Longitudinal Outcomes of Malignant Ureteral Obstruction Secondary to Ovarian Cancer: Predictors of Resolution and the Role of Surgical Management.

OBJECTIVE: To review the management of ovarian cancer (OCa) associated hydronephrosis (HN). Specifically, we aim to identify optimal management of HN in the acute setting, predictors of HN resolution, and the role of surgery (tumor debulking/(+/-)ureterolysis/hysterectomy). MATERIALS/METHODS: The study cohort included OCa patients managed at our institution from 2004-2019 that developed OCa-associated HN. Initial HN management was recorded as none, retrograde ureteral stent (RUS) or percutaneous nephrostomy tube (PCN). Primary outcomes included (1) HN management failure, (2) HN management complications, and (3) HN resolution. Patient, cancer, and treatment predictors of outcomes were assessed using logistic regression and fine-Gray competing risk models. RESULTS: Of 2580 OCa patients, 190 (7.4%) developed HN. HN was treated in 121; 90 (74.4%) with RUS, 31 (25.6%) with PCN. Complication rates were similar between PCN and RUS (83% vs 85.1%; P = .79; all Clavian Grade I/II). Initial HN treatment failure occurred in 28 patients, predicted by renal atrophy (hazard ratios (HR) 3.27, P <.01). HN resolution occurred in only 52 (27%) patients and was predicted by lower International Federation of Gynecology and Obstetrics (FIGO) stage (FIGO III/IV HR 0.42, P <.01) and surgical tumor debulking/ureterolysis (HR 2.83, P = .02). CONCLUSION: Resolution of HN associated with malignant obstruction from OCa is rare and is most closely associated with tumor debulking and International Federation of Gynecology and Obstetrics (FIGO) stage. Initial endoscopic treatment modality was not significantly associated with complications or resolution, though RUS failures were slightly more common. Ureteral reconstruction at time of debulking/ureterolysis is potentially underutilized.

Decisional conflict in American parents regarding newborn circumcision.

BACKGROUND: Decisional conflict surrounding the topic of circumcision in the newborn male is assumed in some parents but has not been quantified or qualified. It is known that parents often base their decision on cultural and social factors and that physician discussions do affect ultimate decision-making. Information on parents' decision-making surrounding newborn circumcision and ways to mitigate conflict or uncertainty around the decision-making process is needed to better counsel them appropriately. OBJECTIVES: To identify the presence or absence of decisional conflict in parents-to-be deciding whether or not to circumcise their child as well as to identify determinants of this conflict to direct future educational measures. STUDY DESIGN: Parents presenting to obstetrics clinic as well as contacted by institutional email were recruited using convenience sampling and completed the validated Decisional Conflict Scale (DCS). A smaller subset of subjects were recruited via institutional email to complete semi-structured interviews regarding the decision-making process and specifically uncertainty regarding the decision. Descriptive statistics and unpaired t tests were used for analysis of survey data. For interview data, an iterative, grounded theory methodology was used. RESULTS: 173 subjects completed the DCS. 12% of all participants had high decisional conflict. Intuitively, those who had not yet decided whether to circumcise had the highest proportion of high DCS (69%), followed by those who had decided to circumcise (9.3%) and those who had decided not to circumcise (1.7%). 24 subjects were interviewed, and based on their DCS scores and interview responses were classified as low, intermediate and high conflict. Three primary themes emerged delineating the high from low conflict groups. There were notable differences in the feelings of subjects regarding knowledge and feeling informed, the importance of particular values and clarity of the roles of these values in decision-making, and feelings of supported decision-making. These themes were used to create a visual model depicting the individual needs of each decision-maker (Fig. 1). DISCUSSION: This study highlights the need for decision support for parents that is not only information-based but focuses on values clarity and supported decision-making. This study provides a jumping-off point for creation of shared decision-making tools directed at individual needs. The limitations of this study are a single institution design and homogeneous population, so when designing materials, additional unrecognized needs will likely be identified. CONCLUSION: A small, but real proportion of parents-to-be experience significant uncertainty around the decision to circumcise their newborn boys. Identified needs of parents include feeling informed, feeling supported and clarification of important values related to the problem.

Longitudinal Outcomes from Conservative Management of Cervical Cancer Associated Ureteral Obstruction.

OBJECTIVE: To identify predictors of hydronephrosis (HN) resolution and HN treatment failure. HN is a common comorbid condition with cervical cancer (CCa). Treatments for CCa continue to improve and long-term management strategies of HN are becoming increasingly necessary. METHODS: A query of a single hospital (2004 - 2019) ICD-9 and CPT codes was made to develop a cohort of CCa patients with HN. A retrospective review was performed. The effects of patient, renal/HN, and cancer covariates on time to HN treatment failure, treatment complications and time to HN resolution were evaluated using logistic regression and competing risk Cox regression models. RESULTS: Of the 1670 women treated for CCa during the study period, 179 (10.7%) developed HN (n = 72 (40%) bilateral), 78 (44%) at time of CCa diagnosis and 101 (56%) as a result of treatment, of which 145 (81%) underwent initial treatment with a PCN (n = 77, 53%) or US (n = 68, 47%). Complication rates were similar between PCN (56%) and US (61%) when adjusting for treatment time. Initial treatment failure was more likely with US vs PCN (HR 3.2, P <0.01). HN resolution (n = 32, 22%) without reconstruction was predicted by HN concurrent with CCa diagnosis (HR 3.1, P <0.01) and bilateral HN (HR 0.2, P <0.01). CONCLUSION: CCa associated HN has a resolution rate of only 19% at 12 months. Those presenting with HN after CCa treatment are less likely to resolve without reconstruction. PCN and US have similar complication rates but initial US placement has a nearly three times increased risk of failing than PCN.

Bulbar urethrocavernous fistula in setting of inflatable penile prosthesis: a case report.

BACKGROUND: Urethral injury or erosion of an inflatable penile prosthetic (IPP) cylinder is a rare complication of IPP placement. It can present with varying symptoms and management can be difficult with risk for future complications. We present a patient with an eroded IPP who developed a secondary contralateral urethrocavernous fistula requiring repeat urethroplasty. We also describe the literature surrounding these complications and strategies to prevent them. CASE PRESENTATION: A 69-year-old man with poorly controlled diabetes presented to our clinic with 6 months of intermittent white urethral discharge first noted after IPP removal and replacement by an outside urologist for device malfunction. Office cystoscopy revealed an eroded right-sided prosthetic cylinder in the bulbar urethra. The patient was taken to the operating room for IPP explantation with closure of right corporal defect, left sided malleable prosthesis placement, and primary excision with anastomosis of his bulbar urethra. A catheter was left in place for two weeks postoperatively, at which time a peri-catheter retrograde urethrogram was performed which showed no evidence of contrast extravasation and his catheter was subsequently removed. Several months later, he presented with recurrent urethral discharge without evidence of recurrent erosion on cystoscopy with development of scrotal abscesses following office cystoscopy, concerning for an unidentified urethral defect. He returned to the operating room for scrotal exploration and was noted on cystoscopy to have a pinpoint fistula between his left corporal body and his bulbar urethra. He underwent left sided malleable prosthetic explant, and non-transecting bulbar urethroplasty. Peri-catheter retrograde urethrogram two weeks later showed no contrast extravasation and he has had no recurrence of urethral discharge or scrotal abscesses since. CONCLUSIONS: Urethral erosion and urethrocavernous fistula formation are rare complications of penile prosthesis placement. Risks are elevated in patients with corporal fibrosis, diabetes, those undergoing penile implant revision surgery, and those requiring prolonged urethral catheterization.

Is the age of cervical cancer diagnosis changing over time?

OBJECTIVES: The objective of this study was to determine if there has been an increase in the age of diagnosis of cervical cancer over time, specifically in the proportion of patients over 65 years old, given decreasing rates of hysterectomy. MATERIALS AND METHODS: A retrospective review of a single institution was conducted including cervical cancer patients seen between 1986 and 2016. Data included demographic variables including age of diagnosis, last cervical cancer screening, and cancer information. Cochran-Armitage test was used to assess temporal trends in the proportion of patients diagnosed over 65. RESULTS: A total of 1,019 patients with cervical cancer were reviewed, of whom 116 were over the age of 65. The age of diagnosis increased by 0.2 years per calendar year, with an average age of diagnosis of 43.7 years old in 1986 versus 49.5 years old in 2016 (p<0.01). The proportion of patients diagnosed with cervical cancer over the age of 65 did not significantly differ over time (17.2 % in 1986 vs. 14.8 % in 2016, p=0.39). 19.0 % of women diagnosed with cervical cancer over the age of 65 developed cancer despite exiting screening appropriately. CONCLUSIONS: In our cohort, the age of diagnosis of cervical cancer increased over time, however, there was no significant difference in the percentage of women diagnosed over the age of 65.

Effect of Obesity on Cervical Cancer Screening and Outcomes.

OBJECTIVES: The aims of the study were to identify whether obese women are less appropriately screened for cervical cancer before diagnosis and to explore related cancer outcomes. METHODS: We retrospectively reviewed all cervical cancer patients at a single institution between 1986 and 2016 and collected demographic information including age, cancer stage, body mass index (BMI), screening information, and cancer outcomes. Morbid obesity was defined as BMI of 40 kg/m or greater, obesity as BMI of 30 to less than 40 kg/m, and nonobese as BMI of less than 30 kg/m. χ, Fisher exact, and Wilcoxon rank sum tests were used to compare variables between BMI categories. Cox regression models were used to evaluate recurrence-free survival and overall survival (OS). RESULTS: A total of 1,080 patients were reviewed, of whom 311 (29.4%) were obese and 107 (10.1%) morbidly obese. A significant association between BMI and cytology screening was evidenced with morbidly obese women having the highest incorrect rate (64.4%), followed by obese (51.5%) and nonobese women (46.0%, p < .01). There was no significant difference in presence of symptoms at presentation (p = .12) or stage (p = .06) between BMI categories. In multivariable analysis of cancer outcomes, higher BMI was associated with worse OS (p < .01) with a hazard ratio of 1.25 (95% CI = 0.92-1.69) for obese women and hazard ratio 2.27 (95% CI = 1.56-3.31) for morbidly obese women relative to normal weight but recurrence-free survival did not differ between BMI groups (p = .07). CONCLUSIONS: Our study strengthens evidence that obese and morbidly obese women have disproportionate inappropriate screening before cervical cancer diagnosis, and morbidly obese women have worse OS than their counterparts.