Prevalence of Cognitive and Manual Dexterity Disorders Among Men Following Artificial Urinary Sphincter Placement.

PURPOSE: Cognitive ability and manual dexterity sufficient to operate an artificial urinary sphincter (AUS) are critical for device function and safety. We aimed to define the incidence of cognitive and/or dexterity disorders among men after AUS. We secondarily aimed to assess for association between these disorders and postimplant complications. MATERIALS AND METHODS: This is a retrospective cohort study using the SEER (Surveillance, Epidemiology, and End Results)-Medicare linked database (2000-2018). We included men ≥ 66 years diagnosed with prostate cancer between 2001 to 2015 who subsequently underwent AUS placement. We excluded patients with < 1-year continuous fee-for-service Medicare enrollment or cognitive and/or manual dexterity disorder diagnoses prior to AUS implant. Subsequent cognitive/dexterity disorders and implant-related complications were queried using appropriate ICD (International Classification of Diseases)-9/10 and/or CPT (Current Procedural Terminology) codes. Associations between cognitive/dexterity disorders and postimplant complications were assessed using extended Cox proportional hazards modeling. Secondary analysis focused on serious complications (device revision/removal, Fournier's gangrene, urethral erosion). RESULTS: We identified 1560 men who underwent AUS who met inclusion criteria. Median age was 73.0 (IQR 70-77) years. Cumulative incidence function analysis estimated 44% and 17% incidence of cognitive and manual dexterity disorder, respectively, at 15 years post-AUS. Presence of cognitive with/without manual dexterity disorder was associated with increased hazard of any, but not serious, complication during follow-up. CONCLUSIONS: A significant proportion of patients develop cognitive and/or manual dexterity disorders following AUS. These data support the need for close longitudinal monitoring after implant.

Sacral neuromodulation device biofilm differs in the absence and presence of infection, harbors antibiotic resistance genes, and is reproducible in vitro.

INTRODUCTION/PURPOSE: Sacral neuromodulation (SNM) is effective therapy for overactive bladder refractory to oral therapies, and non-obstructive urinary retention. A subset of SNM devices is associated with infection requiring surgical removal. We sought to compare microbial compositions of explanted devices in the presence and absence of infection, by testing phase, and other clinical factors, and to investigate antibiotic resistance genes present in the biofilms. We analyzed resistance genes to antibiotics used in commercially-available anti-infective device coating/pouch formulations. We further sought to assess biofilm reconstitution by material type and microbial strain in vitro using a continuous-flow stir tank bioreactor, which mimics human tissue with an indwelling device. We hypothesized that SNM device biofilms would differ in composition by infection status, and genes encoding resistance to rifampin and minocycline would be frequently detected. MATERIALS/METHODS: Patients scheduled to undergo removal or revision of SNM devices were consented per IRB-approved protocol (IRB 20-415). Devices were swabbed intraoperatively upon exposure, with controls and precautions to reduce contamination of the surrounding field. Samples and controls were analyzed with next-generation sequencing and RT-PCR, metabolomics, and culture-based approaches. Associations between microbial diversity or microbial abundance, and clinical variables were then analyzed using t-tests and ANOVA. Reconstituted biofilm deposition in vitro using the bioreactor was compared by microbial strain and material type using plate-based assays and scanning electron microscopy. RESULTS: Thirty seven devices were analyzed, all of which harbored detectable microbiota. Proteobacteria, Firmicutes and Actinobacteriota were the most common phyla present overall. Beta-diversity differed in the presence versus absence of infection (p = 0.014). Total abundance, based on normalized microbial counts, differed by testing phase (p < 0.001), indication for placement (p = 0.02), diabetes mellitus (p < 0.001), cardiac disease (p = 0.008) and history of UTI (p = 0.008). Significant microbe-metabolite interaction networks were identified overall and in the absence of infection. 24% of biofilms harbored the tetA tetracycline/minocycline resistance gene and 53% harbored the rpoB rifampin resistance gene. Biofilm was reconstituted across tested strains and material types. Ceramic and titanium did not differ in biofilm deposition for any tested strain. CONCLUSIONS: All analyzed SNM devices harbored microbiota. Device biofilm composition differed in the presence and absence of infection and by testing phase. Antibiotic resistance genes including to rifampin and tetracycline/minocycline, which are used in commercially-available anti-infective pouches, were frequently detected. Isolated organisms from SNM devices demonstrated the ability to reconstitute biofilm formation in vitro. Biofilm deposition was similar between ceramic and titanium, materials used in commercially-available SNM device casings. The findings and techniques used in this study together provide the basis for the investigation of the next generation of device materials and coatings, which may employ novel alternatives to traditional antibiotics. Such alternatives might include bacterial competition, quorum-sensing modulation, or antiseptic application, which could reduce infection risk without significantly selecting for antibiotic resistance.

Pilot Study of a Novel Online Comprehensive Pelvic Floor Program for Urinary Incontinence in Women.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is common in women and has a vast impact on quality of life (QOL), financial health, and work disability. Robust evidence demonstrates the efficacy of comprehensive conservative therapy (pelvic floor muscle training [PFMT], and behavioral and dietary modification) in the treatment of UI. However, numerous barriers impede access to this care, including limited specialized therapists, financial barriers, and scheduling obstacles. To address these barriers, we developed a novel comprehensive online pelvic floor program (oPFP). METHODS: We performed a prospective study assessing continence and QOL outcomes in women with stress urinary incontinence (SUI), urge urinary incontinence (UUI), or mixed urinary incontinence (MUI) treated with oPFP between May 2019 and November 2022. Outcomes were assessed at baseline and following completion of the 2-month program using the validated International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms, Urgency Perception Scale (UPS), Incontinence Impact Questionnaire (IIQ-7) questionnaires, and 24-h bladder diary. Data were analyzed using linear, Poisson mixed models, or generalized estimating equations. RESULTS: Twenty-eight women (2 SUI, 3 UUI, 23 MUI) were enrolled and 19 (2 SUI, 2 UUI, 15 MUI) completed the study. Following oPFP, participants showed significantly improved SUI domain scores (3.04 ± 0.19 vs 1.81 ± 0.23, p < 0.001), UPS reason score (2.52 ± 0.18 vs 2.05 ± 0.14, p = 0.003), IIQ-7 sum scores (5.16 ± 0.88 vs 3.07 ± 0.70, p = 0.038), and daily incontinence episodes (2.96 ± 0.60 vs 1.06 ± 0.29, p < 0.001). Mean patient-reported improvement was 5.4 ± 2.5 (ten-point Likert scale). Of respondents, 89% reported program satisfaction, ease of use, and would recommend the program to others. CONCLUSION: The oPFP results in significant improvements to a variety of UI and QOL measures. This program provides an important UI treatment option and gives women greater access to effective conservative therapy.

Longitudinal urgency outcomes following robotic-assisted laparoscopic prostatectomy.

PURPOSE: Stress urinary incontinence (SUI) is a well-known adverse outcome following robotic-assisted laparoscopic prostatectomy (RALP). Although postoperative SUI has been extensively studied, little focus has been placed on understanding the natural history and impact of urgency symptoms following RALP. The UVA prostatectomy functional outcomes program (PFOP) was developed to comprehensively assess and optimize continence outcomes following RALP. The present study focuses on assessing urgency outcomes in this cohort. METHODS: PFOP patients with a minimum of 6-months follow up following RALP were included. The PFOP includes prospectively assessed incontinence and quality of life outcomes utilizing ICIQ-MLUTS, Urgency Perception Score (UPS), and IIQ-7 questionnaires. The primary study outcome was urgency urinary incontinence (UUI) as determined by ICIQ-MLUTS UUI domain. Secondary outcomes included urgency (UPS score) and quality of life (IIQ-7). RESULTS: Forty patients were included with median age 63.5 years. Fourteen (35%) patients reported UUI at baseline. UUI and QOL scores worsened compared to baseline at all time-points. Urgency worsened at 3-weeks and 3-months but returned to baseline by 6-months. Notably, 63% of patients without baseline UUI reported de-novo UUI at 6 months. Although QOL was lower in patients with versus without UUI (IIQ-7 score 3.0 vs 0.0, p = 0.009), severity of UUI was not associated with QOL when controlling for SUI severity. CONCLUSION: Our data demonstrate significantly worsened UUI from baseline and a large incidence of de-novo UUI following RALP. Further study is needed to inform how urgency and UUI and its treatment affect health-related quality of life following RALP.

Cognitive impairment does not impact sacral neuromodulation implant rates for overactive bladder.

OBJECTIVE: To evaluate the impact of cognitive impairment (CI) diagnoses on sacral neuromodulation (SNM) outcomes in older patients. MATERIALS AND METHODS: We completed a retrospective review of all patients aged ≥55 years who underwent test-phase SNM (peripheral nerve evaluation (PNE) or stage 1) for overactive bladder (OAB) between 2014 and 2021 within a large multi-regional health system. Patient demographics, relevant comorbidities, CI diagnoses (dementia or mild CI), and SNM procedures were recorded. Logistic regression modeling was performed to evaluate the impact of CI on SNM implantation rates. RESULTS: Five-hundred and ten patients underwent SNM test phase (161 PNE, 349 Stage 1) during the study period. The mean age was 71.0(8.5) years, and most (80.6%) were female. Overall, 52(10.1%) patients had a CI diagnosis at the time of SNM, and 30 (5.8%) were diagnosed at a median of 18.5 [9.25, 39.5] months after SNM. Patients with CI diagnoses were older, with more comorbidities, and were more likely to undergo PNE. Univariable comparison found no difference in implantation rate based on pre-SNM CI (85.4% vs. 76.9%, p = 0.16). Multivariable analysis identified PNE (OR 0.43, 95% CI 0.26-0.71), age (OR 0.96, 95%CI 0.93-0.98), and prior beta-3 agonist use (OR 0.60, 95% CI 0.37-0.99) but not CI or dementia as independent negative predictors of implantation. Implanted patients had a median follow-up of 25 [12.0, 55.0] months. Explant and revision rates did not differ according to CI. CONCLUSION: Patients with OAB and CI diagnoses proceed to SNM implant at rates similar to patients without CI diagnoses. A diagnosis of CI should not necessarily exclude patients from SNM therapy for refractory OAB.

Patient perceived improvement and medication resumption rates after intradetrusor onabotulinumtoxina for idiopathic urgency urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Intradetrusor onabotulinumtoxinA (BTX-A) is a third-line therapy for overactive bladder (OAB), however several gaps exist in periprocedural care. Prior studies have demonstrated BTX-A efficacy at 2-3 weeks, but there are limited data documenting when patients should begin to note symptom improvement. The primary aim of this study was to evaluate patient-reported temporal improvement in symptoms, with secondary aim to evaluate medication resumption rates, following initial BTX-A injection. METHODS: A prospective, single-arm cohort study of patients with non-neurogenic urgency incontinence undergoing initial BTX-A injection was performed. Intradetrusor 100 units BTX-A was administered in standard 20-site template. Patients discontinued OAB medication(s) at BTX-A injection and completed a daily Patient Global Impression of Improvement (PGI-I) diary for 3 weeks. Data were collected at 1 month, including final satisfaction score, medication resumption rates, and adverse outcomes. RESULTS: Fifty-one patients were included, with 25 patients (49%) actively taking an OAB medication. Median time to first improvement was 3 days, at least "much better" (PGI-I <2) was 5 days, and maximal improvement was 7 days. Twenty of 25 patients (80%) opted to remain off OAB medications at 1 month based on symptomatic improvement following injection. Adverse outcomes included urinary tract infection in three patients (6%) and symptomatic incomplete emptying requiring temporary intermittent catheterization in two patients (4%). CONCLUSIONS: Median time to first and maximal improvement was 3 and 7 days, respectively, following initial 100 units BTX-A. Eighty percent of patients on medications opted to remain off at 1 month. These data may help further counsel patient expectations following initial BTX-A therapy.

Third-line therapy for overactive bladder in the elderly: Nuances and considerations.

INTRODUCTION: Overactive bladder (OAB) disproportionally affects older adults in both incidence and severity. OAB pharmacotherapy is often problematic in the elderly due to polypharmacy, adverse side effect profiles and contraindications in the setting of multiple comorbidities, and concerns regarding the risk of incident dementia with anticholinergic use. The burden of OAB in older patients coupled with concerns surrounding pharmacotherapy options should motivate optimization of nonpharmacologic therapies in this population. At the same time, several aspects of aging may impact treatment efficacy and decision-making. This narrative review critically summarizes current evidence regarding third-line OAB therapy use in the elderly and discusses nuances and treatment considerations specific to the population. METHODS: We performed an extensive, nonsystematic evidence assessment of available literature via PubMed on onabotulinumtoxinA (BTX-A), sacral neuromodulation, and percutaneous tibial nerve stimulation (PTNS) for OAB, with a focus on study in elderly and frail populations. RESULTS: While limited, available studies show all three third-line therapies are efficacious in older populations and there is no data to support one option over another. BTX-A likely has a higher risk of urinary tract infection and retention in older compared to younger populations, especially in the frail elderly. PTNS incurs the lowest risk, although adherence is poor, largely due to logistical burdens. CONCLUSION: Advanced age and frailty should not preclude third-line therapy for refractory OAB, as available data support their efficacy and safety in these populations. Ultimately, treatment choices should be individualized and involve shared decision-making.

Is sacral neuromodulation effective in patients with Parkinson's disease? A retrospective review.

INTRODUCTION AND OBJECTIVE: Parkinson's disease (PD) is the second-most common degenerative neurologic disease worldwide. Overactive bladder (OAB) is prevalent in this population but can be challenging to treat. Sacral neuromodulation (SNM) is an attractive option but remains understudied. We have utilized SNM in PD patients and herein describe our outcomes. METHODS: We performed a retrospective chart review of PD patients who underwent peripheral nerve evaluation (PNE) or Stage 1 SNM from 2000 to 2020. The primary outcome was progression to a permanent implant. The impact of PD stage and preprocedural urodynamic (UDS) parameters on test-phase outcome were investigated. Long-term efficacy was assessed using Wilcoxon matched-pairs test looking at a change in urinary symptoms (frequency, nocturia, incontinence episodes, and pad use) documented at follow-up visits and further need for treatment. RESULTS: Thirty-four patients underwent test phase SNM (7 PNE and 27 Stage 1). Median follow-up was 11 (interquartile range 5.8-29.8) months. Indications included refractory OAB (30/34) and nonobstructive urinary retention (4/34). Overall, 82% (28/34) of patients proceeded to a permanent implant. 71% (5/7) of PNEs were successful. Test-phase success did not differ based on PD disease severity or UDS parameters. In patients with OAB/urgency incontinence who progressed to the permanent implant, there was a statistically significant improvement in their urinary symptoms from baseline. Most (68%) patients were able to discontinue OAB medications post-implant. The overall lead revision rate was 14% (4/28) and 3 devices required removal. CONCLUSIONS: SNM is an efficacious treatment option for PD patients with a high percentage of patients having improvement in their urinary symptoms.

Predictors of prolonged admission after outpatient female pelvic reconstructive surgery.

OBJECTIVES: This study aimed to determine factors associated with prolonged hospital admission following outpatient female pelvic reconstructive surgery (FPRS) and associated adverse clinical outcomes. METHODS: Using the National Surgical Quality Improvement Program database, we identified outpatient FPRS performed 2011-2016. Isolated hysterectomy without concurrent prolapse repair was excluded. Surgeries were classified as major or minor for analysis. The primary outcome was prolonged length of stay (LOS), defined as admission of ≥2 days. Secondary outcomes included complications, readmission and reoperation associated with prolonged LOS. We abstracted data on covariates, and following univariable analysis, performed backward stepwise regression analysis. RESULTS: A total of 29645 women were included: 12311 (41.5%) major and 17334 (58.5%) minor procedures. A total of 6.9% (2033) had a prolonged LOS. On full cohort multivariable regression analysis, patient characteristics associated with prolonged LOS were older age (odds ratio [OR]: 1.1 per 10 years, confidence interval [CI]: 1.06-1.1, p < 0.001), frailty (OR: 1.8, 95% CI: 1.3-2.6, p = 0.001), and Caucasian race (OR: 1.2, CI: 1.02-1.3, p = 0.024). Associated surgical factors included having a major surgical procedure (OR: 1.3, CI: 1.2-1.4, p < 0.001), use of general anesthesia (OR: 2.0, CI: 1.5-2.6, p < 0.001) and longer operative time (OR: 2.0, CI: 1.8-2.2, p < 0.001). The occurrence of any complication (10.3% vs. 4.7%, p < 0.001), hospital readmission (4.3% vs. 1.7%, p < 0.001), and reoperation (2.7% vs. 1.0%, p < 0.001) were more likely with prolonged LOS. CONCLUSIONS: After outpatient FPRS, 6.9% of patients experience an admission of ≥2 days. Prolonged LOS is more common in patients who are older, frail and Caucasian, and in those who have major surgery with long operative time and general anesthesia.

SUFU white paper on overactive bladder anticholinergic medications and dementia risk.

AIMS: Anticholinergic medications are widely used in the treatment of overactive bladder (OAB), as well as for short-term treatment of bladder symptoms following a variety of urologic surgeries. Mounting evidence points to an association between anticholinergic medications and the increased risk of incident dementia. The Society for Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) thus convened a committee of subject experts to contextualize the current understanding of the cognitive risks of anticholinergic medications in the urologic patient population and to provide practical clinical guidance on this subject. METHODS: Statements are based on an expert literature review and the committee's opinion. The document has been reviewed and approved by the SUFU board. RESULTS: Chronic use (>3 months) of OAB anticholinergic medications is likely associated with an increased risk of new-onset dementia. Short-term (<4 weeks) use of most OAB anticholinergic medications is likely safe in most individuals. Clinicians should consider potential cognitive risks in all patient populations when prescribing OAB anticholinergics for chronic use. Consideration should be given to progressing to advanced therapy (botulinum toxin or neuromodulation) earlier in the OAB treatment paradigm CONCLUSIONS: The current body of literature supports a likely small but significant increased risk of dementia with chronic exposure to OAB anticholinergic medications. Potential harms should be balanced against potential quality of life improvement with treatment.

Successfully treated urethral condyloma acuminatum utilizing intraurethral self-application of 5-fluorouracil via Q-tip.

Condyloma acuminatum is a benign genital lesion associated with low-risk human papillomavirus subtypes. Approximately 20% of HPV-associated genital warts occur in the urethra. Topical treatment of urethral condyloma in women can be challenging to treat due to difficulty applying the medication such that it maintains contact with the urethra long enough to be effective. We present a case of a successfully cleared urethral condyloma acuminatum treated via self-application using a Q-tip.

Same-day discharge across FPMRS surgical cases is safe and feasible: A 10-year single-surgeon experience.

INTRODUCTION: Enhanced recovery after surgery protocols and increased attention to value-based care have led to the reconsideration of routine postoperative admission in female pelvic medicine and reconstructive surgery (FPMRS) cases. We aimed to assess trends in same-day discharge (SDD) and associated readmissions and emergency room visits in a single-surgeon 10-year experience. METHODS: The electronic medical record was queried for 30-day outcomes (readmission and emergency department visits with associated indications) for all cases performed between June 2010 and August 2020 by a single FPMRS surgeon. Non-FPMRS specialty cases were excluded. Patient characteristics and 30-day outcomes were compared based on SDD status for the overall cohort as well as the subset of cases traditionally involving an overnight stay (i.e., robotic transabdominal, apical prolapse repair). RESULTS: 1793 surgeries were identified and analyzed, including 357 apical prolapse repairs, 370 slings, 392 neuromodulation and 114 complex mesh excisions. The majority (79.1%) had SDD. For admitted patients, mean length of stay was 1.5 (1.3) days. Among cases traditionally involving overnight stay, rates of SDD were significantly higher in 2020 than 2010 (84% vs. 32%, p < 0.001), and increased over time. Overall rates of 30-day readmission and ED visits were low (1.9% and 2.6%, respectively) and did not differ based on SDD status (p = 0.76). Readmissions occurred at mean 11.6 (7.0) days, most commonly for urinary tract infection (13/34). CONCLUSIONS: SDD is not associated with increased 30-day readmission or ED visits across a wide breadth of FPMRS cases. SDD is safe and feasible in the majority of FPMRS cases.

Prevalence and characterization of dyspareunia in a general urology clinic population.

INTRODUCTION: To assess the character and prevalence of dyspareunia in a general urology population presenting for evaluation of unrelated non-painful complaints. MATERIALS AND METHODS: This is an IRB-approved, prospective, cross-sectional survey-based assessment of dyspareunia in a general cohort of female patients presenting to a urology clinic over a 10-month period (7/2018-5/2019). Patients presenting specifically for acute painful complaints were excluded. Participating patients completed an original 23-item survey with questions pertaining to dyspareunia. Specific focus was placed on pain characteristics, including location, quality, frequency, severity, and quality of life. Descriptive analysis, pain mapping, and plotting analyses were performed to assess pain patterns. RESULTS: A total of 181 women completed the survey, with a mean age of 56 years. Overall, 53 (29%) women reported dyspareunia. However, among currently sexually active women the prevalence of dyspareunia was 46% (38/83). Patients reported a significant variety of pain locations and qualities. Women most commonly reported multiple pain locations (median 2 (IQR 1,4)), with 33 distinct combinations identified. The majority (70%) of women endorsed only one pain quality, although eight unique combinations were nonetheless seen. A significant proportion (34%) reported high or very high pain severity, with 45% having pain most or all times of sexual activity. A majority (53%) of patients indicated moderate to severe dissatisfaction with their sexual activity. Despite this finding, a significant proportion (33%) of patients with dyspareunia reported having at least weekly sexual activity. CONCLUSIONS: A significant percentage of women presenting to a general urology clinic experience dyspareunia. Notably, patient-reported pain characteristics, including location and quality, varied significantly across women assessed. Further study is needed to understand how these characteristics may relate to different and specific etiologies of sexual pain and directed treatment options.

Has the use of preoperative urodynamics for stress urinary incontinence surgery changed following the VALUE study?

AIMS: To assess whether routine urodynamic testing (UDT) in women undergoing slings for uncomplicated stress urinary incontinence (SUI) has decreased following publication of the landmark VALUE study, which recommended against routine UDT in uncomplicated SUI. METHODS: We identified women in the Virginia All Payers Claims Database diagnosed with SUI between 2011 and 2016 using International Classification of Disease (ICD) codes (N39.3, 625.6). Appropriate ICD/CPT (current procedural terminology) codes were used to exclude non-index patients (prior anti-incontinence/prolapse surgery, urge incontinence, neurogenic bladder). Beta regression was used to assess for changes in the monthly proportion of urethral slings with preoperative UDT. Interventional ARIMA modeling was used to assess for a relationship between the date of VALUE (The Value of Urodynamic Evaluation) publication and the incidence of slings with preoperative UDT. RESULTS: Analysis identified 6740 women with SUI undergoing sling placement, with 343 non-index patients excluded. Of 6397 remaining women, 4026 (62.9%) underwent preoperative UDT. The annual number of slings with preoperative UDT declined from 748 to 402 between 2011 and 2016. Beta regression analysis demonstrated a decrease in the proportion of slings with preoperative UDT over the study (68%, 2011; 58%, 2016), with a statistically significant decrease in the proportion of slings with UDT after May 2012 (ß coefficient, -.0093; P < .001). Interventional ARIMA models showed a trend toward decreasing slings with preoperative UDT after the VALUE trial (P = .057). CONCLUSIONS: Our analysis demonstrated a decrease in the proportion of women undergoing preoperative UDT in uncomplicated SUI patients following the VALUE study. Further research is needed to examine factors underlying UDT utilization trends and promote value-driven care.

Opioid prescription use in patients with interstitial cystitis.

INTRODUCTION AND HYPOTHESIS: The opioid epidemic is a recent focus of national initiatives to reduce opioid misuse and related addiction. As interstitial cystitis (IC) is a chronic pain state at risk for narcotic use, we sought to assess opioid prescription use in patients with IC. METHODS: Data were accessed from the Virginia All Payers Claims Database. We identified female patients diagnosed with IC from 2011 to 2016 using International Classification of Disease codes. A patient identifier was used to link diagnoses with outpatient prescription claims for opioids using generic product identifiers. We then analyzed opioid prescriptions within 30 days of a claim with a diagnosis of IC. RESULTS: A total of 6,884 patients with an IC diagnosis were identified. The median number of IC claims per patient was 2 (IQR 1 to 4). Mean patient age was 47.8. Twenty-eight percent of patients received at least 1 opioid prescription, with a median of 2 (IQR 1, 4) per patient. Among those receiving opioids, 185 (9.5%) had more than 10 opioid prescriptions, with a maximum of 129. The most common prescriptions were hydrocodone (n = 2,641, 32.3%), oxycodone (n = 2,545, 31.2%), and tramadol (n = 1,195, 14.6%). There was a decline in opioid prescriptions per month for IC, although the rate per IC diagnosis remained stable. CONCLUSIONS: A significant number of patients with IC are treated with opioids. Although the overall number of opioid prescriptions associated with IC had declined, the prescription rate per IC diagnosis had not. As part of the national initiative to reduce opioid use, our data suggest that IC treatment strategies should be examined.

Assessment of complications following urinary diversion for benign indications.

INTRODUCTION: To evaluate complications following urinary diversion for non-malignant conditions. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing urinary diversion for benign indications between 2000 and 2017. Data collected including patient demographic and clinical characteristics, surgical characteristics, and complications. Complications were graded using Clavien-Dindo classification and were categorized as early versus delayed (≤ versus > 90 day postoperatively). Logistic regression assessed for predictors of developing any postoperative complication. RESULTS: A total of 68 patients were identified for study analysis with median follow up of 24 (7-72) months. Sixty-eight and 25% of patients underwent diversion for neurogenic bladder and complications related to pelvic radiation, respectively. A majority (90%) underwent ileal conduit with the remainder undergoing continent diversion. A total of 121 complications were identified, comprising 50 early and 72 delayed. Overall, 77% of patients had at least one complication during the follow up period. Fifty-one percent of patients experienced early complication, while 66% of patients experienced delayed complications. Complications of Clavien-Dindo Score ≥ IIIB were seen in 48% of patients. The most common early complication was wound infection (12%); delayed was urinary tract infection (39%). Multivariable logistic regression modeling found no independent predictors of complication, although the best-fit model included BMI, diabetes, presence of multiple comorbidities, and operative time (hr) as positive predictors of complication. CONCLUSION: Our study demonstrates that urinary diversion for benign etiologies is associated with a significant rate of complication. A large percentage of these complications occur in the delayed period and are classified as severe complications.

Online Ratings of Urologists: Comprehensive Analysis.

BACKGROUND: Physician-rating websites are being increasingly used by patients to help guide physician choice. As such, an understanding of these websites and factors that influence ratings is valuable to physicians. OBJECTIVE: We sought to perform a comprehensive analysis of online urology ratings information, with a specific focus on the relationship between number of ratings or comments and overall physician rating. METHODS: We analyzed urologist ratings on the Healthgrades website. The data retrieval focused on physician and staff ratings information. Our analysis included descriptive statistics of physician and staff ratings and correlation analysis between physician or staff performance and overall physician rating. Finally, we performed a best-fit analysis to assess for an association between number of physician ratings and overall rating. RESULTS: From a total of 9921 urology profiles analyzed, there were 99,959 ratings and 23,492 comments. Most ratings were either 5 ("excellent") (67.53%, 67,505/99,959) or 1 ("poor") (24.22%, 24,218/99,959). All physician and staff performance ratings demonstrated a positive and statistically significant correlation with overall physician rating (P<.001 for all analyses). Best-fit analysis demonstrated a negative relationship between number of ratings or comments and overall rating until physicians achieved 21 ratings or 6 comments. Thereafter, a positive relationship was seen. CONCLUSIONS: In our study, a dichotomous rating distribution was seen with more than 90% of ratings being either excellent or poor. A negative relationship between number of ratings or comments and overall rating was initially seen, after which a positive relationship was demonstrated. Combined, these data suggest that physicians can benefit from understanding online ratings and that proactive steps to encourage patient rating submissions may help optimize overall rating.

Improvements in semen parameters in men treated with clomiphene citrate-A retrospective analysis.

Clomiphene citrate (CC) is commonly used off-label for the treatment of male infertility, yet there is limited data to guide patient selection. To identify a subset of patients more likely to benefit from CC, we aimed to define predictors of improvement in semen parameters among men receiving CC. We retrospectively analysed 151 men treated with at least 25 mg CC daily for male infertility and/or hypogonadism at two institutions between 2004 and 2014. Men previously on testosterone were excluded. The primary outcome was change in semen parameters. Variables included baseline patient characteristics, pre-treatment hormone profiles and pre-treatment semen analyses. A total of 77 men met inclusion criteria. Median length of therapy was 2.8 months. There was significant improvement in sperm concentration (14-21 million/ml; p = 0.002) and total motile count (TMC; 13-28 million; p = 0.04). One third of patients who began with fewer than 5 million motile spermatozoon improved to a TMC > 5 million, increasing reproductive options to include intrauterine insemination. Patient characteristics, pre-treatment hormone profile and degree of oligozoospermia did not predict treatment response. While no predictors of improvement were identified, clinically useful response rates are described for use in shared decision-making.

Ileal perforation in the setting of atezolizumab immunotherapy for advanced bladder cancer.

Atezolizumab is a promising immunotherapy for advanced urothelial carcinoma. Like other immune checkpoint inhibitors, it can produce rare immune-related adverse events (IRAEs). Here we present the recent case of a patient with metastatic bladder cancer who developed diarrhea and abdominal pain months after beginning atezolizumab therapy. He presented to our institution with an ileal perforation secondary to atezolizumab-induced enterocolitis. After surgical repair, the patient's condition improved, and he was discharged. We discuss the management of atezolizumab-induced enterocolitis, including the importance of early recognition and intervention to prevent more devastating complications.

Management of Penile Calciphylaxis: A Case Study.

BACKGROUND: Calciphylaxis, also called calcific uremic arteriolopathy, is a highly morbid syndrome characterized by calcium deposition and occlusion of small arterial vessels of the dermis and subdermal adipose tissue, leading to necrosis and gangrene. Penile involvement is rare and its management presents considerable challenges. CASE: We review the case of a 47-year-old man with end-stage renal disease managed with hemodialysis, diabetes mellitus, and urinary incontinence who presented with a painful necrotic lesion on his glans penis, and the second and third toes of his right foot. Following diagnosis of calciphylaxis of the toes and penis, he was conservatively managed with topical wound care, sodium thiosulfate adjustment of hemodialysis, and phosphate binder medications. Over the course of 2 months, his wound worsened in the setting of continued urinary incontinence, and before planned diversion with a suprapubic catheter, he progressed to gangrene and sepsis. After a goals-of-care discussion with the patient and family, he elected to forego debridement and was discharged on home-based palliative care. CONCLUSIONS: Penile calciphylaxis is a rare, life-threatening disease that portends a poor prognosis. Conservative principles for management include normalization of calcium phosphate levels and local wound care. Penectomy may not impact survival. Ultimately, each case is individualized, and we encourage establishing goals of care in collaborative discussion with an interdisciplinary care team, patient, and family.