥ 6.0. The analysis demonstrated a corrected AUC of 0.853. These data suggest that certain dietary recommendations (increases in urine volume, citrate, GIAA, and decreased acid load) may normalize urine pH in a select group of patients. This may allow urologists to counsel patients with low urine pH on possibility of success with dietary modification alone.

Anterior gland focal cryoablation: proof-of-concept primary prostate cancer treatment in select men with localized anterior cancers detected by multi-parametric magnetic resonance imaging.

BACKGROUND: Due to their location away from the nerve bundles, anterior prostate cancers (APC) represent a rational target for image-guided cryoablation. This report describes the feasibility and short-term outcomes of anterior focal cryosurgery. METHODS: A retrospective review between 2012 and 2016 of patients with clinically localized APC treated with anterior gland cryoablation was performed. Descriptive statistics were used to report: age, PSA, prostate volume, prostate cancer grade group (PGG), median time to follow-up, and changes in functional status measured with the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function (IIEF-5) score. RESULTS: A total of 17 patients underwent anterior focal cryoablation with a median follow-up of 15 months. Median age and PSA at diagnosis were 67 years and 8.7 ng/mL. Pre-operative PGG1 was identified in 12 (71%) men and PGG2 in 5 (29%) men. Median (IQR) lesion volume was 2 mL(0.86, 3.1). Preoperative median IIEF-5 and IPSS scores were 19.5 and 5, and decreased to 19 and 4, post-operatively. All patients remained continent with no change in sexual function. All post-procedure targeted biopsies of the treated cancers were negative. CONCLUSION: Our pilot study demonstrates the feasibility of treating APCs with image-guided targeted focal cryoablation as a good balance between short-term oncologic control and near complete preservation of genitourinary function. Further follow-up is necessary to examine the potential benefits long-term.

Psychiatric Diagnoses and Other Factors Associated with Emergency Department Return within 30 Days of Ureteroscopy.

PURPOSE: Emergency department visits after ureteroscopy are costly and inconvenient. To better understand those at risk we aimed to identify patient demographic, medical and surgical factors associated with 30-day emergency department presentation following ureteroscopy for urolithiasis with particular attention to those with a history of a psychiatric diagnosis. MATERIALS AND METHODS: We retrospectively reviewed 1,576 cases (1,395 adults) who underwent stone related ureteroscopy during 3 years at a total of 2 hospitals. We collected patient demographics, medical history and operative details. The primary outcome was return to the emergency department within 30 days of ureteroscopy. Logistic regression was performed to examine factors associated with emergency department presentation. RESULTS: Of the patients 613 (43.9%) had a history of psychiatric diagnosis. Of those with ureteroscopy encounters 12.6% returned to the emergency department within 30 days of ureteroscopy, including 58.8% with a history of psychiatric diagnosis. On multivariable analysis variables associated with emergency department return included a history of psychiatric diagnosis (OR 1.57, p = 0.012), uninsured status (OR 2.46, p = 0.001) and a stone only in the kidney (OR 1.76, p = 0.022). Patients who returned to the emergency department had had more emergency department visits in the year prior to surgery (OR 1.40, p <0.001). On univariable analysis older patients and those with longer operative time were more frequently admitted from the emergency department (OR 1.03, p = 0.002 and OR 1.96, p = 0.03. respectively) while uninsured patients were admitted less frequently (OR 0.19, p = 0.013). No difference was noted in admissions between those with a psychiatric diagnosis and all others (60.7% vs 55.8%, p = 0.48). CONCLUSIONS: We identified factors associated with emergency department return after ureteroscopy, including a history of psychiatric diagnosis, uninsured status and emergency department visits in the year before surgery. These patients may benefit from targeted interventions to help avoid unnecessary emergency department visits.

NLRP3 Promotes Diabetic Bladder Dysfunction and Changes in Symptom-Specific Bladder Innervation.

The NLRP3 inflammasome senses diabetic metabolites and initiates inflammation implicated in diabetic complications and neurodegeneration. No studies have investigated NLRP3 in diabetic bladder dysfunction (DBD), despite a high clinical prevalence. In vitro, we found that numerous diabetic metabolites activate NLRP3 in primary urothelial cells. In vivo, we demonstrate NLRP3 is activated in urothelia from a genetic type 1 diabetic mouse (Akita) by week 15. We then bred an NLRP3-/- genotype into these mice and found this blocked bladder inflammation and cystometric markers of DBD. Analysis of bladder innervation established an NLRP3-dependent decrease in overall nerve density and Aδ-fibers in the bladder wall along with an increase in C-fiber populations in the urothelia, which potentially explains the decreased sense of bladder fullness reported by patients and overactivity detected early in DBD. Together, the results demonstrate the role of NLRP3 in the genesis of DBD and suggest specific NLRP3-mediated neuronal changes can produce specific DBD symptoms.

Simulation Training in Penile Implant Surgery: Assessment of Surgical Confidence and Knowledge With Cadaveric Laboratory Training.

INTRODUCTION: Constraints on surgical resident training (work-hour mandates, shorter training programs, etc.) and availability of expert surgical educators may limit the acquisition of prosthetic surgical skills. As a result, training courses are being conducted to augment the prosthetic surgery learning experience. AIM: To evaluate the impact of a hands-on cadaver-based teaching program on resident procedural knowledge and procedural confidence with placement of a penile prosthesis. MAIN OUTCOME MEASURE: Changes in procedural knowledge and self-confidence following a focused training program on penile prosthetics. METHODS: As part of the 2017 Society of Urologic Prosthetic Surgeons and the Sexual Medicine Society of North America Annual Meeting, 31 urology residents participated in a simulation lab in prosthetic urology. The lab included didactic lectures and a hands-on cadaveric laboratory. Participants completed surveys before and after the course. Wilcoxon Signed Rank tests for matched pairs were used to compare respondents' pre- and postcourse knowledge (% questions answered correctly) and confidence ratings. Prior implant experience was assessed. RESULTS: 31 residents participated in this study. The majority of the participants were 4th- (41.9%) and 5th-year residents (38.7%). Participants showed a significant improvement in procedural knowledge test scores (68.8±13.4 vs 74.2 ± 13.0, P < .05) and self-reported increased median surgical confidence levels (4 vs 3, P value < .001) after completion of the cadaveric course. Subgroup analysis demonstrated that residents with prosthetic surgery experience of <10 cases benefited the most. In addition, improvement in surgical confidence levels observed was greater than the improvement in surgical knowledge. The overall cost of the simulation training course was approximately $1,483 per resident. CONCLUSION: Simulation training in prosthetic surgery seems to improve surgical confidence and knowledge. Further research is needed to better understand the benefits and limitations of simulation training. Lentz AC, Rodríguez D, Davis LG. Simulation training in penile implant surgery: Assessment of surgical confidence and knowledge with cadaveric laboratory training. Sex Med 2018;6:332-338.

Lower Urinary Tract Symptoms in Older Children With and Without Diabetes Mellitus.

Lower urinary tract symptoms (LUTS) are an underrecognized complication of diabetes mellitus (DM) in adults and have undergone limited investigation in children. We estimated the prevalence of LUTS in 120 older children (11-17 years) with and without DM and identified patient factors associated with LUTS in logistic regression. Older children (11-17 years) completed a validated LUTS measure and questions about age, ethnicity, gender, body mass index, and degree of bother secondary to LUTS. The unadjusted prevalence of LUTS was 20.87% in the overall cohort, and LUTS was twice as prevalent in children with DM (33.3% vs 16.7%) than children without DM. In logistic regression, Hispanic/Latino ethnicity was positively associated with LUTS (odds ratio = 8.45, P = .011). LUTS may be a prevalent but underrecognized condition, which is more prevalent in Hispanic/Latino and diabetic children.

Over half of contemporary clinical Gleason 8 on prostate biopsy are downgraded at radical prostatectomy.

INTRODUCTION: Contemporary clinical guidelines utilize the highest Gleason sum (HGS) in any one core on prostate biopsy to determine prostate cancer treatment. Here, we present a large discrepancy between prostate cancer risk stratified as high risk on biopsy and their pathology after radical prostatectomy. MATERIALS AND METHODS: We retrospectively reviewed 1424 men who underwent either open or robotic-assisted prostatectomy between 2004 and 2015. We analyzed 148 men who were diagnosed with HGS 8 on prostate biopsy. Biopsy and prostatectomy pathology were compared in aggregate and over 1 year time intervals. Chi-squared test, Fisher's exact test, Student's t-test, and Wilcoxon Rank-Sum test were used for statistical analysis. RESULTS: A total of 61.5% (91/148) of clinical HGS 8 diagnoses were downgraded on prostatectomy, with 58.8% (87/148) downgraded to Gleason 7 (Gleason 4 + 3 n = 59; Gleason 3 + 4 n = 28). Factors associated with downgrading include lower prostate-specific antigen (PSA) at biopsy (median 6.8 ng/mL versus 9.1 ng/mL, p < 0.001), number of Gleason 8 biopsy cores (median 1 versus 2, p < 0.02), presence of Gleason pattern 3 on biopsy cores (67.9% versus 44.8%, p < 0.03), pT2 staging (72.4% versus 55.1%, p < 0.04), positive margins (53.9% versus 69.1%, p < 0.04), extracapsular extension (53.4% versus 74.1%, p < 0.02), and smaller percent tumor (median 10% versus 15%, p < 0.004). CONCLUSION: The large percentage of pathology downgrading of biopsy-diagnosed HGS 8 suggests suboptimal risk-stratification that may lead to suboptimal treatment strategies and much patient distress. Our study adds great urgency to the efforts refining prostate cancer clinical assessment.