Post-hospital syndrome predicts poor postoperative outcomes and increased cost following transvaginal midurethral sling placement.

INTRODUCTION AND HYPOTHESIS: Post-hospital syndrome (PHS), a 90-day period of health vulnerability related to physiologic stressors following recent inpatient admission, has been observed in surgical and non-surgical patients. We aim to explore its effects on readmission and complication rates in patients undergoing elective female mid-urethral sling placement for the treatment of stress urinary incontinence. METHODS: The Healthcare Cost and Utilization Project State Inpatient Database, State Emergency Department Database, and State Ambulatory Surgery Database for Florida between 2009 and 2014 were linked and utilized. Patients were identified as having undergone an outpatient mid-urethral sling placement with or without cystoscopy by CPT code. The primary exposure was PHS, defined as any inpatient admission within 90 days of mid-urethral sling placement. Patients with inpatient hospitalizations within 1 year of sling procedure were categorized based on timing of prior admission and analyzed. The primary outcomes were 30-day hospital readmission, rates of postoperative ED visits, minor/major complications rates, and overall 30-day cost. A multivariable logistic regression model was fit to assess independent predictors of adverse surgical outcomes. RESULTS: A total of 17,081 female patients who underwent mid-urethral sling procedures were identified. Patients with PHS were at higher risk for 30-day readmission [OR: 5.36 (IQR: 3.61-7.93); p < 0.005], 30-day ED visits [OR: 2.38 (IQR: 1.75-3.25); p < 0.005], major complications [OR: 6.22 (IQR: 4.67-8.29); p < 0.005], and minor complications [OR: 4.62 (IQR: 3.77-5.67); p < 0.005]. This risk was time dependent in nature with a decreasing risk profile the further surgery was from index hospitalization. Furthermore, PHS patients were more likely to incur an increased cost burden with an average 30-day increased cost of $705.80. CONCLUSIONS: Hospitalization within 90 days prior to mid-urethral sling placement is a risk-adjusted, independent predictor of increased rates of 30-day readmission rates, 30-day ED visits, 30-day minor/major complications, and increased hospital-related cost. Clinical and surgical outcomes may be improved with consideration of prior hospitalizations in determining the timing of mid-urethral sling placement for stress urinary incontinence.

Small-bore catheter drainage of pleural injury after percutaneous nephrolithotomy: feasibility and outcome from a single large institution series.

BACKGROUND AND PURPOSE: A well-known complication of percutaneous nephrolithotomy (PCNL) is pleural injury. Pneumothorax and hydrothorax sustained during PCNL may necessitate the placement of a chest tube. Current literature describes placement of standard chest tubes as well as small-bore catheters for management of hydrothorax sustained during PCNL. This study aims to better delineate the clinical utility and outcomes associated with use of small-bore catheters when compared with standard chest tubes for managing pneumothorax and hydrothorax after PCNL. PATIENTS AND METHODS: We queried an institutional database of 735 renal units that underwent PCNL for endourologic disease between 2001 and 2013. Postoperative upright chest radiographs were analyzed in patients who needed chest tube placement for pneumothorax or hydrothorax after PCNL. Those who met inclusion criteria were divided based on the size of chest tube placed: Small-bore (8-12F) or standard chest tube (32F). Analysis of clinical outcomes was performed. RESULTS: Of the 735 procedures, 15 (2% of total, 7 right, 8 left) needed chest tube placement for a pleural injury after PCNL. Those who needed chest tube placement had an average stone size of 2.1 cm. Five had large-bore standard chest tubes (32F) and 10 had small-bore catheters (<14F) for management of pleural injury. The average length of time the chest tube stayed in place was 3.9 days (minimum 2, maximum 6) for small bore and 4.4 days (minimum 2, maximum 7) for standard chest tubes. There was a statistical trend toward decreased hospital stay and decreased length of time the chest tube was in place when a small-bore chest tube was used. CONCLUSION: The use of small-bore catheters for management of hydrothorax and pneumothorax have reasonable clinical outcomes when compared with standard large-bore chest tubes after PCNL.

Comparison of complication rates for unilateral and bilateral percutaneous nephrolithotomy (PCNL) using a modified Clavien grading system.

OBJECTIVE: To compare complication rates of unilateral vs bilateral percutaneous nephrolithotomy (PCNL) using the modified Clavien grading system. PATIENTS AND METHODS: Single-institution retrospective chart review. Identified patients who had synchronous bilateral PCNL (B-PCNL) over an 11-year period (2000-2011). B-PCNL patients were matched by age, gender, and stone burden per renal unit with patients who underwent unilateral PCNL (U-PCNL) over the same period. Complications were recorded and classified using the modified Clavien classification system, and then compared with a two-sided chi-square test of proportions. RESULTS: In all, 47 B-PCNL patients [mean (range) age 54 (14-84) years] and 78 U-PCNL patients [mean (range) age 54 (17-91 years] were compared. The mean (range) stone burden per renal unit was 2.8 (0.7-7.0) cm and 2.9 (0.7-9.0) cm, respectively. The overall complication rate was higher for B-PCNL (53.2% vs 30.8%, P = 0.013). Rates of Grade I and Grade II complications trended toward being higher in the B-PCNL group. Low-grade complications (Grade I and II combined) occurred more often in the B-PCNL group (P = 0.011); the most common low-grade complication was fever. Two procedures terminated for poor visualisation due to bleeding were successfully completed in delayed fashion with no transfusion and were classified as Grade I complications. There were equivalently low rates of Grade III complications. There were no Grade IV or V complications. CONCLUSIONS: B-PCNL carries a higher overall complication rate than U-PCNL when the modified Clavien system is used for classification. Patients undergoing U-PCNL who have more than one tract dilatation have a higher complication rate than those who have only one tract dilatation. High-grade complications are uncommon for both procedures.

Unusual videourodynamic finding: massive scrotal cystocele.

Urinary bladder involvement within inguinal hernias occurs in up to 4% of patients. However, massive extension of the bladder into the scrotum, or scrotal cystocele, is very rare, with less than 30 reported cases. The presenting symptoms vary. Most patients will have some element of voiding dysfunction. However, some patients will present with renal failure, sepsis, or bladder necrosis, although others will remain asymptomatic.(1-4) We report a patient who presented with irritative voiding symptoms and a large, right-sided hydrocele. On evaluation of his voiding symptoms, he was found to have a large scrotal cystocele.

Metabolic syndrome and urinary stone composition: what factors matter most?

OBJECTIVE: To determine which metabolic syndrome (MetS) factors lead to differences in stone composition in a multivariate analysis. METHODS: We retrospectively reviewed medical charts of patients who had a kidney stone removed over a 5-year period (2006-2011). MetS factors (obesity [body mass index {BMI} >30], diabetes mellitus [DM], hypertension [HTN], and dyslipidemia [DLD]) were tallied in each patient. For the latter 3 factors, medical treatment for the condition was used to tag a patient with the condition. Stone composition was determined by the dominant (>50%) component. Statistical analysis was designed to determine which MetS factors were independently associated with differences in stone composition. RESULTS: Five hundred ninety kidney stones were included in the analysis. Patients with MetS had a higher prevalence of uric acid stones and lower prevalence of calcium phosphate stones. HTN and DM were independently associated with differences in composition, specifically uric acid stones (higher proportion), and calcium phosphate stones (lower proportion). Obesity was not associated with differences in composition, although a secondary analysis of morbidly obese patients showed a higher proportion of uric acid stones and a lower proportion of calcium oxalate stones. CONCLUSION: HTN and DM are the MetS factors independently associated with differences in stone composition, specifically the uric acid and calcium phosphate components. Obesity has little effect on stone composition until a very high (>40) BMI is reached. The overall effect of MetS factors on stone type is relatively small, because most stones are calcium oxalate and MetS factors have little impact on calcium oxalate frequency.