Does Marital Status Impact Outcomes After Total Knee Arthroplasty?

BACKGROUND: There is a paucity of research on the relationship between marital status and patient outcomes following total knee arthroplasty (TKA). METHODS: This was a retrospective chart review of patients who underwent TKA by a single surgeon at a university-based orthopedic practice. Data abstracted included age, gender, marital status, body mass index, length of hospital stay, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Oxford Knee Score (OKS). The WOMAC and OKS were administered at the preoperative visit and at approximately 10, 30, 90, and 180 days after TKA. Multivariate analyses with patient-reported outcomes as repeated measures, marital status, day of assessment; and the interaction of marital status and day of assessment as fixed effects; and age, gender, body mass index, and length of hospital stay as covariates were conducted as well as analyses in which preoperative patient-reported outcomes were treated as fixed effects. RESULTS: Of 422 patients who underwent TKA during the study period, complete data were available for 249, of whom 124 were married and 125 unmarried. Married patients had significantly higher WOMAC scores than unmarried patients at all postoperative assessments, even after controlling for preoperative scores. Although married patients also had significantly higher postoperative OKS scores than their unmarried peers, differences between groups were attenuated after adjusting for preoperative OKS scores. CONCLUSION: This study found that married patients have better overall outcomes after TKA but yielded conflicting results as to whether the positive effects of marriage are specific to the postoperative period.

Digital image analysis using video microscopy of human-derived prostate cancer vs normal prostate organoids to assess migratory behavior on extracellular matrix proteins.

The advent of perpetuating living organoids derived from patient tissue is a promising avenue for cancer research but is limited by difficulties with precise characterization. In this brief communication, we demonstrate via time-lapse imaging distinct phenotypes of prostate organoids derived from patient material- without confirmation of cellular identity. We show that organoids derived from histologically normal tissue more readily spread on a physiologic extracellular matrix (ECM) than on pathologic ECM (p<0.0001), while tumor-derived organoids spread equally on either substrate (p=0.2406). This study is an important proof-of-concept to defer precise characterization of organoids and still glean information into disease pathology.

Leiomyosarcoma of the scrotum: a case report and literature review.

Leiomyosarcoma (LMS) is one of the most common forms of soft tissue sarcoma with approximately 2,500 cases per year in the United States. The symptoms LMS vary depending upon the location, size, and spread of the tumor. In early stages, it may not be associated with any obvious symptoms so diagnosis and treatment may be delayed. In some cases, it can grow quickly and behave aggressively. Most types of LMS occur in the abdomen or in the uterus; although, scrotal LMS can be a very rare presentation of the disease. Here we present our case of a large, ulcerated scrotal LMS originating from subcutaneous tissue but not invading spermatic cord or tunica. Radical orchiectomy with high ligation of spermatic cord was performed, and patient had an uneventful postoperative course. This disease entity remains rare in the literature, and warrants larger studies in order to better understand treatment and oncologic outcomes. When LMS is identified early and is removed by surgical excision, prognosis can be good and full recovery quite likely. When LMS is already large or has spread to other parts of the body, treatment is relatively more complex and the prognosis poor. Hence, prompt diagnosis and treatment of genitourinary LMS require prompt attention, referral to tertiary, referral center should be strongly considered.

National trends and survival outcomes of penile squamous cell carcinoma based on human papillomavirus status.

BACKGROUND: There are no series evaluating penile squamous cell carcinoma (pSCC) based on human papillomavirus (HPV) infection. Herein, we present national registry data on clinical and survival outcomes for pSCC based on HPV status. METHODS: We performed a retrospective review of 1224 pSCC patients with known HPV staining from the National Cancer Database. Patients with cM1 disease, those who did not receive treatment, or had missing follow-up data were excluded. Logistic regression identified factors associated with locally aggressive disease. Univariable, multivariable, and inverse probability of treatment weighting (IPTW)-Cox proportional hazard modeling were used to assess hazard ratios (HR) associated with overall survival (OS). RESULTS: After exclusion criteria, we identified 825 cases of which 321 (38.9%) were HPV positive. The HPV-positivity rate did not significantly change by year. HPV-positive patients were younger, had lower Charlson-Deyo performance score, and resided in areas with both lower median household income and lower school education completion. HPV-positive tumors presented with lower American Joint Committee on Cancer clinical T-stage (cT), poorer differentiation, lower rates of lymphovascular invasion (LVI), but more node-positive disease (cN+). For those who underwent lymph node surgery, there were no differences in final pathologic stage, upstaging, or presence of extranodal extension. Only tumor differentiation, LVI, and performance score were independent predictors for locally aggressive disease. HPV status was not a predictor of OS (IPTW-HR:0.89, p = 0.13). CONCLUSIONS: In the largest series evaluating pSCC based on HPV status, HPV-positive tumors were associated with lower cT stages, less LVI, but more cN + disease. More studies on prognostic factors are needed, and time may still be immature to use HPV information for risk stratification.

Comparison of magnetic resonance defecography grading with POP-Q staging and Baden-Walker grading in the evaluation of female pelvic organ prolapse.

PURPOSE: The physical examination and pelvic imaging with MRI are often used in the pre-operative evaluation of pelvic organ prolapse. The objective of this study was to compare grading of prolapse on defecography phase of dynamic magnetic resonance imaging (dMRI) with physical examination (PE) grading using both the Pelvic Organ Prolapse Quantification (POP-Q) staging and Baden-Walker (BW) grading systems in the evaluation of pelvic organ prolapse (POP). METHODS: We retrospectively reviewed the charts of 170 patients who underwent dMRI at our institution. BW grading and POP-Q staging were collected for anterior, apical, and posterior compartments, along with absolute dMRI values and overall grading of dMRI. For the overall grading/staging from dMRI, BW, and POP-Q, Spearman rho (ρ) was used to assess the correlation. The correlations between dMRI grading and POP-Q staging were compared to the correlations between dMRI grading and BW grading using Fisher's Z transformation. RESULTS: A total of 54 patients were included. dMRI grading was not significantly correlated with BW grading for anterior, apical, and posterior compartment prolapse (p > 0.15). However, overall dMRI grading demonstrated a significant (p = 0.025) and positive correlation (ρ = 0.305) with the POP-Q staging system. dMRI grading for anterior compartment prolapse also demonstrated a positive correlation (p = 0.001, ρ = 0.436) with the POP-Q staging derived from measurement locations Aa and Ba. The overall dMRI grade is better correlated with POP-Q stage than with BW grade (p = 0.024). CONCLUSION: Overall and anterior compartment grading from dMRI demonstrated a significant and positive correlation with the overall POP-Q staging and anterior compartment POP-Q staging, respectively. The overall dMRI grade is better correlated with POP-Q staging than with BW grading.

Postoperative and Survival Outcomes After Cytoreductive Surgery in the Treatment of Metastatic Upper Tract Urothelial Carcinoma.

OBJECTIVE: To analyze utilization and outcomes of cytoreductive surgery (CRS) after systemic chemotherapy in select patients with metastatic upper tract urothelial carcinoma (UTUC). MATERIAL AND METHODS: We identified 1,73 patients with cM1 UTUC from the National Cancer Database who were treated with first-line multiagent chemotherapy from 2004 to 2015. Patients considered surgical candidates based on Charlon-Deyo performance score were stratified into nonsurgical versus surgical arms based on receipt of CRS after systemic therapy. Those receiving radiation, immunotherapy, or other types of treatment were excluded. Cox proportional hazard models were used to analyze prognostic factors for overall survival (OS). Propensity-score matching and inverse probability of treatment weighting-adjusted regression models were used to compare OS. RESULTS: A total of 1182 patients were included of which 349 (29.5%) were treated with definitive surgery. Median follow-up was 64 months (95% confidence interval:49.8-79.4) for chemotherapy+surgery versus 61.2 (52.2-78.7) for the chemotherapy-alone arms (P = .09). Patients treated with surgery were younger and more commonly treated at academic facilities. Patients who received CRS had improved median-OS versus those treated with chemotherapy alone (13.7 vs 10.8 months, log-rank P-value <.001). Predictors of OS were performance score, treatment at academic facility, and performance of CRS. Furthermore, in propensity-score and inverse probability of treatment weighting-adjusted Cox regression analyses, CRS was associated with significant OS benefit (hazard ratios = 0.61, 95% confidence interval:0.49-0.77, and 0.63;0.55-0.72; respectively). CONCLUSION: We provide a contemporary report on the survival benefit of CRS after treatment with systemic therapy for M1 UTUC patients. Longitudinal studies are needed to evaluate the role of surgery, when feasible, within multidisciplinary approaches for this relatively, rare disease.

National trends in the management of low-risk prostate cancer: analyzing the impact of Medicaid expansion in the United States.

PURPOSE: To evaluate recent trends in the management of low-risk prostate cancer (PCa) and analyze differences in adoption of surveillance based on state Medicaid-expansion status in the United States (US). METHODS: Using the National Cancer Database, we identified men diagnosed from 2012 to 2016. Men with histologically confirmed low-risk PCa defined as PSA less than 10 ng/ml, Gleason score ≤ 6, and cT1-T2a were included. The Cochran Armitage test was used to evaluate trends in surveillance versus treatment. Comparisons on surveillance adoption based on 2014 Medicaid expansion status and difference-in-difference analysis were performed. RESULTS: The cohort included 84,340 men. During the study period, surveillance as initial management increased from 13.6% in 2012 to 32.1% in 2016 (p < 0.01). When comparing by Medicaid-expansion status, expansion states had higher rates in adoption of surveillance as compared to non-expansion states over the study period (36.6 vs 28.5%). Following expansion, men in expansion states were 1.94% more likely to be treated with surveillance than in earlier years (p < 0.01). Men in non-expansion states were 1.97% more likely to receive surveillance following expansion (p < 0.01) for a relative 0.03% difference in active surveillance adoption among men with low-risk PCa (95% CI - 0.004 to 0.013, p = 0.344). CONCLUSION: Based on the data from 2012 to 2016, there has been a significant increase in active surveillance as initial management for low-risk PCa in the US. Medicaid expansion was not found to be detrimental in adoption of surveillance. Understanding the impact of payer status on health outcomes can aid in the development of future health care policies aiming to mitigate disparities.

Partial Penectomy for Dry Penile Gangrene in a Patient With Penile Calciphylaxis.

Penile calciphylaxis is a difficult urologic condition to manage. First described by Wood et al in 1997, penile calciphylaxis is a rare cause of penile gangrene.1 One study found the overall mortality rate associated with penile calciphylaxis to be 64%, with a mean time to death of 2.5 months.2 Additionally, no statistically significant difference in survival has been seen between patients treated with penectomy and those treated nonoperatively.3 We report a case of penile calciphylaxis in a patient treated with partial penectomy with scrotoplasty who has survived greater than 1 year without any complication or progression of disease.

Robotic Cystoprostatectomy With Intracorporeal Ileal Conduit Diversion in a Patient With Chronic Schistosomiasis.

We present an interesting case of a patient who initially presented with urinary retention and was subsequently found to have bilateral grade 5 vesicoureteral reflux, a thick and noncompliant bladder, and biopsy proven ova of Schistosoma haematobium. This patient was subsequently managed surgically with a robotic radical cystoprostatectomy with intracorporeal ileal conduit diversion. Final pathology revealed chronic schistosomiasis with numerous ova present throughout the bladder. To our knowledge, no similar cases have been previously documented in the literature.

Pelvic Hematoma Following UroLift procedure for BPH.

We present an interesting complication following the UroLift procedure: the development of a pelvic hematoma. This patient presented to the emergency department with pelvic pain, penile ecchymosis, and edema on postoperative day 4 following his UroLift procedure. A computed tomography scan revealed that his symptoms were due to the formation of a large pelvic hematoma. To our knowledge, pelvic hematoma formation following UroLift is a unique complication not previously described in the literature.

Surgery for Posterior Compartment Vaginal Prolapse: Graft Augmented Repair.

Posterior compartment vaginal prolapse can be approached with multiple surgical techniques, including transvaginally, transperineally, and transanally, repaired with either native tissue or with the addition of an augment. Augment material for posterior compartment prolapse includes biologic graft (dermal, porcine submucosal), absorbable mesh (Vicryl polyglactin), or nonabsorbable synthetic mesh (polypropylene). Anatomic success rates for posterior compartment repair with augment has ranged from 54% to 92%. Augmented posterior compartment repair has not been shown to have superior outcome to native tissue repair. The focus of this article is on the transvaginal approach comparing native tissue repair with graft or mesh augmented repair.

Impact of Age on Patient-Reported Outcome Measures in Total Knee Arthroplasty.

Patient expectations and demographics are vital factors in determining patient satisfaction and outcomes from total knee arthroplasty (TKA). This study was a retrospective chart review that analyzed data from TKA patients to determine the impact of age on patient-reported outcomes measures following TKA. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford knee scores were collected as primary outcome measures from 356 consecutive patients who underwent TKA. Oxford knee scores were further divided into pain and function subscores. Patients were age categorized as <50, 50 to 59, 60 to 69, 70 to 79, and >79. Preoperative scores were compared among age categories including age category, gender, body mass index (BMI), and length of stay (LOS) in the model as fixed effects. Scores collected postoperatively (∼10, 30, 90, and 180 days postoperation) were analyzed as repeated measures including age category, day and their interaction, gender, BMI, LOS, and preoperative score in the model. Preoperative OXFORD scores significantly differed among age categories (p < 0.05) and were numerically higher for the older (≥60 years old) compared with younger patients (<60 years old). After adjusting for preoperative scores, postoperative WOMAC and overall, pain, and function OXFORD scores significantly differed among the age groups (p < 0.05), with patients younger than 60 years reporting the worst scores in the postoperative time period. Older patients reported better preoperative overall, pain, and function scores and greater post-TKA outcomes than younger patients. A better understanding of factors that influence patient-reported outcomes can help providers to better manage patient expectations.

Holmium laser ureterocele excision with transurethral incision of the prostate

ABSTRACT Introduction: Ureteroceles present a diagnostic and treatment challenge in adults (1). With an estimated prevalence of 1/500 to 1/4000, it is not uncommon for any urologist to encounter ureteroceles in clinical practice (2). The incidence of prolapsed ureteroceles in adults is unknown (3). Materials and Methods: We present an interesting case of a 53-year-old male with a 20-year history of obstructive voiding symptoms who presented with urinary retention with a Foley catheter in place. Pre-operative evaluation included a transrectal ultrasound of the prostate which revealing prostate volume of 20cc. Urodynamics revealed a high-pressure, low flow voiding pattern with a functional detrusor muscle. Cystourethroscopy was performed revealing an orthotopic ureterocele on the left side that was prolapsed into the prostatic urethra, and the bladder neck was elevated. The patient then underwent holmium laser ureterocele excision with transurethral incision of the prostate (TUIP). Using MOSES technology and laser settings of 30Hz and 1.5J, the ureterocele was completely excised and a TUIP was performed. Results: The patient was discharged home on the day of surgery with a Foley catheter in place. On post-operative day 1 he passed a voiding trial with a post-void residual volume of 25cc. Renal ultrasonography was performed 3 months postoperatively revealing no hydronephrosis. His postoperative International Prostate Symptom Score of 2 was improved compared to his preoperative score of 34. Conclusion: Holmium laser ureterocele excision with a TUIP is an effective treatment modality in the management of a prolapsed orthotopic ureterocele causing bladder outlet obstruction in a male patient.