Stent vs Stent-Less Ileal Conduits After Radical Cystectomy: Is There a Difference in Early Postoperative Outcomes?

INTRODUCTION: Placing ureteral stents at the uretero-ileal anastomosis for radical cystectomy with ileal conduit (RCIC) has long been common practice. Recently, some providers have begun omitting stents. We sought to investigate differences in perioperative and 30-day outcomes between patients who underwent radical cystectomy with ileal conduit (RCIC) with and without stents placed at the uretero-ileal anastomosis. METHODS: We identified RCICs performed between 2019 to 2021 in the National Surgical Quality Improvement Program database and corresponding Cystectomy-Targeted Participant Use File. Baseline demographics, comorbidities, and operative parameters were compared via Pearson's chi-square and t-tests between stented and stent-less RCICs. Outcomes of interest, including rates of urinary tract infections (UTIs), acute kidney injury (AKI), renal failure requiring dialysis, ileoileal anastomotic leaks, ureteral obstruction, urinary leak or fistula formation, reoperations, and 30-day hospital readmissions were compared using Pearson's chi-square. All statistical tests were 2 tailed with P < .05 considered significant. RESULTS: Five Thousand Four Hundred Eighteen RCICs were identified. Four hundred ninety-eight (9.2%) were stent-less. There were no differences in baseline demographics or comorbidities. Significantly fewer stented patients had robotic-assisted operations (23% vs 29%, P < .01). Stented patients had lower rates of urinary leak or fistula formation (3.1% vs 4.8%, P = .04). There was no significant difference in 30-day rates of UTIs, AKIs, renal failure, ileoileal anastomotic leaks, ureteral obstruction, reoperations, and readmissions. Limitations include retrospective design and lack of longitudinal tracking past 30 days. CONCLUSIONS: Stent-less patients had non-inferior outcomes compared to stented patients in most important 30-day outcomes. Our analysis suggests that stents may not be necessary in ileal conduit urinary diversion procedures.

A global, propensity-score matched analysis of patients receiving inflatable penile prostheses and the risk of complications, infections, and re-interventions.

Background: Over 25,000 men undergo inflatable penile prosthesis (IPP) placement yearly to treat erectile dysfunction (ED). Although various comorbidities are hypothesized risk factors for complications, this remains incompletely understood. Our objective was to utilize multi-institutional data to characterize risk for reintervention, complications, and infections in patients with common suspected risk factors undergoing IPP placement. Methods: We queried the TriNetX database for adult men who underwent IPP placement from 2003-2023 utilizing Current Procedural Terminology (CPT) codes. We examined the impact of diabetes mellitus (DM), hypertension (HTN), nicotine use, radiation therapy (RT), radical prostatectomy (RP), and urethral surgery [urethroplasty, artificial urinary sphincter (AUS), male urethral sling (MS)] on clinical outcomes defined by International Classification of Diseases 10th Revision (ICD-10) codes. Our primary outcome was need for reintervention based on CPT codes. Secondary outcomes included overall rates of complication and infection utilizing ICD-10 codes. Analytics were performed using TriNetX to calculate risk ratios (RRs) and Kaplan-Meier (KM) survival. We evaluated outcomes overall and for each individual comparison cohort using the remaining demographic variables to perform propensity score matching (PSM). Results: In a total of 11,026 patients there was an overall 13.5% risk of undergoing at least one reintervention, with some undergoing multiple based on CPT codes. KM analysis showed a median IPP survival of 18.2 years and a projected 10- and 20-year survival probability at 70.6% and 48.4% respectively. Overall complication rate was 19.3% with a 5.2% rate of infection based on ICD codes. Patients with history of urethral surgery were at higher risk of both IPP complication and re-intervention. When further analyzing type of re-intervention, patients with a history of smoking, prior RP, and prior AUS/MS placement had higher rates of device removal. Patients with a history of diabetes were less likely to undergo IPP replacement at the time of explant. There were no identified risk factors for IPP infection. Conclusions: This is the largest cohort of patients ever evaluated and can help guide patient selection and counseling. There was a higher rate of IPP complications than previously reported, but this may be due to different reporting parameters. History of prior urethral surgery conferred a higher risk of complications and re-intervention. These results can help guide patient selection and counseling.

Evaluating the management trends for priapism and assessing the risk of priapism after in-office intracavernosal injections: a cross-sectional analysis.

We describe the management trends of patients suffering from any priapism and evaluate the risks of developing priapism after intracavernosal injections (ICI) performed in office. We queried TriNetX for two separate male adult cohorts - those presenting with any priapism based on International Classification of Disease code, N48.3 (priapism) and those who underwent ICI in office based on Current Procedural Terminology code, 54235 (injection of corpora cavernosa with pharmacologic agent[s]). We evaluated treatment options for these patients after any priapism and described demographic risks for developing priapism after ICI performed in office. There were 17,545 priapism encounters and 26,104 usages of ICI in the office. Most common treatment for any priapism was corporal irrigation/injection of medications (11.3%). Patients presenting with priapism after ICI were younger (age > 65 years, OR 0.44 [95% CI 0.38-0.51], p < 0.01) and had a higher prevalence of mood disorders (20% vs 14%), behavioral disorders (7% vs 2%) and sickle cell disease (6% vs <1%). They were less likely to have diabetes (14% vs 22%), hypertension (33% vs 40%), prostate cancer (13% vs 25%) or have taken sildenafil or tadalafil (29-30% vs 35-38%). For patients administering ICI, proper screening and counseling of priapism is important to reduce complications.

Androgens and Urethral Health: How Hypogonadism Affects Postoperative Outcomes of Patients Undergoing Artificial Urinary Sphincter or Inflatable Penile Prosthesis Placement.

OBJECTIVE: To determine the role of androgens in penile and urethral health, we sought to understand what impact hypogonadism may have on artificial urinary sphincter (AUS) and inflatable penile prosthesis (IPP) outcomes. We hypothesize that patients with hypogonadism are at increased risk of reinterventions, complications, and infections. METHODS: We queried the TriNetX Global Database in March 2023 for patients receiving an AUS or IPP, looking at lifetime reintervention, complication, and infection rates. We conducted multiple comparisons: (1) eugonadal patients against hypogonadal patients, (2) hypogonadal patients on testosterone replacement therapy (TRT) against hypogonadal patients not on TRT, and (3) hypogonadal patients on TRT against eugonadal patients. RESULTS: Hypogonadal patients undergoing AUS had more complications (33.5% vs 28.3%), higher reintervention rates (27.7% vs 24.3%) and higher infection rates (7.3% vs 6.8%), albeit none reaching significance. Hypogonadal patients undergoing IPP had significantly higher infection rates (6.3% vs 4.4%, RR 1.5 (1.04, 2.04)) and reintervention rates (14.9% vs 11.9%, RR 1.3 (1.04, 1.61)), but not complication rates (21.9% vs 18.9%). When comparing patients with hypogonadism on TRT vs off TRT, there was not a significant difference in reinterventions, or complications, in AUS and IPP patients, but there were significantly more infections in IPP patients (7.0% vs 3.9%, RR 1.9 (1.002, 3.5)). CONCLUSION: Hypogonadal patients have more reinterventions, complications, and infections following urologic implant surgery, to varying levels of significance. TRT may not be completely protective to improve tissue health but with many limitations that should be explored in further research.

Oxycodone prescription after inflatable penile prosthesis has risks of persistent use: a TriNetX analysis.

We sought to evaluate the impact of Oxycodone prescriptions on short-term patient outcomes and long-term Oxycodone use following inflatable penile prosthesis (IPP) placement. We queried the TriNetX research database for all adult patients undergoing IPP. Cohorts included opioid naïve patients prescribed postoperative Oxycodone against propensity score-matched patients without a prescription. We compared return visits to the emergency department (ED) within 14 and 90 days of surgery, a diagnosis of opioid abuse or dependence disorder 6 months or later after surgery and persistent Oxycodone use 9-15 months after surgery. After matching, there were 2433 patients in each group. There was an increase in 90-day ED visits based on receipt of Oxycodone (6.8% of patients vs 5.0%, risk ratio (RR) 1.4 95% confidence interval (CI) [1.1, 1.7]). Groups had similar 14-day ED visits (3.7% of patients vs 2.9%, RR 1.3, 95% CI [0.95, 1.7]). Patients prescribed Oxycodone (5.1% of patients vs 2.7%, RR 1.9, 95% CI [1.4, 2.6]) were more likely to have persistent Oxycodone use at 9-15 months. There were low instances of diagnosis of opioid dependence or abuse for both groups limiting comparison. Oxycodone prescription after IPP has risks of persistent use and withholding Oxycodone does not appear to increase postoperative healthcare utilization.

A global, propensity-score matched analysis of patients receiving artificial urinary sphincters and the risk of complications, infections, and re-interventions.

Background: Artificial urinary sphincters (AUS) are the gold standard treatment for patients with stress urinary incontinence. However, risk factors for implant infection, complication, or re-intervention (removal, repair, replacement) are incompletely understood. We sought to understand the impact of various patient factors on the risk of device failure by leveraging a large, multi-national research database. Methods: We queried the TriNetX database for all adult patients undergoing AUS. We evaluated the impact of age, body mass index, race, ethnicity, diabetes (DM), smoking history, history of radiation therapy (RT), history of radical prostatectomy (RP) and history of urethroplasty on select clinical outcomes. Our primary outcome was the need for re-intervention defined by current procedural terminology (CPT) codes. Secondary outcomes included overall device complication rate and infection rate defined by international classification of diseases (ICD) codes. Analytics were performed on TriNetX which calculated risk ratios (RR) and Kaplan-Meier (KM) survival. We evaluated our outcomes first on the entire population and then repeated analyses for each individual comparison cohort using the remaining demographic variables to perform propensity score matching (PSM). Results: The overall rates of AUS re-intervention, complication and infection were 23.4%, 24.1% and 6.4%, respectively. KM analysis showed median AUS survival (no need for re-intervention) at 10.6 years and projected 20-year survival probability at 31.3%. Patients with a history of smoking or urethroplasty were at higher risk of AUS complication and re-intervention. Patients with DM or a history of RT were at higher risk of AUS infection. Patients with a history of RT were at higher risk of AUS complication. All risk factors besides race showed a difference in device removal itself. Conclusions: To our knowledge, this represents the largest series to follow patients with an AUS. About one-quarter of AUS patients needed re-intervention. Multiple demographics place patients at increased risk of re-intervention, infection, or complication. These results can help guide patient selection and counseling with the goal of reducing complications.

A narrative review on surgical treatment options for male stress urinary incontinence.

Background and Objective: Stress urinary incontinence (SUI) can occur due to a variety of etiologies. For male patients specifically, SUI is typically thought of as iatrogenic secondary to intrinsic sphincter deficiency occurring after prostate surgery. Given the noted negative impact that SUI can have on a man's quality of life, multiple treatment options have been developed to improve symptoms. However, there is no "One-Size-Fits-All" approach to management of male SUI. In this narrative review, we sought to highlight some of the various procedures and devices available to treat men with bothersome SUI. Methods: This narrative review gathered primary resources through Medline search, and secondary resources by cross-referencing citations used in articles of interest. We started our investigation by searching for previous systematic reviews on male SUI and treatments for male SUI. Furthermore, we reviewed societal guidelines, such as the American Urological Association and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction guidelines and the recently published European Urological Association guidelines. Our review focused on English-language full-length manuscripts when available. Key Content and Findings: We present multiple surgical options for men with SUI. This review focuses on surgical options including 5 fixed male slings, 3 adjustable male slings, 4 artificial urinary sphincters (AUS), and an adjustable balloon device. This review includes treatment options from across the globe, although not all included devices are available in the United States. Conclusions: A great variety of treatment options exist for men with SUI, although not all Federal Drug Administration (FDA) approved. Shared decision making is paramount to generate the greatest satisfaction for patients.

Utilization of a Virtual Tumor Board for the Care of Patients With Renal Masses: Experience From a Quality Improvement Collaborative.

INTRODUCTION: Multidisciplinary tumor board meetings are useful sources of insight and collaboration when establishing treatment approaches for oncologic cases. However, such meetings can be time intensive and inconvenient. We implemented a virtual tumor board within the Michigan Urological Surgery Improvement Collaborative to discuss and improve the management of complicated renal masses. METHODS: Urologists were invited to discuss decision-making for renal masses through voluntary engagement. Communication was performed exclusively through email. Case details were collected and responses were tabulated. All participants were surveyed about their perceptions of the virtual tumor board. RESULTS: Fifty renal mass cases were reviewed in a virtual tumor board that included 53 urologists. Patients ranged from 20-90 years old and 94% had localized renal mass. The cases generated 355 messages, ranging from 2-16 (median 7) per case; 144 responses (40.6%) were sent via smartphone. All urologists (100%) who submitted to the virtual tumor board had their questions answered. The virtual tumor board provided suggestions to those with no stated treatment plan in 42% of cases, confirmed the physician's initial approach to their case in 36%, and offered alternative approaches in 16% of cases. Eighty-three percent of survey respondents felt the experience was "Beneficial" or "Very Beneficial," and 93% stated increased confidence in their case management. CONCLUSIONS: Michigan Urological Surgery Improvement Collaborative's initial experience with a virtual tumor board showed good engagement. The format reduced barriers to multi-institutional and multi-disciplinary discussions and improved the quality of care for selected patients with complex renal masses.

Trends in Male and Female Urethral Endoscopic Management and Urethroplasty Using the TriNetX Database.

BACKGROUND: How quickly providers adapt to new practice guidelines is not well known. The objective of this study was to evaluate temporal trends in the performance of urethral endoscopic management and urethroplasty surrounding the release of the American Urological Association (AUA) Male Urethral Stricture Guidelines in 2017. We also evaluate in parallel trends in female urethral stricture disease, where AUA guidelines are not present. We hypothesized that the ratio of urethroplasty versus urethral endoscopic management in both males and females is increasing and that guidelines do not result in immediate changes in management trends. METHODS: Endoscopic management and urethroplasty data were collected from the TriNetX database on adult males and females five years before (starting 1 January 2012) and after (ending 31 December 2022) the 2017 AUA guidelines. Cohorts were built using Current Procedural Terminology (CPT) codes and grouped into urethral endoscopic management (Males: CPT 52275, 52281, 52282, 53600, 53601, 53620, 53621; Females: CPT 52270, 53660, 53661, 53665) or urethroplasty (Males: CPT 53000, 53010, 53400, 53410, 53415, 53420, 53450, 53460; Females: CPT 53430). Data on patient age, race, and geographic distribution were also collected. RESULTS: In total, 27,623 (Males: 25,039; Females: 2584) endoscopic managements and 11,771 (Males: 11,105; Females: 666) urethroplasties were reviewed across 51 Health Care Organizations. The mean age of endoscopic management and urethroplasty patients was 67.1 and 55.7, respectively (p < 0.01). The urethroplasty-to-endoscopic management ratio decreased for males between 2012 and 2013 and then steadily increased until 2017. The ratio steadily increased for females from 2012 to 2017. The urethroplasty-to-endoscopic management ratio showed a slight decline from 2017 to 2020 across both males and females before rising again through 2022 to a study high (Males: 0.62; Females: 0.63). Regional differences were identified, with the West having the highest urethroplasty-to-endoscopic management ratios for both males and females, the Northeast having the lowest urethroplasty-to-endoscopic management ratio for males, and the Midwest having the lowest ratio for females. CONCLUSIONS: The utilization of urethroplasty for males and females is increasing. An immediate benefit on post-guideline urethroplasty rates was not observed, and the utilization of female urethroplasty increased despite the absence of AUA guidelines. These illustrate that the impact of guideline dissemination takes time and supports the need for continued provider outreach and education on urethral stricture disease and management.

A TriNetX Registry Analysis of the Need for Second Procedures following Index Anterior and Posterior Urethroplasty.

BACKGROUND: We queried a global database to understand re-intervention rates following urethroplasty with the goal of evaluating whether they align with previously published data. METHODS: Using the TriNetX database and Common Procedural Terminology (CPT) and International Classification of Diseases-10 (ICD) codes, we identified adult male patients with urethral stricture disease (ICD N35) who underwent one-stage anterior (CPT 53410) or posterior urethroplasty (CPT 53415), with or without (substitution urethroplasty) a tissue flap (CPT 15740) or buccal graft (CPT 15240 or 15241). We set urethroplasty as the index event and used descriptive statistics to report the incidence of secondary procedures (using CPT codes) within 10 years after the index event. RESULTS: There were 6606 patients who underwent urethroplasty within the last 20 years, with 14.3% of patients undergoing a second procedure after index event. Upon subgroup analysis, reintervention rates were 14.5% for anterior urethroplasty vs. 12.4% of patients with an anterior substitution urethroplasty (RR 1.7, p = 0.09) and 13.3% for posterior urethroplasty vs. 8.2% for patients with a posterior substitution urethroplasty (RR 1.6, p < 0.01). CONCLUSIONS: Most patients will not need any form of re-intervention following urethroplasty. These data align with previously described recurrence rates, which may help urologists counsel patients considering urethroplasty.

Do Sodium-Glucose Co-Transporter 2 Inhibitors Increase the Risk of Urologic Implant Reintervention?

OBJECTIVE: To understand whether patients taking sodium-glucose co-transporter 2 inhibitors (SGLT2i) would be at a similar risk of genitourinary device infection or failure as patients not taking these medications. METHODS: We queried the TriNetX database for all adult male patients undergoing artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) and compared patients taking SGLT2i against those not. Cohorts and outcomes were defined using current procedural terminology and International Classification of Diseases (ICD-10) codes. We used Age, body mass index, diabetes, smoking history and history of prostatectomy to generate propensity score matching. Our primary outcome was need for reintervention after implantation based on current procedural terminology codes. Secondary outcomes included infection rate and overall complication rate based on ICD-10 codes. Analytics were performed via TriNetX which calculated risk ratios. RESULTS: Analyses were run on November 28, 2022. After propensity score matching, there were 319 and 83 patients in each IPP and AUS cohort and comorbidity profiles were similar. Patients with an IPP on an SGLT2i were at a lower risk of overall complication (10.6% vs 16.1%, RR 0.66, P = .049). There was similar rates for AUS and risk of complication and for either implant on risk of infection or reintervention. CONCLUSION: Patients taking SGLT2is may be safely offered urologic implants. Patients taking an SGLT2 had a lower risk of complication for IPP, and there were similar rates of infection and reintervention for both IPP and AUS.

Does antithrombotic use enable earlier diagnosis of bladder cancer? A brief institutional assessment.

INTRODUCTION: Wallis et al (JAMA 2017) demonstrated use of antithrombotic medications (ATMs) is associated with increased prevalence of hematuria-related complications and subsequent bladder cancer diagnosis within 6 months. Stage of diagnosis was lacking in this highly publicized study. This study examined the association of ATM use on bladder cancer stage at the time of diagnosis. MATERIALS AND METHODS: We completed a retrospective chart review of patients with a bladder cancer diagnosis at our institution. Patient demographics and bladder cancer work up information were assessed. Patients were stratified based on use of ATMs at time diagnosis. Descriptive statistics were completed to identify association between ATM use and stage of bladder cancer diagnosis, as stratified by non-muscle invasive bladder cancer (NMIBC) versus muscle invasive bladder cancer (MIBC). RESULTS: A total of 1052 patient charts were reviewed. Eight hundred and forty-four were included and 208 excluded due to unavailability of diagnosis history. At diagnosis, 357 (42.3%) patients were taking ATMs. Patients on ATMs presented with NMIBC at similar rates as patients not taking ATMs (81.2% vs. 77.8%, p = 0.23). Subgroup analysis by ATM class similarly demonstrated no statistically significant differences in staging. CONCLUSION: While Wallis et al established that patients on blood thinners who present with hematuria are more likely to be diagnosed with genitourinary pathology, this factor does not appear to enable an earlier diagnosis of bladder cancer. Future study may assess hematuria at presentation (gross, microscopic), type of blood thinners, and low versus high risk NMIBC presentation.

Perspectives on the Role of Biopsy for Management of T1 Renal Masses: Survey Results From Two Regional Quality Improvement Collaboratives.

OBJECTIVE: To understand perspectives on renal mass biopsy, a survey was distributed to urologists in the Michigan Urological Surgery Improvement Collaborative and Pennsylvania Urologic Regional Collaborative. Renal mass biopsy (RMB) may reduce treatment of benign renal neoplasms; however, utilization varies widely. MATERIALS AND METHODS: Michigan Urological Surgery Improvement Collaborative and Pennsylvania Urologic Regional Collaborative are two quality improvement collaboratives that include a "real-world" collection of urologists from academic- and community-based settings. A 12-item survey assessing current RMB utilization, patient- and tumor-specific factors, adverse events, impact on management, and simulated patient scenarios was distributed. Responses are reported using descriptive statistics. RESULTS: Many responders (n = 54) indicated using RMB in less than 25% of cT1a (59%) and cT1b (85%) tumors. The most important patient-specific factors on the decision to recommend RMB were possible metastasis to the kidney (94%), patient comorbidity as a risk factor for active treatment (89%), and patient age (81%). The most important tumor-specific factors were the presence of bilateral tumors (81%), tumor size (70%) and perceived potential of performing nephron-sparing surgery (67%). Ten responders (19%) noted barriers to RMB in their practice, 23 (43%) recalled experiences with complications or poor outcomes, and 43 (80%) reported experiences where the results of RMB altered management. When presented with simulated patients, few urologists (9%-20%) recommended RMB in younger patients with any sized mass. Recommendations varied based on patient age, comorbidity, and tumor size. CONCLUSION: Understanding perspectives on RMB usage is essential prior to implementing quality improvement efforts. Most urologists participating in two statewide collaboratives infrequently recommend RMB. Optimizing RMB utilization may help reduce unnecessary treatments.

Socioeconomic Disparities and Risk Factors in Patients Presenting With Ischemic Priapism: A Multi-Institutional Study.

OBJECTIVES: To evaluate contemporary clinical presentations of priapism, their association with socioeconomic characteristics, and the role of prescribing providers in priapism episodes in a large cohort of patients managed at 3 major academic health systems. METHODS: We identified all consecutive patients presenting with ischemic priapism to the emergency departments of three major academic health systems (2014 -2019). Demographic characteristics, priapism etiologies, and clinical management were evaluated. Univariable and multivariable analyses were used to assess the contribution of socioeconomic characteristics and the role of prescribing providers in priapism episodes. RESULTS: We identified 102 individuals with a total of 181 priapism encounters. Hispanic race, lower income quartile, sickle-cell disease, and illicit drug use were associated with increased risk of recurrent episodes. Of ICI users, 57% received their prescriptions from non-urological medical professionals (NUMPs); the proportion with recurrent episodes was higher for NUMPs compared to urologists (24% vs 0%, P = 0.06) with no demographic differences identified between patients treated by either group. CONCLUSION: Socioeconomic disparities exist among patients presenting with recurrent episodes of priapism, potentially highlighting systemic issues with access to care and patient education. With most patients who developed ischemic priapism from ICI being prescribed these medications by NUMPs, further investigation is required to elucidate the prescribing and counseling patterns of these providers. Increased awareness of disparities and complications may improve patient safety.

The prognostic value of digital rectal exam for the existence of advanced pathologic features after prostatectomy.

BACKGROUND: Accurate staging at the time of prostate cancer diagnosis is fundamental to risk stratification and management counseling. Digital rectal exam (DRE) is foundational in clinical staging of prostate cancer, even with a known limited interexaminer agreement and poor sensitivity for detecting extraprostatic disease. We sought to evaluate the prognostic value of DRE for the presence of advanced pathologic features (APFs) following radical prostatectomy (RP). METHODS: All patients undergoing RP as primary treatment for clinically localized prostate cancer in the National Cancer Database between 2008 and 2014 were identified. Patients with additional malignancies, prior treatment with radiation or systemic therapy, incongruent clinical staging and DRE findings or without fully evaluable clinical staging were excluded. The primary outcome was the presence of postsurgical APFs, defined as positive surgical margins, nodal disease, or pathologic stage T3 or greater. Multivariable logistic regression analysis was performed to account for prostate-specific antigen (PSA), biopsy grade group, percent of positive biopsy cores, and clinical stage. RESULTS: In total, 91,525 patients consisting of 69,182 cT1, 20,641 cT2, and 1702 cT3-T4 were included. The average age was 61.1 ± 7.0 years, and the average PSA was 8.6 ± 10.3 ng/ml. On multivariable analysis, cT3 and T4 were associated with the presence of APFs (odds ratio [OR] 11.12, p < .01 and 5.28, p = .04), however, cT2 was only slightly associated with the presence of APFs when compared with cT1 (OR 1.15, p < .01). Furthermore, cT2 was associated with more node-positive disease (OR 1.63, p < .01), positive margins (OR 1.06, p < .01), and more than or equal to pT3 disease (OR 1.22, p < .01). CONCLUSIONS: Overall, advanced clinical stage as assessed by DRE was independently associated with an increasing risk of APFs. For individual APFs, the greatest effect is noticed between clinical stage and nodal positivity and less so between clinical stage and positive margins. DRE continues to hold value, particularly for patients with locally advanced disease and potential lymph node disease.

Is a 50% improvement threshold adequate to justify progression from sacral neuromodulation testing to implant?

PURPOSE: A ≥50% subjective improvement in urinary symptoms during sacral neuromodulation testing (SNM-I) is currently used as the indication for progression to second-stage implantation (SNM-II). While most patients will have successful SNM-I and proceed to SNM-II, deterioration in efficacy over time has been reported. It remains unclear if the durability of efficacy is related to the initial symptom reduction. We sought to determine if the degree of improvement after SNM-I is sufficient to predict long-term success. METHODS: The records of all patients who underwent sacral neuromodulation (SNM) for overactive bladder were reviewed. Subjects were divided into those who reported 50%-75% improvement (Group 1) and more than 75% improvement (Group 2) after SNM-I. Differences in clinical variables and long-term device efficacy were compared between groups. RESULTS: Of 213 patients who underwent SNM-I, 137 underwent permanent device implantation. A total of 76 (55%) and 61 (45%) patients reported 50%-75% (Group 1) and more than 75% (Group 2) symptomatic improvement, respectively. With a mean follow-up of 46 months, 44% of Group 1 patients and 68% of Group 2 patients still had a functioning device providing the symptomatic benefit (p = 0.007). Univariate analyses identified the presence of stress urinary incontinence at baseline and having a more than 75% improvement after SNM-I as predictors of long-term functional success. CONCLUSIONS: Compared to patients reporting 50%-75% symptomatic reduction after SNM-I, individuals with a more than 75% improvement during SNM-I were more likely to maintain device efficacy over time. Additional study is warranted to determine if the improvement threshold for progression to SNM-II should be increased.