Trends in the Diagnosis and Management of Combined Rectal and Vaginal Pelvic Organ Prolapse.

OBJECTIVE: To examine the rates of surgical repair of comorbid rectal prolapse (RP) and pelvic organ prolapse (POP) over time in a large population-based cohort. MATERIALS AND METHODS: We queried Optum, a national administrative claims database, from 2003 to 2017. We evaluated female patients age 18 or older with a diagnosis of POP and/or RP. Sociodemographic characteristics, comorbidities, and rates of procedures were collected. RESULTS: We identified 481,051 women diagnosed with RP and/or POP. Only 2.0% of women in the cohort had comorbid POP and RP. While 29.9% of women with RP had dual prolapse, only 2.1% of women with POP had both diagnoses. Overall, 25.8% of women had one or more surgical repairs. Surgical repairs were done in 26.0% of women with POP, 15.0% of women with RP, and 48.2% of women with comorbid POP/RP, though only 19.8% of patients with dual diagnoses had both RP and POP repairs. Over the study period, the rate of multidisciplinary surgical repairs increased by 2.7-fold. CONCLUSION: The prevalence of comorbid RP and POP among women in our cohort is low (2.0%). Rates of multidisciplinary surgery have increased possibly due to the increased use of imaging, laparoscopic surgery, and awareness of the shared pathophysiology of the disease.

What to do after a mid-urethral sling fails.

PURPOSE OF REVIEW: After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated. RECENT FINDINGS: Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling. SUMMARY: MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.

Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy on an Enhanced Recovery After Surgery Protocol.

BACKGROUND: Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients. OBJECTIVE: To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC. DESIGN, SETTING, AND PARTICIPANTS: Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Women's Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program. INTERVENTION: Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts. RESULTS AND LIMITATIONS: Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown. CONCLUSIONS: Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention. PATIENT SUMMARY: This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.

Use of Preventive Health Services Among Cancer Survivors in the U.S.

INTRODUCTION: With improvements in early detection and treatment, a growing proportion of the population now lives with a personal history of a cancer. Although many cancer survivors are in excellent health, the underlying risk factors and side effects of cancer treatment increase the risk of medical complications and secondary malignancies. METHODS: The 2013 National Health Interview Survey was utilized to assess the association between personal history of cancer and receipt of U.S. Preventive Services Task Force-recommended services, comprising three cancer screening tests (mammography, colonoscopy, and Pap smear) and six general medical preventive care services (aspirin for prevention of cardiovascular disease; blood pressure, cholesterol, and diabetes screening; diet/activity counseling; and tobacco use counseling). For each preventive service, patients with a history that would preclude that test were excluded. One to three matching of cancer survivors to controls was performed using propensity scores generated from patient-level demographic variables. Conditional logistic regression models were employed to compare odds of screening between matched cohorts of cancer survivors and controls. The years of analysis were 2015 and 2017. RESULTS: A total of 2,639 cancer patients and 31,885 controls were extracted from the merged 2013 National Health Interview Survey. In the propensity score-matched cohorts of eligible adults, only one of the three cancer screening tests, colorectal, was more common in cancer survivors (OR=1.52, 95% CI=1.32, 1.75, p<0.001), whereas breast and cervical cancer screening were not more common in survivors. By contrast, all of the medical screening tests, with the exception of diabetes screening, were more common among cancer survivors. CONCLUSIONS: The association between receipt of recommended preventive medical care and personal history of cancer varied, depending on the preventive service in question, but in the majority of preventive services assessed, cancer survivors had more frequent screening compared with non-cancer survivors.

Impact of adequate pelvic lymph node dissection on overall survival after radical cystectomy: A stratified analysis by clinical stage and receipt of neoadjuvant chemotherapy.

PURPOSE: An adequate pelvic lymph node dissection (LND) during radical cystectomy (RC) for muscle-invasive bladder cancer (BCa) has been shown to provide a survival benefit. We designed a study to assess the effect of adequate LND on overall survival (OS) according to cT stage and receipt of neoadjuvant chemotherapy (NAC). MATERIAL AND METHODS: We identified 16,505 patients with localized BCa who received RC in the National Cancer Database (2004-2012). Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox regression analyses were used to compare OS between patients who received adequate LND (defined as ≥10 nodes removed) and those who did not, stratified by cT stage and receipt of NAC. RESULTS: Overall 8,673 (52.55%) patients underwent adequate LND at RC for localized BCa. Median time to last follow-up was 55.49 months (IQR, 34.73-75.96 months). IPTW-adjusted Kaplan-Meier curves showed that median OS was improved in patients who received adequate LND (60.06 vs. 46.88 months). In patients who did not receive NAC, adequate LND was associated with an OS benefit for cT1/a/cis, cT2, and cT3/4 disease (P ≤ 0.008). Among patients who received NAC, adequate LND was not associated with any OS difference regardless of cT stage. CONCLUSION: Our data suggest that patients who did not receive NAC benefit from an adequate LND. However, the receipt of an adequate LND was not associated with an OS benefit in patients pretreated with NAC. Our study indicates that the receipt of NAC may eradicate micrometastatic disease, and thus limit the benefit of an adequate LND.

The Effect of Physician Specialty Obtaining Access for Percutaneous Nephrolithotomy on Perioperative Costs and Outcomes.

OBJECTIVE: To evaluate the impact of the specialty (urologist vs radiologist) of the physician obtaining percutaneous renal access (RA) on perioperative outcomes, complications, and costs of percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: We used data from a national hospital discharge database to identify patients undergoing PCNL between 2003 and 2015. Procedure codes related to RA were linked to physician specialty. We examined patient demographics, Charlson comorbidity index, postoperative complications, length of stay (LOS), and direct hospital costs, as well as hospital and surgeon characteristics stratified by specialty of the physician obtaining RA. A multivariable regression model was created adjusting for potential confounders. RESULTS: We identified 40,501 patients undergoing PCNL between 2003 and 2015. Urologists obtained access in 17.0% of cases. RA by urologists was associated with a lower 90-day complication rate (5.0% vs 8.3%, p < 0.001) and lower rates of prolonged hospitalization ≥4 days (22.5% vs 42.1%, p < 0.001). On multivariable analysis, RA by urologists was associated with lower rates of any complication (Clavien 1-5) (odds ratios [OR] 0.70, p ≤ 0.001), shorter LOS (OR 0.67, p < 0.001), and lower direct hospital costs (OR 0.65, p < 0.001). CONCLUSION: In the United States, radiologists obtain percutaneous RA in the majority of PCNLs. Access by urologists is associated with lower overall complications, shorter hospitalizations, and lower direct hospital costs. Coding errors and absence of stone complexity information may limit the cogency of our findings and requires further investigation.

Recurrence in Localized Renal Cell Carcinoma: a Systematic Review of Contemporary Data.

PURPOSE OF REVIEW: Patients with localized renal cell carcinoma (RCC) are at risk of recurrence. The purpose of this review was to characterize the literature on recurrence rates and risk factors after diagnosis of localized RCC. RECENT FINDINGS: Our search revealed that existing data examining the prevalence of recurrence rates predominantly originates from cohorts of patients diagnosed and treated in the 1980s to 1990s, and may therefore not be as useful for counseling for current patients today. Many nomograms including the Cindolo Recurrence Risk Formula, the University of California-Los Angeles (UCLA) Integrated Scoring System (UISS), the SSIGN score, the Kattan nomogram, and the Karakiewicz nomogram have shown value in identifying patients at higher risk for recurrence. Biomarkers and gene assays have shown promise in augmenting the predictive accuracy of some of the aforementioned predictive models, especially when multiple gene markers are used in combination. However, more work is needed in not only developing a model but also validating it in other settings prior to clinical use. Adjuvant therapy is a promising new treatment strategy for patients with high-risk disease. Importantly, too many surveillance strategies exist. This may stem from the lack of a consensus in the urological community in how to follow these patients, as well as the variable guideline recommendations. In conclusion, contemporary recurrence rates are needed. Recurrence risk prediction models should be developed based on a series of more contemporary patients, and externally validated prior to routine clinical practice. Surveillance strategies following treatment of localized RCC need to be identified and standardized. Finally, there is a trend toward personalizing surveillance regimens to more appropriately screen patients at higher risk of recurrence.

The Effect of Resident Involvement on Surgical Outcomes for Common Urologic Procedures: A Case Study of Uni- and Bilateral Hydrocele Repair.

OBJECTIVE: Previous studies have investigated the effect of resident involvement (RI) on surgical complications in minimally invasive and complex surgical cases. This study evaluates the effect of surgical education on outcomes in a simple general urologic procedure, unilateral and bilateral hydrocele repair, in a large prospectively collected multi-institutional database. METHODS: Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User files (2005-2013), we extracted patients who underwent unilateral or bilateral hydrocele repair using Current Procedural Terminology codes 55040, 55041, and 55060. Cases with missing information on RI were excluded. Descriptive and logistic regression analyses were performed to assess the impact of RI on perioperative outcomes. A prolonged operative time (pOT) was defined as operative time >75th percentile. RESULTS: Overall, 1378 cases were available for final analyses. The overall complication, readmission, and reoperation rates were 2.3% (32/1378), 0.5% (7/1378), and 1.4% (19/1378), respectively. A pOT was more frequently observed in bilateral procedures (35.2% vs 21.3%, P < .0001) and with RI (33.8% vs 19.0%, P < .0001). Procedures with RI had a 2.2-fold higher odds of pOT (95% confidence interval 1.7-2.8, P < .0001). Overall complications (odds ratio 1.1, 95% confidence interval 0.5-2.3) were not associated with RI (P = .789). In sensitivity analyses, all postgraduate years of training were associated with a pOT (P < .0001). CONCLUSION: Although the involvement of a resident in hydrocele repairs leads to higher odds of pOT, it does not affect patient safety, as evidenced by similar complication rates.

Dose-dependent effect of androgen deprivation therapy for localized prostate cancer on adverse cardiac events.

OBJECTIVES: To investigate the dose-dependent effect of androgen deprivation therapy (ADT) on adverse cardiac events in elderly men with non-metastatic prostate cancer (PCa) stratified according to life expectancy. PATIENTS AND METHODS: A total of 50 384 men diagnosed with localized PCa between 1992 and 2007 were identified within the Surveillance, Epidemiology, and End Results registry areas. We compared those who received ADT within 2 years of PCa diagnosis with those who did not, calculated as monthly equivalent doses of GnRH agonists (<8, ≥8 doses), or orchiectomy. Men were further stratified according to life expectancy (<5 years, 5-10 years and >10 years). Adjusted Cox hazard models assessed the risk of new-onset coronary heart disease (CHD), acute myocardial infarction (AMI), sudden cardiac death (SCD) and cardiac-related interventions, as well as any of these events. RESULTS: Overall, patients receiving GnRH agonists were more likely to experience a cardiac event, with the most pronounced effect among those receiving ≥8 doses (hazard ratio [HR] <8 doses: 1.13, 95% confidence interval [CI] 1.09-1.16, and HR ≥8 doses: 1.18, 95% CI 1.14-1.22; both P < 0.001). The effect of prolonged (≥8 doses) GnRH agonist use on cardiac events was sustained across all strata of life expectancy; however, there was no effect among men with a life expectancy of <5 years and when use of GnRH agonists was limited to <8 doses (HR 0.99, 95% CI 0.67-1.46; P = 0.964). The use of GnRH agonists was associated with a higher risk of CHD (HR <8 doses: 1.13, 95% CI 1.09-1.17 and HR ≥8 doses: 1.17, 95% CI 1.13-1.21; both P < 0.001). Conversely, the use of GnRH was generally not associated with an increased risk of AMI or SCD, except for men who received ≥8 doses of GnRH agonists and had a life expectancy of ≥5 years, who were at a significantly higher risk of SCD (HR for life expectancy 5-10 years: 1.19, 95% CI 1.06-1.33; P = 0.003 and HR for life expectancy >10 years: 1.16, 95% CI 1.04-1.29; P = 0.006). Finally, orchiectomy was not associated with overall cardiac events, AMI or SCD, and was protective with regard to cardiac-related interventions (HR 0.78, 95% CI 0.68-0.90, P = 0.001). CONCLUSION: Exposure to ADT with GnRH agonists is associated with an increased risk of cardiac events in elderly men with localized PCa and a decent life expectancy. Clinicians should carefully weigh the risks and benefits of ADT in patients with a prolonged life expectancy. Routine screening and lifestyle interventions are warranted in at-risk subpopulations treated with ADT.