Perspectives on technology: Single-use catheters - evidence and environmental impact.

OBJECTIVE: To explore the data comparing single- vs multi-use catheters for clean intermittent catheterisation (CIC), consider if the widespread use of single-use catheters is warranted given the cost and environmental impact, and put forth ideas for future consideration. METHODS: A primary literature review was performed in PubMed over the past 50 years. Studies that performed comparative analysis of single- and multi-use catheters were included in our review. All studies that reported on primary data were narratively summarised. RESULTS: A total of 11 studies were identified that reported on primary data comparing single- and multi-use catheters. There was no appreciable evidence suggesting reusable multi-use catheters were inferior to single-use catheters from an infection or usability standpoint. In addition, the environmental and monetary burden of single-use catheters is significant. CONCLUSIONS: The intermittent catheter landscape in the USA has a complex past: defined by policy, shaped by industry, yet characterised by a paucity of data demonstrating superiority of single-use over multi-use catheters. We believe that the aversion to reusable catheters by many patients and healthcare professionals is unwarranted, especially given the cost and environmental impact. Moving forward, better comparative data and more sustainable practices are needed.

Evaluating limited biopsy templates for men with markedly elevated PSAs.

INTRODUCTION: To define the smallest prostate needle biopsy (PNB) template necessary for accurate tissue diagnosis in men with markedly elevated PSA while decreasing procedural morbidity. MATERIALS AND METHODS: We performed a chart review of 80 men presenting with a newly elevated PSA > 100 ng/mL who underwent biopsy (PNB or metastatic site). For patients who underwent a full 12-core biopsy, simulated templates of 2- to 10-cores were generated by randomly drawing subsets of biopsies from their full-template findings. Templates were iterated to randomize core location and generate theoretical smaller template outcomes. Simulated biopsy results were compared to full-template findings to determine accuracy to maximal Grade Group (GG) diagnosis. RESULTS: Amongst those that underwent PNB, 93% had GG 4 or 5 disease. Twenty-two (40%) underwent a full 12-core biopsy, 20 (37%) a 6-core biopsy, and only 8 (15%) had fewer than six biopsy cores sampled at our hospital. Simulated templates with 2-, 4-, 6-, and 8-cores correctly diagnosed prostate cancer in all patients, and accurately identified the maximal GG in 82%, 91%, 95%, and 97% of patients, respectively. The biopsy locations most likely to detect maximal GG were medial mid and base sites bilaterally. A 4-core template of these sites would have accurately detected the maximal GG in 95% of patients relative to a full 12-core template. CONCLUSIONS: In men presenting with PSA > 100 ng/mL, decreasing from a 12-core to a 4-core prostate biopsy template results in universal cancer detection and minimal under-grading while theoretically decreasing procedural morbidity and cost.

Adoption of Single-Use Clean Intermittent Catheterization Policies Does Not Appear to Affect Genitourinary Outcomes in a Large Spinal Cord Injury Cohort.

PURPOSE: In April 2008, Medicare amended its policy for clean intermittent catheterization, increasing coverage from 4 reused catheters per month to up to 200 single-use catheters. The primary reason for the policy change was an assumed decrease in risk of urinary tract infection with single-use catheters. Given its economic/environmental impact (∼50-fold increase in cost and plastic waste) and a paucity of supporting evidence, we retrospectively evaluate the policy's effect in a prospective spinal cord injury registry. MATERIALS AND METHODS: We accessed data for the years 1995 to 2020 from the National Spinal Cord Injury Database focusing on 1-year follow-up in those unable to volitionally void after injury. We asked 2 questions: (1) Did hospitalizations for genitourinary reasons decrease after the clean intermittent catheterization policy change?; and (2) Did clean intermittent catheterization adoption and adherence increase after the clean intermittent catheterization policy change? RESULTS: During the study period, 2,657 of the 6,843 (38.8%) participants unable to volitionally void after spinal cord injury were hospitalized during their first follow-up year. Of the cohort performing clean intermittent catheterization, fewer individuals were hospitalized for genitourinary reasons prior to the clean intermittent catheterization policy change compared to after (10.6% vs 14.6%, P < .001), a finding that persisted on multivariate logistic regression (odds radio, 0.67, P < .001). In addition, the number of individuals performing clean intermittent catheterization at 1-year follow-up was less after the policy change compared to prior (57.0% vs 59.1%, P = .044). CONCLUSIONS: Our findings suggest the 2008 policy change shifting clean intermittent catheterization coverage from catheter reuse to single-use did not decrease hospitalizations for urinary tract infection or increase clean intermittent catheterization uptake in individuals with spinal cord injury.

The Effect of Early Infection on the Rate of Volitional Voiding after Spinal Cord Injury: A Potential Modifiable Risk Factor for Bladder Outcomes.

PURPOSE: Recently, it has been observed that early infections after spinal cord injury (SCI) are associated with decreased long-term motor and sensory recovery. We investigate the effects of early infection after SCI on long-term bladder function. MATERIALS AND METHODS: We assessed data for the years 1995 to 2006 using the National Spinal Cord Injury Database. Postoperative wound infections and pneumonia were used to classify infections during the acute inpatient and rehabilitation periods. The effect of early infections on volitional voiding status at 1-year followup was assessed. Age, gender and neurological status at rehabilitation discharge (level of injury, American Spinal Injury Association Impairment Scale [AIS] and bilateral lower extremity motor scores) were included in multivariate logistic regression modeling to control for confounding. RESULTS: Of the 3,561 persons studied, 1,233 (34.6%) had an early infection. Those with an infection during early recovery were less likely to void than their noninfected counterparts if in the AIS A (0.3% vs 1.9%, p=0.010), AIS B (3.8% vs 10.5%, p=0.018) and AIS C (29.1% vs 37.3%, p=0.071) classification, while those with less complete injuries (AIS D) did not appear to be affected (62.6% vs 65.4%, p=0.456). Similar findings were found when stratifying by lower extremity motor scores and persisted on multivariate analysis, where early infection decreased the odds of volitional voiding at 1-year followup (OR=0.79, p=0.042). CONCLUSIONS: Infections during the early recovery period may modify volitional voiding at 1-year followup by 20% or more. Future investigations to confirm our findings and potentially evaluate mitigation strategies are warranted.

Differences in the incidence of urinary tract infections between neurogenic and non-neurogenic bladder dysfunction individuals performing intermittent catheterization.

PURPOSE: To measure the incidence and severity of urinary tract infections (UTI) in intermittent catheter (IC) users with neurogenic and non-neurogenic diagnoses. MATERIALS AND METHODS: Administrative health insurance claims data from the IBM MarketScan® Database between January 1, 2015 and  December 31, 2019, were analyzed. New IC-users with neurogenic lower urinary tract dysfunction (NLUTD); IC-users without NLUTD (non-NLUTD); and age-and-sex-matched general population without IC use (GEN) were compared. Individuals were followed for one year after initial IC utilization or random index date for GEN. The primary outcome was a patient seeing a physician or attending a hospital for a UTI (measured with a primary or secondary diagnosis code related to a UTI). UTI incidence, hospitalizations, and length of hospital stay were compared. RESULT: We identified 6944 NLUTD, 5102 non-NLUTD, and 120 426 GEN individuals. The annualized UTI incidence was higher in IC-users (54.9% NLUTD IC-users and 38.9% non-NLUTD IC-users) compared to GEN individuals (9.8%) (p < 0.001 between groups). Hospitalization for UTI was more common in NLUTD and non-LUTD (11.3% and 4.0%, respectively) compared with GEN individuals (1.0%) (p < 0.001 between groups). NLUTD individuals had a greater average length of hospital stay than non-NLUTD (2.2 ± 3.6 vs. 1.6 ± 2.1 days, p < 0.001). CONCLUSION: IC users had a significantly higher incidence of UTIs than the general population. NLUTD IC-users had a higher incidence of UTIs that required hospitalization compared to non-NLUTD individuals. Strategies to decrease the patient and healthcare burden of UTIs in those that catheterize should be prioritized.

Predictors of Colpocleisis Outcomes in an Older Population Based Cohort.

PURPOSE: Colpocleisis is an obliterative surgical option for women with pelvic organ prolapse that is often performed in a frail population. However, because outcomes remain largely unknown we aimed to assess the durability and perioperative safety of colpocleisis in a large population based cohort. MATERIALS AND METHODS: All women undergoing colpocleisis and other pelvic organ prolapse repairs in California (2005-2011) were identified using the Office of Statewide Health Planning and Development data sets. Durability was defined as the absence of future pelvic organ prolapse repair after index repair for the duration of the data sets. Thirty-day morbidity was assessed by identifying readmissions, repeat surgeries and complications. A metric to assess frailty in large administrative databases was applied to assess the impact of frailty on outcomes. Colpocleisis outcomes were compared to other types of pelvic organ prolapse repairs by developing propensity score matched groups. RESULTS: Among the 2,707 women undergoing colpocleisis, reoperation for prolapse occurred in 47 (1.8%). At least 1 complication occurred in 11.1% of the cohort, with serious complications occurring in 2%. Frail patients were more likely to experience any complication (23.3% vs 10.3%, p <0.01) and a serious complication (5.0% vs 1.8%, p=0.02) and was the best predictor of morbidity. Colpocleisis was associated with a more durable repair (overall failure 1.8% vs 3.5%, p <0.01) with no difference in complication rates as compared to the matched cohort. CONCLUSIONS: Colpocleisis provides a more durable outcome than reconstructive pelvic organ prolapse repairs without increased perioperative morbidity. Frailty is a better predictor than age for perioperative complications after colpocleisis.

Using conjoint analysis to measure the importance of psychosocial traits in the choices of bladder management after spinal cord injury.

OBJECTIVE: To conduct a conjoint analysis experiment to better understand the psychosocial priorities related to bladder management in individuals after spinal cord injury (SCI). METHODS: We developed a conjoint analysis survey that included 11 psychosocial attributes phrased in the context of bladder management (including attributes for urinary infections, and incontinence). We then performed a multi-center prospective cross-sectional study of adults with existing SCI which consisted of a baseline interview, followed by the online conjoint analysis survey (delivered through Sawtooth software). Hierarchical Bayes random effects regression analysis was used to determine the relative importance of the attributes. RESULTS: A total of 345 people complete the study. There was good representation of both men and women, and individuals with cervical and thoracic or lower lesions. The most important attribute was the frequency of urinary infections. Age, sex, and level of SCI were generally not related to the attributes measured in the study. In the subgroup of 256 patients who used a catheter for bladder management, significantly more importance was placed on urinary tract infections, time, fluid intake, and social life among indwelling catheter users compared to intermittent catheter users. CONCLUSIONS: Most bladder-related psychosocial priorities are not impacted by a patient's age, sex or level of SCI. Differences in psychosocial priorities between indwelling and intermittent catheter users may represent factors that should be focused on to optimize bladder management after SCI.

Urinary Stone Disease in Pregnancy: A Claims Based Analysis of 1.4 Million Patients.

PURPOSE: Urinary stone disease during pregnancy is poorly understood but is thought to be associated with increased maternal and fetal morbidity. We determined the prevalence of urinary stone disease in pregnancy and whether it is associated with adverse pregnancy outcomes. MATERIALS AND METHODS: We identified all pregnant women from 2003 through 2017 in the Optum® national insurance claims database. We used diagnosis claims to identify urinary stone disease and assess medical comorbidity. We established the prevalence of urinary stone disease during pregnancy stratified by week of pregnancy. We further evaluated associations among urinary stone disease, maternal complications and pregnancy outcomes in univariable and multivariable analyses. RESULTS: Urinary stone disease affects 8 per 1,000 pregnancies and is more common in white women and women with more comorbid conditions. In fully adjusted models pregnancies complicated by urinary stone disease had higher rates of adverse fetal outcomes including prematurity and spontaneous abortions. This analysis is limited by its retrospective, administrative claims design. CONCLUSIONS: The rate of urinary stone disease during pregnancy is higher than previously reported. Urinary stone disease is associated with adverse pregnancy outcomes.

Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study.

AIMS: Evidence is sparse on the long-term outcomes of continent cutaneous ileocecocystoplasty (CCIC). We hypothesized that obesity, laparoscopic/robotic approach, and concomitant surgeries would affect morbidity after CCIC and aimed to evaluate the outcomes of CCIC in adults in a multicenter contemporary study. METHODS: We retrospectively reviewed the charts of adult patients from sites in the Neurogenic Bladder Research Group undergoing CCIC (2007-2017) who had at least 6 months of follow-up. We evaluated patient demographics, surgical details, 90-day complications, and follow-up surgeries. the Mann-Whitney U test was used to compare continuous variables and χ² and Fisher's Exact tests were used to compare categorical variables. RESULTS: We included 114 patients with a median age of 41 years. The median postoperative length of stay was 8 days. At 3 months postoperatively, major complications occurred in 18 (15.8%), and 24 patients (21.1%) were readmitted. During a median follow-up of 40 months, 48 patients (42.1%) underwent 80 additional related surgeries. Twenty-three patients (20.2%) underwent at least one channel revision, most often due to obstruction (15, 13.2%) or incontinence (4, 3.5%). Of the channel revisions, 10 (8.8%) were major and 14 (12.3%) were minor. Eleven patients (9.6%) abandoned the catheterizable channel during the follow-up period. Obesity and laparoscopic/robotic surgical approach did not affect outcomes, though concomitant surgery was associated with a higher rate of follow-up surgeries. CONCLUSIONS: In this contemporary multicenter series evaluating CCIC, we found that the short-term major complication rate was low, but many patients require follow-up surgeries, mostly related to the catheterizable channel.

Treatment of urethral stricture disease in women: A multi-institutional collaborative project from the SUFU research network.

AIM: Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. METHODS: This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. RESULTS: Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. CONCLUSION: This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.

Balancing the possibility of needing a future incontinence procedure versus a future urethral sling revision surgery: a tradeoff analysis for continent women undergoing pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Although urinary incontinence surgery has potential benefits such as preventing de novo stress urinary incontinence in women undergoing pelvic organ prolapse (POP) surgery, it comes with the potential cost of overtreatment and complications. We compared future surgery rates in a population cohort of women undergoing vaginal pelvic organ prolapse surgery. METHODS: All women undergoing POP repair in California from 2005 to 2011 were identified from the Office of Statewide Health Planning and Development databases. Rates of repeat surgery in those with and without concomitant urethral sling procedures were compared. To control for confounding effects, multivariate mixed effects logistic regression models were constructed to compare each woman's individualized risk of undergoing either sling revision surgery or future incontinence surgery. RESULTS: In the cohort, 38,456 underwent a sling procedure at the time of POP repair and 42,858 did not. The future surgery rate was higher for sling-related complications in the POP + sling cohort compared with future incontinence surgery in the POP alone cohort (3.5% versus 3.0% respectively, p < 0.001). The difference persisted in multivariate modeling, where most women (60%) are at a higher risk of requiring sling revision surgery compared with needing a future primary incontinence procedure (40%). CONCLUSIONS: Women who undergo vaginal prolapse repair without an incontinence procedure are at a low risk of future incontinence surgery. Women without urinary incontinence who are considering vaginal POP surgery should be informed of the risks and benefits of including a sling procedure.

Reoperation rates for pelvic organ prolapse repairs with biologic and synthetic grafts in a large population-based cohort.

INTRODUCTION AND HYPOTHESIS: As the long-term complications of synthetic mesh become increasingly apparent, re-evaluation of alternative graft options for pelvic organ prolapse (POP) repairs is critical. We sought to compare the long-term reoperation rates of biologic and synthetic grafts in POP repair. METHODS: Using the California Office of Statewide Health Planning and Development database, we identified all women who underwent index inpatient POP repair with either a synthetic or biologic graft between 2005 and 2011 in the state of California. ICD-9 and CPT codes were used to identify subsequent surgeries in these patients for either recurrent POP or a graft complication. RESULTS: A total of 14,192 women underwent POP repair with a biologic (14%) or synthetic graft (86%) during the study period. Women with biologic grafts had increased rates of surgery for recurrent pelvic organ prolapse (3.6% vs 2.5%, p = 0.01), whereas women with synthetic grafts had higher rates of repeat surgery for a graft complication (3.0 vs 2.0%, p = 0.02). There were no significant differences between the overall risk of repeat surgery between the groups (5.7% vs 5.6%, p = 0.79). These effects persisted in multivariate modeling. CONCLUSIONS: We demonstrate in a large population-based cohort that biologic grafts are associated with an increased rate of repeat surgery for POP recurrence whereas synthetic mesh is associated with an increased rate of repeat surgery for a graft complication. These competing risks result in an equivalent overall any-cause repeat surgery rate between the groups. These data suggest that neither type of graft should be excluded from use and encourage a personalized risk assessment.

Combination therapy in overactive bladder-untapped research opportunities: A systematic review of the literature.

AIMS: Overactive bladder (OAB) affects over 17% of the population and significantly effect the health-related quality of life. The treatments for OAB include first line (lifestyle modification, pelvic floor muscle training), second line (anticholinergic or beta-3 agonist medications), and third line therapies (intradetrusor botulinum toxin injection, sacral neurostimulation [SNM], or percutaneous tibial nerve stimulation [PTNS]). For those with urinary incontinence secondary to OAB, complete continence is the goal of therapy, though cure rates are only 5% to 40%. The use of combination therapies can be employed in refractory OAB, however, the efficacy of pooled modalities is relatively unknown. Our objective was to determine the volume of data supporting combination therapy in treating OAB. METHODS: We systematically reviewed PubMed, EMBASE, the Cochrane Library, and Google Scholar for articles published before October 2018. Each was independently reviewed by two reviewers and examined in detail if they met inclusion criteria. RESULTS: A total of 32 studies met inclusion criteria and were reviewed. Most large prospective studies evaluated combinations of medications with behavioral therapy or medications together. Combination therapy studies of third-line treatments were rare and centered on medication with PTNS. No studies examined intradetrusor botulinum toxin injections in combination with another therapy and only one retrospective study briefly examined SNM therapy in combination with medication. CONCLUSION: Combination therapy, with certain first, second, and third-line OAB therapies, appears to be efficacious. There is a further need for carefully designed combination therapy studies, particularly those including third line modalities.

Do appreciable changes in the upper extremity motor capability to perform clean intermittent catheterization come about with time after traumatic spinal cord injury?

INTRODUCTION: Bladder dysfunction after spinal cord injury (SCI) often requires clean intermittent catheterization (CIC) or other management strategies. A common dilemma in those desiring to perform CIC independently but lacking the appropriate upper extremity (UE) motor function is the timing of reconstructive surgery. METHODS: We assessed the National Spinal Cord Injury Data Set for the years 2000-2016. Our cohort consisted of persons with cervical SCI, who underwent complete motor examination upon discharge from rehabilitation and at 1-year follow-up. Using a previously published algorithm, UE motor scores were transformed to predict a patient's ability to independently perform CIC. Improvements in the predicted ability to self-catheterize were evaluated. RESULTS: Of the 1428 individuals meeting the inclusion criteria, improvements in the predicted UE motor function necessary to independently self-catheterize were observed in 39%, 42%, and 38% of those deemed possibly able, only able with surgical assistance, or unable to self-catheterize at rehabilitation discharge, respectively. On multivariate analysis, only increasing Association Impairment Scale (AIS) classification and AIS classification improvement over the first year were associated with an increased odds of improving predicted CIC ability (odds ratio [OR] = 1.44 for AIS C and 1.97 for AIS D compared with AIS A, and OR = 1.90 for AIS classification improvement versus stable AIS classification, P < 0.05 for each). CONCLUSION: Improvements in UE motor function to independently perform CIC occur in approximately 40% of persons with cervical SCI in the first year after rehabilitation discharge. Those with incomplete injuries are more likely to improve. These findings should enhance patient bladder management counseling and guide surgeons in determining an appropriate timeline for offering reconstruction.

To stage or not to stage?-A cost minimization analysis of sacral neuromodulation placement strategies.

AIMS: Sacral neuromodulation (SNM) is a standard therapy for refractory overactive bladder (OAB). Traditionally, SNM placement involves placement of an S3 lead with 1-3 weeks of testing before considering a permanent implant. Given the potential risk of bacterial contamination during testing and high success rates published by some experts, we compared the costs of traditional 2-stage against single-stage SNM placement for OAB. METHODS: We performed a cost minimization analysis using published data on 2-stage SNM success rates, SNM infection rates, and direct reimbursements from Medicare for 2017. We compared the costs associated with a 2-stage vs single-stage approach. We performed sensitivity analyses of the primary variables listed above to assess where threshold values occurred and used separate models for freestanding ambulatory surgery centers (ASC) and outpatient hospital departments (OHD). RESULTS: Based on published literature, our base case assumed a 69% SNM success rate, a 5% 2-stage approach infection rate, a 1.7% single-stage approach infection rate, and removal of 50% of non-working single-stage SNMs. In both ASC ($17 613 vs $18 194) and OHD ($19 832 vs $21 181) settings, single-stage SNM placement was less costly than 2-stage placement. The minimum SNM success rates to achieve savings with a single-stage approach occur at 65.4% and 61.3% for ASC and OHD, respectively. CONCLUSIONS: Using Medicare reimbursement, single-stage SNM placement is likely to be less costly than 2-stage placement for most practitioners. The savings are tied to SNM success rates and reimbursement rates, with reduced costs up to $5014 per case in centers of excellence (≥ 90% success).

Validation of Upper Extremity Motor Function as a Key Predictor of Bladder Management After Spinal Cord Injury.

OBJECTIVE: To validate if better upper extremity (UE) motor function predicts clean intermittent catheterization (CIC) adoption and adherence after spinal cord injury (SCI) using a validated instrument (as opposed to prior research using scales based on expert opinion). DESIGN: We examined data from the Neurogenic Bladder Research Group SCI registry, a multicenter, prospective, observational study assessing persons with neurogenic bladder following SCI. All participants who were unable to volitionally void and were >1 year post injury were included. Participants were dichotomized into those performing CIC vs those using other bladder management methods. In addition to demographic and clinical characteristics, UE motor function was examined using the SCI-Fine Motor Function Index using validated categorization levels: (1) no activities requiring hand function, (2) some activities involving gross hand movement, (3) some activities requiring dexterity or coordinated UE movement, or (4) most activities requiring dexterity and coordinated UE movement. Associations were examined using logistic regression. SETTING: Multicenter study. PARTICIPANTS: Registry participants unable to volitionally void after SCI (N=1236). INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Upper extremity motor function association with CIC. RESULTS: A total of 1326 individuals met inclusion criteria (66% performing CIC, 60% male, and 82% white). On multivariate analysis, better UE motor function was associated with a statistically increased odds of performing CIC (odds ratio, 3.10 [Level 3] and odds ratio, 8.12 [Level 4] vs Levels 1 and 2 [P<.001]). CONCLUSION: In persons with SCI who are unable to volitionally void, UE motor function is highly associated with CIC. These results validate prior findings and continue to suggest that following SCI, the degree of preserved UE motor function is associated with CIC more than any other factor.

What Impacts the All Cause Risk of Reoperation after Pelvic Organ Prolapse Repair? A Comparison of Mesh and Native Tissue Approaches in 110,329 Women.

PURPOSE: Several factors are hypothesized to impact the risks of mesh augmented pelvic organ prolapse repair, including 1) the characteristics of the material, 2) surgical experience and 3) patient selection. We present a large, population based approach to explore the impact of these factors on outcomes and describe an ideal mesh use strategy. MATERIALS AND METHODS: Data from the Office of Statewide Health Planning and Development were accessed to identify all women who underwent pelvic organ prolapse repair in California from 2005 to 2011. Multivariate mixed effects logistic regression models were constructed to explore which patient, surgical and facility factors were associated with repeat surgery for a complication due to mesh or recurrent pelvic organ prolapse. RESULTS: A total of 110,329 women underwent pelvic organ prolapse repair during the study period and mesh was used in 16.2% of the repairs. The overall repeat surgery rate was higher in women who underwent mesh repair (5.4% vs 4.3%, p <0.001). However, multivariate modeling revealed that mesh itself was not independently associated with repeat surgery. Rather, repair at a facility where there was a greater propensity to use mesh was independently associated with repeat surgery (highest vs lowest mesh use quartile OR 1.55, p <0.01). Further modeling revealed that the lowest risk occurred when mesh was used in 5% of anterior and 10% of anterior apical repairs. CONCLUSIONS: Our findings demonstrate that mesh is not independently associated with an increase in the rate of complications of pelvic organ prolapse repair on a large scale. We present a model that supports judicious use of the product on the population level which balances the risk of complications against that of recurrent pelvic organ prolapse.

Volitional Voiding of the Bladder after Spinal Cord Injury: Validation of Bilateral Lower Extremity Motor Function as a Key Predictor.

PURPOSE: In many individuals with spinal cord injury a return of volitional bladder voiding is considered more important than regaining motor function. Recently a predictive model using only composite bilateral lower extremity motor scores for levels L2-S1 (range 0 to 50) was proposed by the EMSCI (European Multicenter Study about Spinal Cord Injury) group. The model showed exceptional predictive power with an AUC of 0.912. We sought to further validate the EMSCI model in a national spinal cord injury cohort. MATERIALS AND METHODS: We created models of volitional voiding using the United States NSCID (National Spinal Cord Injury Database) for 2007 to 2016. In addition to testing lower extremity motor scores, we evaluated other patient variables that we hypothesized might affect volitional voiding. RESULTS: Volitional voiding was present in 1,333 of the cohort of 4,327 individuals (30.8%) at 1-year followup. While younger age, female gender, increased sacral sparing, improved AIS (American Spinal Injury Association Impairment Scale) classification and a more caudal sensory level predicted volitional voiding, lower extremity motor scores were most predictive (AUC 0.919). Adding the other patient characteristics did little to improve model performance (full model AUC 0.932). Further analysis of the predictive power of lower extremity motor scores suggested that while the AUC appeared to decrease in persons who were most likely to void volitionally, the performance of the predictive model remained outstanding with a combined AIS C and D AUC of 0.792. CONCLUSIONS: Our study verifies the validity of the EMSCI predictive model of volitional voiding after spinal cord injury. The differing performance of lower extremity motor scores in various AIS classifications should be noted.