A retrospective longitudinal evaluation of new overactive bladder patients in an FPMRS urologist practice: Are patients following up and utilizing third-line therapies?

AIMS: Third-line therapies are efficacious in improving overactive bladder (OAB) symptoms; however, OAB patients have poor follow-up and rarely progress to these therapies. Clinical care pathways (CCP) may improve OAB follow-up rates and third-line therapy use. We sought to determine how new OAB patients follow up and utilize third-line therapies with the implementation of an OAB CCP in a fellowship Female Pelvic Medicine and Reconstructive Surgery (FPMRS) trained urologist's academic practice. METHODS: We identified new OAB patients using ICD-9 and 10 codes. They were placed into two groups: pre- and post-CCP use. Basic demographic data were collected. Patients were evaluated in a retrospective longitudinal fashion over 12 months to determine follow-up and third-line therapy utilization. RESULTS: A total of 769 new OAB patients (261 pre-CCP and 508 post-CCP) were identified. The mean number of follow-up visits increased significantly at 6 months (0.94 vs. 1.64 visits, p = .001) and 12 months (1.26 vs. 2.46 visits, p < .003). Follow-up rates increased significantly at 3 months (38.7% vs. 50.2%, p = .002). Mean time to third-line therapy decreased significantly (280 days vs. 160 days, p = .016). Third-line therapy utilization therapy rates increased at 6 months (7.7% vs. 13.4%, p = .018) and at 12 months (11.1% vs. 16.5%, p = .044). CONCLUSIONS: New OAB patients follow-up and progress to third-line therapies faster and more frequently with the use of a CCP in an FPMRS-trained urologist practice. However, many OAB patients still fail to follow up and overall utilization of third-line therapies remains low. Future studies are warranted to identify factors to why overall OAB compliance remains low.

I leaked, then I Reddit: experiences and insight shared on urinary incontinence by Reddit users.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is a highly prevalent condition, but is often not discussed owing to social stigma. Reddit is an internet platform for anonymous information sharing, expression, and discussion. We sought to qualitatively analyze people's behavioral, psychological, and illness experiences with UI expressed on Reddit to improve our understanding of patients' perceptions and ultimately the care we provide. METHODS: We used the Subreddit group "Incontinence" over 5 years and "BeyondtheBump" (postpartum forum) over 1 year as transcripts for qualitative analysis. Two independent researchers read and coded relevant threads (>100 posts and >400 comments). Charmaz's principles of grounded theory were applied. This included line-by-line coding of transcripts utilizing key phrases followed by grouping similarly coded phrases into preliminary themes. Emergent concepts were derived from these themes. RESULTS: A group of Reddit users with diverse UI etiologies were sampled. Qualitative analysis resulted in six preliminary themes. Users with UI were initially self-aware of their incontinence. They were interested in optimal product use. Users struggled with major life adjustments and relating to others. Nonetheless, they learned gradually to cope with their symptoms. Last, postpartum women specifically wanted additional immediate help for managing UI, often in the form of pelvic physiotherapy. Three emergent concepts were formed: the sense of isolation, acceptance over time, and self-drive to manage their UI. CONCLUSIONS: Internet forums such as Reddit may serve as a health resource for people with UI. Physicians can strive to better understand the patient perspective and their needs in order to provide optimal care.

Barriers to Healthcare: Non-English Speaking and Elderly Patients More Likely to Have Retained Ureteral Stents.

OBJECTIVE: To identify factors for retained ureteral stents in our institution of patients receiving de novo ureteral stents. Ureteral stent placement, a commonly performed urologic procedure, is a temporary measure and requires timely removal. Retained ureteral stents may result in significant morbidities and need for additional procedures. MATERIALS AND METHODS: We queried for all de novo ureteral stents indicated for calculi at our institution between July 2019-June 2021. Retained ureteral stents were defined as stents that remained indwelling for a period greater than 90days. Patients with metallic stents, stents on strings, pediatric patients, and planned therapy outside 90days were excluded. Patient demographic information including gender, race, age, insurance status, non-English speaking status as well as clinical data including location of presentation and indication were collected. Characteristics of patients with retained stents were compared to those without. RESULTS: Four hundred fifty-seven de novo stent patients meeting study criteria were identified, of which 61 (13%) patients had retained stents. The median duration of retention was 24days +/- 32days (IQR). Patients with retained stents were older than those with stents removed within 90days (62.1 vs 57.2years, P = .03). Retained stents were more common among non-English-speaking patients (13% vs 5%, P = .012). CONCLUSION: Stent retention was found to be associated with non-English speaking status and older age. Healthcare barriers in language and age may lead to increased morbidity due to stent retention.

Circular STAG2 RNA Modulates Bladder Cancer Progression via miR-145-5p/TAGLN2 and Is Considered as a Biomarker for Recurrence.

The current study aimed to elucidate the regulatory mechanisms of the circRNA hsa_circ_0139697 (circSTAG2(16-25)) in BCa and to consider the opportunity of using circSTAG2(16-25) isolated from BCa patient urine as a marker for disease development prediction. The selection of this circRNA was determined by the special role of its parental gene STAG2 in BCa biology. The circRNA hsa_circ_0139697 was chosen from 25 STAG2 circRNAs due to its differential expression in the urine of BCa patients and healthy volunteers. Higher levels of circSTAG2(16-25) were detected in urine samples obtained from patients with recurrent tumors. A higher expression of circSTAG2(16-25) was also detected in more tumorigenic BCa cell lines. The overexpression of circSTAG2(16-25) in BCa cells induced the elevation of proliferation, motility, and invasion. To study the mechanisms of circSTAG2(16-25) activity, we confirmed that circSTAG2(16-25) can bind miR-145-5p in vitro as was predicted by bioinformatic search. miR-145-5p was shown to suppress some genes that promoted BCa progression. One of these genes, TAGLN2, encodes the protein Transgelin 2, which plays a role in BCa cell motility and invasion. Therefore, the possible mechanism of action of circSTAG2(16-25) could be sponging the tumor suppressor miR-145-5p, which results in activation of TAGLN2. In addition, circSTAG2(16-25) might be considered as a potential biomarker for recurrence prediction.

Analysis of the AUA Guidelines: Strength of Evidence Correlates With Recommendation Levels.

INTRODUCTION: As part of its mission to provide the highest standards of clinical care, the AUA publishes guidelines on numerous urological topics. We sought to evaluate the caliber of evidence used establish the currently available AUA guidelines. METHODS: All available AUA guideline statements in 2021 were reviewed for their level of evidence and recommendation strength. Statistical analysis was performed to identify differences between oncological and nononcologic topics, and statements pertinent to diagnosis, treatment, and follow-up. A multivariate analysis was utilized to identify factors associated with strong recommendations. RESULTS: A total of 939 statements across 29 guidelines were analyzed; 39 (4.2%) were backed by Grade A evidence, 188 (20%) Grade B, 297 (31.6%) Grade C, 185 (19.7%) Clinical Principle, and 230 (24.5%) Expert Opinion. There was a significant association of oncology guidelines (6% vs 3%, P = .021) with more grade A evidence and less Grade C Evidence (24% vs 35%, P = .002). Statements pertaining to diagnosis and evaluation were more likely backed by Clinical Principle (31% vs 14% vs 15%, P < .01), treatment statements backed by B (26% vs 13% vs 11%, P < .01) and C (35% vs 30% vs 17%, P < .01) grade evidence, and follow-up statements backed by Expert Opinion (53% vs 23% vs 24%, P < .01). On multivariate analysis, strong recommendations were more likely supported by high-grade evidence (OR = 12, P < .01). CONCLUSIONS: The majority of evidence for the AUA guidelines is not high grade. Additional high-quality urological studies are needed to improve evidence based urological care.

A Randomized Controlled Trial Comparing Telemedicine Versus In-Person Office Visits for the Follow-Up of Overactive Bladder.

IMPORTANCE: Overactive bladder is a condition that may be ideally suited for the use of telemedicine because initial treatment options are behavioral modification and pharmacotherapy. OBJECTIVE: We sought to evaluate if there was an overall difference in patient follow-up rates between telemedicine and in-person visits. STUDY DESIGN: New patients presenting with overactive bladder from July 2020 to March 2021 were randomized into telemedicine and in-person visits groups. A prospective database was maintained to compare follow-up rates, satisfaction rates, and time commitment. RESULTS: Forty-eight patients were randomized, 23 to the telemedicine group and 25 to the in-person visits group. There was no significant difference in follow-up rates between the telemedicine and in-person follow-up groups at 30 days (39% vs 28%, P = 0.41), 60-days (65% vs 56% P = 0.51) or 90 days (78% vs 60%, P = 0.17). There was no significant difference in satisfaction rates between the 2 groups. There was a significant difference between the average telemedicine visit time and in-person visit time (12.1 ± 6.9 minutes vs 22.8 ± 17.1 minutes; P = 0.02). For in-person visits, the average travel time was 49 minutes (interquartile range, 10-90 minutes) and average miles traveled was 22.1 miles (interquartile range, 10-70 miles). CONCLUSIONS: There was no significant difference in follow-up or satisfaction rates between telemedicine and in-person visits. Telemedicine visits took half the length of time compared with in-person visits. On average, patients in the telemedicine group saved approximately 1 hour per follow-up visit. Telemedicine visits save both the health care provider and patient significant amounts of time without sacrificing patient satisfaction and follow-up rates.

Real-world Compliance With Percutaneous Tibial Nerve Stimulation Maintenance Therapy in an American Population.

OBJECTIVE: To evaluate percutaneous tibial nerve stimulation (PTNS) maintenance therapy dropout rates and identify factors associated with compliance in an American population. METHODS: We retrospectively queried our PTNS database for patients from 2014-2019. Demographic, relevant clinical, and visit data were collected. Maintenance therapy was patient-driven and frequency of sessions was tapered based on symptomology. Upon completion of 12 initial sessions, we assessed dropout from maintenance at 3, 6, 9, and 12 months. Multiple variables were tested for correlation with dropout in patients continuing maintenance therapy for 1 year vs those who dropped out. RESULTS: One hundred and sixty-three PTNS patients were identified, of which 104 completed initial therapy and 81 proceeded with maintenance therapy. At 3, 6, 9, and 12 months, maintenance continuation rates were 77.8% (63/81), 58.0% (47/81), 45.6% (37/81), and 39.5% (32/41), respectively. Primary reasons for dropout were worsening of urinary symptoms/lack of efficacy (n = 21), time commitment (n = 9), loss of insurance (n = 5), medical comorbidities (n = 4), request for alternative OAB treatment (n = 2), and unknown (n = 8). On both univariate and multivariate analysis, perceived symptom improvement (P<.01; HR = 0.02, P< .01) was associated with continuing maintenance therapy. On only univariate analysis, neurological history (P = .02) and multiple sclerosis history (0.02) were associated with continuing therapy. CONCLUSION: Only 39.5% of patients continue to undergo maintenance PTNS therapy after 1 year. Future studies are required to understand and ameliorate factors for low compliance in PTNS maintenance therapy.

"Beyond the Bump" - Insight Into the Postpartum Women's Experience of Pelvic Organ Prolapse as Expressed on Reddit.

OBJECTIVE: To qualitatively analyze the biopsychological experiences of postpartum women regarding pelvic organ prolapse (POP) as expressed on Reddit, a widely used internet platform for anonymous discussion and information sharing. POP is a prevalent condition in postpartum women, yet personal experiences are often not discussed due to social stigma. METHODS: "Beyondthebump," a Subreddit forum for postpartum mothers with >57,000 subscribers, was queried for "prolapse" to collect postings on POP in August 2018. Posts were analyzed qualitatively by 2 independent researchers. The principles of grounded theory were applied and preliminary themes were generated. These themes were used to derive emergent concepts. RESULTS: We analyzed 28 unique posts with 390 responses from 2014 to 2018. Qualitative analysis yielded 3 preliminary themes. (1) Women were unaware POP could occur postpartum and frustrated by the lack of prenatal discussion. (2) Women expressed a need for supportive, comprehensive, and immediate care. (3) Attributed symptoms of POP included pain and discomfort, causing difficulty with daily life. Three emergent concepts were derived. (1) POP is a difficult, debilitating condition with mental and physical effects. (2) Women with POP were self-driven and actively sought help. (3) There was motivation to increase POP awareness. CONCLUSION: Postpartum women's perspectives on POP focused on the difficulty of continuing life routines, self-drive for improvement, and motivation to raise awareness for others. Through learning from women's self-reported experiences, physicians can better meet women's needs and improve care for POP.

Washington State Surgeon Perspectives on Quality Measures in the Surgical Care of Stress Urinary Incontinence in Women.

INTRODUCTION: No consensus exists on outcomes that define high quality care in female stress urinary incontinence management. A working group of surgeons from diverse health care settings in Washington State who treat stress urinary incontinence was convened through a state level quality collaborative. Preliminary questions were developed and focus groups conducted to obtain surgeon input and perspectives on stress urinary incontinence surgery quality measures to guide future research. METHODS: Washington State surgeons who perform sling surgery were recruited via email. Focus groups were convened via teleconference using preliminary questions as discussion points. Participants were surgeons from a variety of locations and practice types. Focus groups were led by a trained moderator, recorded and transcribed verbatim, and qualitatively analyzed using inductive content analysis. RESULTS: Eight urologists and 6 gynecologists from 5 academic, 4 private practice and 5 hospital based settings participated in 3 focus groups. The 4 emergent concepts derived, were a perceived need to individualize rather than standardize the management approach to recurrent and persistent stress urinary incontinence, a need to establish and validate shared decision making tools for synthetic mesh procedures, a need to define risk factors and treatment strategies for unique populations, including those with mixed urinary incontinence, younger patients and those with concomitant prolapse, and an enthusiasm to identify practical and clinically meaningful quality measures. CONCLUSIONS: Focus groups with clinical experts on quality of stress urinary incontinence care identified several priority topics for future study. Further work is needed to refine research prioritization on this important area of women's health.

Access to Academic Female Pelvic Medicine and Reconstructive Surgery Providers for New Patient Visits: How Long Are Wait Times?

OBJECTIVES: To determine the wait times to see an academic Female Pelvic Medicine and Reconstructive Surgery (FPMRS) urologist or gynecologist and to identify factors that may impact these wait times. METHODS: We reviewed all Accreditation Council for Graduate Medical Education accredited urology and gynecology residency programs. Offices of FPMRS providers were called to ascertain the earliest available new patient visit for a fictional female patient with "urine leakage." Programs without FPMRS faculty (18.7%) were excluded. FPMRS providers that did not accept Medicaid (15.6%) were also excluded. Negative binomial regression was performed using SPSS v24. RESULTS: Final analysis included 362 FPMRS providers. Median wait time for a patient with Medicaid was 30 days (interquartile range [IQR] 15-51) and 26 days (IQR 14-42) for Medicare. The median wait time to see an FPMRS-trained gynecologist was 28 days (IQR 15-50) while FPMRS-trained urologists had a median wait time of 25 days (IQR 13.8-43.3). Female providers had longer median wait times when compared to male providers (30 vs 25 days). On regression analysis, only female gender of the provider was significant (P < .01). CONCLUSION: Our study found that nearly 1 in 5 academic departments did not have an FPMRS-trained provider. We found that new patients with urinary incontinence encountered substantial wait times to see FPMRS providers at academic institutions. As we project increased demand for the FPMRS workforce, our findings reflect a challenging landscape where training additional FPMRS providers may be needed to meet demand.

Do Patient Education Materials on Female Pelvic Floor Disorders Meet Readability Standards? Putting Them to the Test.

INTRODUCTION: Patient education materials are widely used vehicles to provide patients with health education. While the Joint Commission recommends patient education materials not exceed the 5th grade level and the National Institutes of Health the 7th grade level, studies show that patient education materials are routinely written above the 8th grade level. We assessed the readability of patient education materials available from national and international organizations on the topics of pelvic organ prolapse, overactive bladder and stress urinary incontinence. METHODS: We identified available online, downloadable English language patient education materials on pelvic organ prolapse, overactive bladder and stress urinary incontinence from the American Urological Association, American Urogynecologic Society, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, International Continence Society, International Urogynecological Association, American College of Obstetricians and Gynecologists and National Association for Continence. We used 4 validated readability indices to evaluate patient education material texts and descriptive statistics to compare calculated readability grades. RESULTS: We evaluated 7 patient education materials on pelvic organ prolapse, 8 on overactive bladder and 7 on stress urinary incontinence. Mean readability scores for pelvic organ prolapse, overactive bladder and stress urinary incontinence patient education materials were grade level 12.3 (range 9.1 to 16.7, SD 1.9), grade level 9.4 (range 5.1 to 17.9, SD 3.0) and grade level 11.5 (range 7.5 to 16.9, SD 2.5), respectively. CONCLUSIONS: Most patient education materials for pelvic organ prolapse, overactive bladder and stress urinary incontinence evaluated were written at a minimum of high school level and above the National Institutes of Health and Joint Commission recommended target readability. Developing and using patient education materials with the appropriate readability for the general patient population may enhance comprehension of the material and improve patient care for pelvic organ prolapse, overactive bladder and stress urinary incontinence.

Beyond Data Capture: A Single Institutional Experience with Establishing a Pelvic Floor Surgery Web Based Database.

INTRODUCTION: The American Urological Association has highlighted the need for complete and long-term data collection in female pelvic medicine and reconstructive surgery. We describe our institution's experience with transitioning our pelvic floor surgery database to a secure web based platform. In this article we share this experience and its challenges to help facilitate the process for other institutions. METHODS: In 1999 our institution implemented electronic data capture of pelvic floor cases using a stand-alone spreadsheet. By 2001 it was apparent that this modality could no longer sustain growth while maintaining data integrity. We converted to a relational database system but limitations involving multiuser data entry and efficient querying became apparent. After consultation with outcomes research experts across the country we evaluated database alternatives for capacity, ease of use and security. REDCap® (Research Electronic Data Capture), a low cost, server based database software, provided all 3. RESULTS: In 2011 the transition of our electronic outcomes database to REDCap commenced. The transition required approximately 100 person-hours for data dictionary creation and 200 person-hours for the transfer of existing data into REDCap. A database administrator was hired to maintain data integrity, automate the process of generating questionnaires for long-term followup and facilitate data queries. CONCLUSIONS: We describe the transition of our institution's outcomes database to REDCap providing the means for secure and streamlined data capture and quality assurance. This platform also facilitates effective multi-institutional collaboration with the goals of developing quality data to advance research and improve care for our patients.

Outcomes after Robotic-assisted Pyeloplasty in Patients Presenting with Pain Versus Nonpain Presenting Symptoms.

OBJECTIVE: To assess the impact of presenting symptom or incidental finding on symptomatic and radiographic outcomes after robotic-assisted pyeloplasty (RAP). METHODS: We retrospectively reviewed the records of 143 patients at our institution who received pyeloplasty from 2001-2017. Patients without both pre- and postoperative radiographic data were excluded. Patients were grouped by primary presenting symptom into either pain at presentation (pain) or nonpain primary presenting symptom, including incidental findings (nonpain). Primary outcomes were persistence of postoperative symptoms and improvement in diuretic renogram half-times. RESULTS: The study inclusion criteria was met by 105 patients. Pain was the most common presenting symptom (70.0%), followed by incidental finding (10.5%), infection (7.6%), hematuria (4.8%), hypertension (2.8%), elevated creatinine (2.8%), and nausea (1.0%). Patients with nonpain presentations were significantly more likely to have postoperative symptoms (P = .04), and less likely to improve on diuretic renogram (P = .03). Incidental presentation was found to be associated with greater likelihood of persistent postoperative symptoms compared with other presentations (36.3% vs 8.5%, P = .02). CONCLUSION: Ureteropelvic junction obstruction (UPJO) patients presenting with pain, experience better symptom and radiographic improvement following RAP compared with patients presenting without pain. Incidental UPJO was the most common nonpain presentation and is associated with less symptomatic and radiographic benefit after RAP. These findings will help reconstructive urologists counsel patients with UPJO regarding outcomes of RAP.