Racial Differences in the Detection Rate of Bladder Cancer Using Blue Light Cystoscopy: Insights from a Multicenter Registry.

The use of blue light cystoscopy (BLC) has been shown to improve bladder tumor detection. However, data demonstrating the efficacy of BLC across different races are limited. Herein, we aim to evaluate heterogeneity in the characteristics of BLC for the detection of malignant lesions among various races. Clinicopathologic information was collected from patients enrolled in the multi-institutional Cysview® registry (2014-2021) who underwent transurethral resection or biopsy of bladder tumors. Outcome variables included sensitivity and negative and positive predictive values of BLC and white light cystoscopy (WLC) for the detection of malignant lesions among various races. Overall, 2379 separate lesions/tumors were identified from 1292 patients, of whom 1095 (85%) were Caucasian, 96 (7%) were African American, 51 (4%) were Asian, and 50 (4%) were Hispanic. The sensitivity of BLC was higher than that of WLC in the total cohort, as well as in the Caucasian and Asian subgroups. The addition of BLC to WLC increased the detection rate by 10% for any malignant lesion in the total cohort, with the greatest increase in Asian patients (18%). Additionally, the positive predictive value of BLC was highest in Asian patients (94%), while Hispanic patients had the highest negative predictive value (86%). Our study showed that regardless of race, BLC increases the detection of bladder cancer when combined with WLC.

"I think my vagina is still there?": Women's perspectives on sexual function and dysfunction following radical cystectomy for bladder cancer, a qualitative study.

BACKGROUND: Women's sexual health after radical cystectomy is an important but poorly understood aspect of bladder cancer survivorship. Dedicated investigation is needed to elucidate patient perceptions on sexual function and dysfunction in this setting. AIMS: In this study we sought to qualitatively examine women's perceptions and experiences of sexual health following radical cystectomy for bladder cancer. METHODS: We conducted one-on-one qualitative telephone interviews with 40 women who underwent radical cystectomy in the past 6 months to 5 years and signed a research consent form to be contacted for future studies. We examined women's experiences of engaging in sexual activity after surgery and their attitudes toward sex and body image. We audio recorded, transcribed, and coded the interviews using ATLAS.ti software and applied grounded theory methods for analysis. OUTCOMES: For data that emerged during the qualitative interviews that was related to lack of knowledge about how physical and psychological sexual health would be affected after surgery, we reviewed and discussed transcripts that enabled coding of the data into emerging topic areas. RESULTS: Our analysis yielded 4 main themes. (1) Women reported receiving little to no information from providers about female sexual dysfunction prior to or after radical cystectomy. Women wished they had been provided more information about female sexual dysfunction from their clinicians, including strategies for postoperative self-pleasure and nonintercourse methods of sexual pleasure with partners. (2) Women shared that they were not sexually active following surgery due to physical and mental barriers. (3) When women did try to engage in sex, they described feeling disappointed that it did not feel the same as prior to surgery. (4) Some women found that physical therapy helped them to physically and mentally recover their strength to engage in sexual activity again. CLINICAL IMPLICATIONS: Clinicians must directly address sexual health concerns with patients who undergo radical cystectomy. STRENGTHS AND LIMITATIONS: This study has several key strengths. Investigation into women's sexual function and dysfunction addresses a gap in understanding of this component of women's health-related quality of life after radical cystectomy, which represents an unmet need. The large number of interviews conducted as well as the in-depth information obtained through one-on-one interviews are additional strengths. This study also has limitations, including possible shortcomings of telephone interviews compared with in-person interviews. However, telephone interviews were beneficial because the interviews took place during the COVID-19 pandemic and spared patients from extra visits or from having to travel long distances to the respective medical centers. Other possible limitations were that patients may have been reluctant to share all of their experiences and that patients who underwent urostomies, also termed ileal conduits, were overrepresented in this study compared with women who underwent continent urine diversions, which allow greater control over urine output. CONCLUSION: Broadening the understanding of sexual health beyond sexual intercourse to encompass sexuality and self-pleasure can provide clinicians, patients, and their families with more effective preparation and strategies to care for an essential aspect of their wellbeing.

Development of a Classification System for Live Surgical Feedback.

Importance: Live feedback in the operating room is essential in surgical training. Despite the role this feedback plays in developing surgical skills, an accepted methodology to characterize the salient features of feedback has not been defined. Objective: To quantify the intraoperative feedback provided to trainees during live surgical cases and propose a standardized deconstruction for feedback. Design, Setting, and Participants: In this qualitative study using a mixed methods analysis, surgeons at a single academic tertiary care hospital were audio and video recorded in the operating room from April to October 2022. Urological residents, fellows, and faculty attending surgeons involved in robotic teaching cases during which trainees had active control of the robotic console for at least some portion of a surgery were eligible to voluntarily participate. Feedback was time stamped and transcribed verbatim. An iterative coding process was performed using recordings and transcript data until recurring themes emerged. Exposure: Feedback in audiovisual recorded surgery. Main Outcomes and Measures: The primary outcomes were the reliability and generalizability of a feedback classification system in characterizing surgical feedback. Secondary outcomes included assessing the utility of our system. Results: In 29 surgical procedures that were recorded and analyzed, 4 attending surgeons, 6 minimally invasive surgery fellows, and 5 residents (postgraduate years, 3-5) were involved. For the reliability of the system, 3 trained raters achieved moderate to substantial interrater reliability in coding cases using 5 types of triggers, 6 types of feedback, and 9 types of responses (prevalence-adjusted and bias-adjusted κ range: a 0.56 [95% CI, 0.45-0.68] minimum for triggers to a 0.99 [95% CI, 0.97-1.00] maximum for feedback and responses). For the generalizability of the system, 6 types of surgical procedures and 3711 instances of feedback were analyzed and coded with types of triggers, feedback, and responses. Significant differences in triggers, feedback, and responses reflected surgeon experience level and surgical task being performed. For example, as a response, attending surgeons took over for safety concerns more often for fellows than residents (prevalence rate ratio [RR], 3.97 [95% CI, 3.12-4.82]; P = .002), and suturing involved more errors that triggered feedback than dissection (RR, 1.65 [95% CI, 1.03-3.33]; P = .007). For the utility of the system, different combinations of trainer feedback had associations with rates of different trainee responses. For example, technical feedback with a visual component was associated with an increased rate of trainee behavioral change or verbal acknowledgment responses (RR, 1.11 [95% CI, 1.03-1.20]; P = .02). Conclusions and Relevance: These findings suggest that identifying different types of triggers, feedback, and responses may be a feasible and reliable method for classifying surgical feedback across several robotic procedures. Outcomes suggest that a system that can be generalized across surgical specialties and for trainees of different experience levels may help galvanize novel surgical education strategies.

A Urine-based DNA Methylation Marker Test to Detect Upper Tract Urothelial Carcinoma: A Prospective Cohort Study.

PURPOSE: We explored the accuracy of a urine-based epigenetic test for detecting upper tract urothelial carcinoma. MATERIALS AND METHODS: Under an Institutional Review Board-approved protocol, urine samples were prospectively collected from primary upper tract urothelial carcinoma patients before radical nephroureterectomy, ureterectomy, or ureteroscopy between December 2019 and March 2022. Samples were analyzed with Bladder CARE, a urine-based test that measures the methylation levels of 3 cancer biomarkers (TRNA-Cys, SIM2, and NKX1-1) and 2 internal control loci using methylation-sensitive restriction enzymes coupled with quantitative polymerase chain reaction. Results were reported as the Bladder CARE Index score and quantitatively categorized as positive (>5), high risk (2.5-5), or negative (<2.5). The findings were compared with those of 1:1 sex/age-matched cancer-free healthy individuals. RESULTS: Fifty patients (40 radical nephroureterectomy, 7 ureterectomy, and 3 ureteroscopy) with a median (IQR) age of 72 (64-79) years were included. Bladder CARE Index results were positive in 47, high risk in 1, and negative in 2 patients. A significant correlation was found between Bladder CARE Index values and tumor size. Urine cytology was available for 35 patients, of whom 22 (63%) results were false-negative. Upper tract urothelial carcinoma patients had significantly higher Bladder CARE Index values compared to the controls (mean 189.3 vs 1.6, P < .001). The sensitivity, specificity, positive predictive value, and negative predictive value of the Bladder CARE test for detecting upper tract urothelial carcinoma were 96%, 88%, 89%, and 96%, respectively.Conclusions:Bladder CARE is an accurate urine-based epigenetic test for the diagnosis of upper tract urothelial carcinoma, with much higher sensitivity than standard urine cytology.

Is a restaging TURBT necessary in high-risk NMIBC if the initial TURBT was performed with blue light?

OBJECTIVES: To evaluate whether a restaging transurethral resection of bladder tumor (TURBT) is necessary in high-risk nonmuscle invasive bladder cancer (NMIBC) if the initial TURBT was performed using blue light (BL) technology. METHODS AND MATERIALS: Using the multi-institutional Cysview registry between 2014 and 2021, all consecutive adult patients with known NMIBC (Ta and T1 disease) who underwent TURBT followed by a restaging TURBT within 8 weeks were reviewed. Patients were stratified according to their initial TURBT, BL vs. white light (WL), and compared to determine rates of residual disease and upstaging. Univariate analysis was performed using Mann-Whitney U and chi-square tests, with P < 0.05 considered significant. RESULTS: Overall, 115 patients had TURBT for NMIBC followed by a restaging TURBT within 8 weeks and were included in the analysis. Patients who underwent BL compared to WL for their initial TURBT had higher rates of benign pathology on restaging TURBT, although this was not statistically significant (47% vs. 30%; P = 0.08). Of patients with residual tumors on restaging TURBT, there were no differences in rates of Ta (22% vs. 26.5%; P = 0.62), T1 (22% vs. 26.5%; P = 0.62), or CIS (5.5% vs. 13%; P = 0.49) when the initial TURBT was done using BL compared to WL. Rates of upstaging to muscle invasive disease were also not different when initial TURBT was performed using BL compared to WL (3% vs. 4%; P = 0.78). CONCLUSIONS: TURBT using BL does not reduce rates of residual disease or risk of upstaging on restaging TURBT in Ta or T1 disease. Thus, a restaging TURBT is still necessary even if initial TURBT was performed using BL.

Radical cystectomy and urinary diversion outcomes in patients with single vs. double renal unit: A 2:1 matched-pair analysis.

OBJECTIVE: To evaluate perioperative and functional outcomes of radical cystectomy (RC) and urinary diversion (UD) in patients with a single kidney (SK) vs. double kidneys (DK). METHODS: We reviewed records of patients who underwent RC for bladder cancer with a history of prior or concurrent nephrectomy at USC between 2004 and 2020. Patients with chronic kidney disease who were already on dialysis were excluded. UD, perioperative complications, and postoperative glomerular filtration rate (GFR) of the SK group were compared with a group of patients who underwent RC with DK using 2:1 matching with respect to age, sex, preop GFR, and tumor stage. RESULTS: We included 186 patients (SK = 62 and DK = 124). Half of the SK patients underwent continent UD. SK patients had a higher length of hospital stay compared to the DK group; however, 90-day complications, readmission, and mortality rates were similar. In patients with continent diversion, SK vs. DK showed similar 90-day complications (71% vs. 69%, P = 1.0). SK patients had significantly lower GFRs at discharge, 3-, and 12-month following RC compared to the DK group. Postoperative GFRs of the SK patients with continent vs. incontinent UD were statistically similar. On multivariable analysis, UD (i.e. continent vs. incontinent) was not associated with post-op GFR decline at discharge, 3- and 12-month following RC. CONCLUSIONS: Perioperative outcomes of radical cystectomy patients with single kidney are similar to double kidney patients, except for more GFR decline in single kidney cases. Continent urinary diversion in single kidney is as safe as double kidney patients.

Recurrence patterns in bladder cancer patients with no residual disease (pT0N0) at radical cystectomy: A 20-year experience.

OBJECTIVE: To examine the oncological outcomes and recurrence patterns in patients with no residual disease at the time of radical cystectomy (RC). METHODS: A retrospective review of our IRB-approved bladder cancer database identified patients who underwent RC between 2000 and 2019 and were found to have no residual disease (pT0N0), either following neoadjuvant chemotherapy (NAC) or transurethral resection (TURBT) alone. The primary outcome was recurrence-free survival (RFS). Regression models assessed factors influencing recurrence, and a detailed description of recurrence patterns was compiled. RESULTS: From a total of 2222 patients, 234 (10.5%) were included with a median age of 67 years. NAC was used in 89 (38%) patients and 145 (62%) cases were rendered pT0 following TURBT alone. At a median follow-up of 44 months, there were 16 (6.8%) recurrences, 10 (63%) of which occurred in the ypT0 group. None of the patients with clinical Ta/Tis disease had a recurrence after RC. The median time to recurrence was 9 months. Ninety-one percent (10/11) of recurrences in the ypT0 group were within 2 years of cystectomy, while half of the recurrences in the pT0 group occurred after 2 years. Patients with ypT0 had worse 2- and 5-year RFS compared to the pT0 group (85% and 84% vs. 99% and 95%, respectively; P = 0.003). Variant histology was noted in 49 (21%) patients; the recurrence rate was higher in this subgroup compared to those with pure urothelial carcinoma (12.2% vs. 5.4%, P = 0.02). Lung metastasis and involvement of distant organs, while rare, were noted at similar rates in both groups. CONCLUSION: Patients with pT0N0 pathology at the time of cystectomy should prudently undergo long-term surveillance as recurrence and metastasis can still develop up to 4 years after surgery. Patients achieving ypT0 after NAC exhibit worse prognosis and shorter times to recurrence, closer follow-up may be considered.

The Association of Physical Activity and Urinary Incontinence in US Women: Results from a Multi-Year National Survey.

OBJECTIVES: To evaluate the relationships between physical activity, both work and recreational, and urinary incontinence among women. METHODS: We assessed women aged 20 years and older in 2008-2018 NHANES (National Health and Nutrition Examination Survey) cycles who answered self-reported urinary incontinence and physical activity questions. Weighted, multivariate logistic regression model was used to determine the association between incontinence and physical activity levels after adjusting for age, body mass index, diabetes, race, parity, menopause and smoking. RESULTS: A total of 30,213 women were included in analysis, of whom 23.15% had stress incontinence, 23.16% had urge incontinence, and 8.42% had mixed incontinence (answered "yes" to both stress and urge incontinence). Women who engaged in moderate recreational activity were less likely to report stress and urge incontinence (OR 0.79, 95% CI 0.62-0.99 and OR 0.66, 95% CI 0.48-0.90, respectively). Similarly, women who engaged in moderate activity work were less likely to report stress, urge and mixed incontinence (OR 0.84, 95% CI 0.70-0.99; OR 0.84, 95% CI 0.72-0.99; and OR 0.66 95% CI 0.45-0.97, respectively). CONCLUSIONS: Moderate physical activity and greater time spent participating in moderate physical activity are associated with a decreased likelihood of stress, urge and mixed incontinence in women. This relationship holds for both recreational and work-related activity. We hypothesize that the mechanism of this relationship is multifactorial, with moderate physical activity improving pelvic floor strength and modifying neurophysiological mediators (such as stress) involved in the pathogenesis of incontinence.

Role of blue-light cystoscopy in detecting invasive bladder tumours: data from a multi-institutional registry.

OBJECTIVES: To evaluate the role of blue-light cystoscopy (BLC) in detecting invasive tumours that were not visible on white-light cystoscopy (WLC). PATIENTS AND METHODS: Using the multi-institutional Cysview registry database, patients who had at least one white-light negative (WL-)/blue-light positive (BL+) lesion with invasive pathology (≥T1) as highest stage tumour were identified. All WL-/BL+ lesions and all invasive tumours in the database were used as denominators. Relevant baseline and outcome data were collected. RESULTS: Of the 3514 lesions (1257 unique patients), 818 (23.2%) lesions were WL-/BL+, of those, 55 (7%) lesions were invasive (48 T1, seven T2; 47 unique patients) including 28/55 (51%) de novo invasive lesions (26 unique patients). In all, 21/47 (45%) patients had WL-/BL+ concommitant carcinoma in situ and/or another T1 lesions. Of 22 patients with a WL-/BL+ lesion who underwent radical cystectomy (RC), high-risk pathological features leading to RC was only visible on BLC in 18 (82%) patients. At time of RC, 11/22 (50%) patients had pathological upstaging including four (18%) with node-positive disease. CONCLUSIONS: A considerable proportion of invasive lesions are only detectable by BLC and the rate of pathological upstaging is significant. Our present findings suggest an additional benefit of BLC in the detection of invasive bladder tumours that has implications for treatment approach.

Safety and feasibility of urological procedures in Jehovah's Witness patients.

OBJECTIVES: To describe the safety and feasibility of urological transfusion-free surgeries in Jehovah's Witness patients. METHODS: An institutional review board-approved, retrospective review of Jehovah's Witness patients who underwent urological transfusion-free surgeries between 2003 and 2019 was carried out. Surgeries were stratified into low, intermediate and high risk based on complexity, invasiveness and bleeding potential. Patient demographics, perioperative data and clinical outcomes are reported. RESULTS: A total of 161 Jehovah's Witness patients (median age 63.4 years) underwent 171 transfusion-free surgeries, including 57 (33.3%) in low-, 82 (47.9%) in intermediate- and 32 (18.8%) in high-risk categories. The mean estimated blood loss increased with risk category at 48 mL (range 10-50 mL), 150 mL (range 50-200 mL) and 388 mL (range 137-500 mL), respectively (P < 0.001). Implementing blood augmentation and conservation techniques increased with each risk category (3.5% vs 29% vs 69%, respectively; P < 0.001). Average length of stay increased concordantly at 1.6 days (range 0-12 days), 2.9 days (range 1-13 days) and 5.6 days (range 2-12 days), respectively (P ≤ 0.001). However, there was no increase in complication rates and readmission rates attributed to bleeding among the risk categories at 30 days (P = 0.9 and 0.4, respectively) and 90 days (P = 0.7 and 0.7, respectively). CONCLUSIONS: Transfusion free urological surgery can be safely carried out on Jehovah's Witness patients using contemporary perioperative optimization. Additionally, these techniques can be expanded for use in the general patient population to avoid short- and long-term consequences of perioperative blood transfusion.

Predictors of need for catheterisation and urinary retention after radical cystectomy and orthotopic neobladder in male patients.

OBJECTIVES: To investigate the prevalence of catheterisation and urinary retention in male patients with bladder cancer after radical cystectomy (RC) and orthotopic neobladder (ONB) and to identify potential predictors. PATIENTS AND METHODS: Using an Institutional Review Board approved, prospectively maintained bladder cancer database, we collected information using a diversion-related questionnaire from 299 consecutive male patients with bladder cancer upon postoperative clinic visit. Urinary retention was defined as ≥3 catheterisations/day or a self-reported inability to void without a catheter. Uni- and multivariable Cox regression analysis was performed to identify predictors of catheterisation and urinary retention. RESULTS: Self-catheterisation was reported in 51 patients (17%), of whom, 22 (7.4% of the total patients) were in retention. Freedom from any catheterisation at 3, 5, and 10 years after RC was 85%, 77%, and 62%, respectively. Freedom from retention at 3, 5, and 10 years after RC was 93%, 88%, and 79%, respectively. Multivariable Cox regression showed that higher body mass index (BMI; ≥27 kg/m2 ) significantly increased the need for catheterisation (hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.26-4.32) as well as retention (HR 5.20, 95% CI 1.74-15.51). Greater medical comorbidity (Charlson Comorbidity Index score ≥2) correlated with the need for any catheterisation (HR 1.84, 95% CI 1.02-3.3), but not retention. Pathological stage and type of diversion were not significant predictors of the need to catheterise or urinary retention. CONCLUSION: In males undergoing RC with ONB, retention requiring catheterisation to void is uncommon. Patients with a BMI of ≥27 kg/m2 are at significantly increased risk of retention and need for self-catheterisation.

Resolution of Hydronephrosis in Children with Dysfunctional Voiding After Biofeedback Therapy: A Randomized Clinical Trial.

We assessed efficacy of biofeedback therapy and home pelvic floor muscle exercises in children with dysfunctional voiding (DV) associated with mild to moderate hydronephrosis. This prospective study comprised fifty seven children (21 boys, 36 girls; mean age 8.9 ± 2.6) with DV and mild to moderate hydronephrosis. Children were randomly allocated into two treatment groups including control group who underwent standard urotherapy and case group who received biofeedback therapy in addition to standard urotherapy. A 99mTc diethylenetriamine pentaacetic acid (99mDTPA) scan, voiding cystoureterography, kidney and bladder ultrasounds, voiding diary and uroflowmetry with electromyography (EMG) were performed in all study participants at the baseline. Children with evidence of complete obstruction in DTPA scan and vesicoureteral reflux were excluded from enrollment. A complete voiding diary, kidney and bladder ultrasounds and uroflowmetry/EMG were also performed 6 months and 1 year after completion of the treatment. We noted a more significant decline in anteroposterior pelvic diameter in case group compared to control group (P < 0.05). The mean maximal urine flow rate prior to treatment was 16.5 ± 2.6 and 16.1 ± 3 ml/s in case and control groups, respectively. This finding increased significantly 1 year after the treatment in case group compared to controls (25 ± 7.2 ml/s vs. 18.4 ± 5.9 ml/s, respectively; P < 0.001). Improvement of various parameters in voiding diary was also more significant in the case group. Biofeedback therapy can effectively resolve non-refluxing and non-obstructive hydronephrosis in children with DV.

Botulinum Toxin Type A Therapy: Intravesical Injection or Electromotive Drug Administration.

OBJECTIVES: To compare the outcomes of intravesical injection of botulinum toxin A (BoNTA) with intravesical electromotive drug administration (EMDA) of BoNTA on urinary incontinence secondary to neuropathic detrusor overactivity (NDO) in children with myelomeningocele (MMC). MATERIALS AND METHODS: A total of 26 children with MMC (11 boys, 15 girls) who had urinary incontinence secondary to NDO were retrospectively enrolled in the study. Patients in EMDA group (n = 14), using an electrode-catheter, 10 IU/kg of BoNTA were inserted into the bladder for EMDA without anesthesia and on an outpatient basis. The EMDA equipment was connected to the electrode of indwelling catheter and 2 dispersive electrodes, a pulsed current generator delivered 10-20 mA for 20 minutes. Patients in injection group (n = 12) were received interavesical injection of 10 IU/kg of BoNTA via rigid cystoscope on an inpatient basis. All patients had been evaluated by a voiding diary, urodynamic study, renal, and bladder ultrasounds before, 6 months and 1 year after the treatment. RESULTS: Six months after the treatment, 12 of 14 (85.7 %) and 8 of 12 (66.6%) patients in EMDA and injection groups respectively became completely dry between 2 consecutive clean intermittent catheterizations, which maintained in 11 of 14 (78.5%) of patients in EMDA group compared to 6 of 12 (50%) of patients in injection group, 1 year after the treatment. CONCLUSION: Patients in both groups improved after the treatment; however improvement in EMDA group was more prominent with better sustained effects. BoNTA/EMDA is a feasible, reproducible, cost benefit, and pain free method as an outpatient basis and no need for anesthesia.

Urinary carbohydrate antigen 19-9 level as a biomarker in children with acute pyelonephritis.

Early and prompt diagnosis of pyelonephritis is of great importance in children. The aim of this study is to evaluate the diagnostic accuracy of urinary carbohydrate antigen 19-9 (CA19-9) levels for predicting acute pyelonephritis (APN) in children with urinary tract infection (UTI). Patients were allocated into two groups of APN and acute cystitis according to their diagnosis. Urine samples of all patients were collected. Also, complete history was taken, and physical examination, kidney and bladder ultrasonography, 99mTc-dimercaptosuccinic acid renal cortical scintigraphy, and urine analysis and culture were performed. Urinary CA19-9 was measured by an electrochemiluminescence enzyme immunometric kit. In addition, CA19-9 levels were measured in the APN group 2 weeks and 3 months later. A total of 100 children were included in this study (mean age 46 ± 31 months, 16 males and 84 females). CA19-9 levels were significantly greater in the APN group than acute cystitis group (510 ± 328 vs. 18.7 ± 18.6 U/ml, P < 0.001). During follow-up periods of the APN group, CA19-9 levels decreased to 180 ± 124 U/ml after 2 weeks (P < 0.001) and 30 ± 23 U/ml after 3 months (P < 0.001). Urinary CA-19-9 had 95.3% sensitivity and 80% specificity for the diagnosis of APN. The area under the curve value of CA19-9 was 0.904 (95% CI 0.831-0.977).Conclusion: Urinary CA19-9 level can be used as a reliable biomarker for early detection of APN prior to urine culture confirmation in children with UTI. What is known: • Early and prompt diagnosis of pyelonephritis is necessary in children to prevent renal damage. • Acute pyelonephritis can present with vague and nonspecific symptoms in infants and children. What is new: • Urinary carbohydrate antigen 19-9 is a reliable biomarker for early detection of acute pyelonephritis prior to urine culture confirmation. • Urinary carbohydrate antigen 19-9 has 95.3% sensitivity and 80% specificity for diagnosis of acute pyelonephritis.

Increased risk of atopic diseases in boys with meatal stenosis: a possible pathophysiological relation.

PURPOSE: To evaluate the role of atopy (i.e. atopic dermatitis, allergic rhinitis, asthma, and food allergies) and its consequences on developing meatal stenosis in boys. METHODS: After obtaining ethics approval from institutional review board, a retrospective chart review was conducted to gather records of patients with meatal stenosis (Group A) presented to our pediatric urology center between August 2012 and May 2016. History of any allergic reactions including allergic rhinitis, asthma, skin, food and drug allergies was considered as positive history of atopy. A control group of children referring to our center due to other etiologies were considered as control group (Group B). Data were analyzed using student t-test and Chi-square test. RESULTS: During the study period, a total of 206 boys (mean age 41.01 months) were assigned to group A and 221 (mean age 35.56 months) to group B. 126 (61.16%) boys had history of allergic reactions in group A compared to 29 (13.12%) in the control arm (group B). Patients with meatal stenosis have a significantly higher (P-value <0.001) likelihood of suffering from allergic reactions. CONCLUSIONS: The pathophysiology of meatal stenosis remains not fully understood yet. This study reveals a significant relation between hypersensitivity reactions and meatal stenosis in boys. Persistent inflammation in meatal area could potentially lead to scarring and stenosis. However, more investigation is required to elucidate this pathophysiology. TYPE OF STUDY: Case-control study. LEVEL OF EVIDENCE: Level III.

Barriers to Women Entering Surgical Careers: A Global Study into Medical Student Perceptions.

BACKGROUND: Barriers to female surgeons entering the field are well documented in Australia, the USA and the UK, but how generalizable these problems are to other regions remains unknown. METHODS: A cross-sectional survey was developed by the International Federation of Medical Students' Associations (IFMSA)'s Global Surgery Working Group assessing medical students' desire to pursue a surgical career at different stages of their medical degree. The questionnaire also included questions on students' perceptions of their education, resources and professional life. The survey was distributed via IFMSA mailing lists, conferences and social media. Univariate analysis was performed, and statistically significant exposures were added to a multivariate model. This model was then tested in male and female medical students, before a further subset analysis by country World Bank income strata. RESULTS: 639 medical students from 75 countries completed the survey. Mentorship [OR 3.42 (CI 2.29-5.12) p = 0.00], the acute element of the surgical specialties [OR 2.22 (CI 1.49-3.29) p = 0.00], academic competitiveness [OR 1.61 (CI 1.07-2.42) p = 0.02] and being from a high or upper-middle-income country (HIC and UMIC) [OR 1.56 (CI 1.021-2.369) p = 0.04] all increased likelihood to be considering a surgical career, whereas perceived access to postgraduate training [OR 0.63 (CI 0.417-0.943) p = 0.03], increased year of study [OR 0.68 (CI 0.57-0.81) p = 0.00] and perceived heavy workload [OR 0.47 (CI 0.31-0.73) p = 0.00] all decreased likelihood to consider a surgical career. Perceived quality of surgical teaching and quality of surgical services in country overall did not affect students' decision to pursue surgery. On subset analysis, perceived poor access to postgraduate training made women 60% less likely to consider a surgical career [OR 0.381 (CI 0.217-0.671) p = 0.00], whilst not showing an effect in the men [OR 1.13 (CI 0.61-2.12) p = 0.70. Concerns about high cost of training halve the likelihood of students from low and low-middle-income countries (LICs and LMICs) considering a surgical career [OR 0.45 (CI 0.25-0.82) p = 0.00] whilst not demonstrating a significant relationship in HIC or UMIC countries. Women from LICs and LMICs were 40% less likely to consider surgical careers than men, when controlling for other factors [OR 0.59 CI (0.342-1.01 p = 0.053]. CONCLUSION: Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering surgical careers. Postgraduate training in particular appears to be most significant for women and cost of training an additional factor in both women and men from LMICs and LICs. Mentorship remains an important and modifiable factor in influencing student's decision to pursue surgery. Quality of surgical education showed no effect on student decision-making.

Impact of transcutaneous interferential electrical stimulation for management of primary bladder neck dysfunction in children.

INTRODUCTION: Several studies have revealed that electrical stimulation is an effective modality for treatment of lower urinary tract (LUT) dysfunction via raising the capacity or compliance of the bladder or maybe by pelvic floor relaxation and reducing detrusor pressure as well. OBJECTIVE: This study aimed to assess the efficacy of transcutaneous interferential (IF) electrical stimulation on LUT symptoms as well as urine flow parameters in children with primary bladder neck dysfunction (PBND). STUDY DESIGN: We reviewed the charts of all children with persistent LUT symptoms who underwent IF electrical stimulation between 2010 and 2017. Twenty-three neurologically and anatomically normal children (mean age: 7.7 years, range: 5-13) with LUT symptoms were included in this study. Children had different LUT symptoms such as hesitancy, straining, urinary incontinence and constipation with no sufficient response to medical treatment (α -blocker) for at least 6 months. IF electrical stimulation was performed for 15 sessions, two times per week. All children were symptomatic and had abnormal urine flow pattern with an electromyographic (EMG) lag time of more than 6 s on uroflowmetry with EMG. A voiding chart, uroflowmetry with EMG and kidney and bladder ultrasounds were performed before and after the treatment for all children. Maximum and average urine flow rates, EMG lag time and postvoid residual volume were analyzed. In addition, alpha blocker therapy was continued during IF therapy. RESULTS: Mean maximum and average urine flow rates improved from 14.1 to 7.6-19.7 ml/s and 9.5 ml/s, respectively, while mean EMG lag time decreased from 11.7 to 5.2 s after the treatment (all P < 0.05). Also postvoid residual volume decreased significantly from 35.6 to 7.6 ml at the end of treatment courses. DISCUSSION: Pelvic floor EMG lag time, a documented parameter on uroflowmetry with EMG, defined as the time from the start of pelvic floor relaxation during a volitional voiding effort (the first stage of normal voiding) to the start of urine flow. Results showed that IF therapy decreased pelvic floor EMG lag time in children with PBND. In addition, increase in mean maximum and average urine flow rates in our patients indicated that pelvic IF therapy and behavioral modification improved voiding dysfunction in most of the patients and probably decreased bladder neck activity during voiding. Future studies with larger sample size are needed to support this finding. CONCLUSION: IF therapy appears safe, effective and reproducible in improvement of PBND in children.

Intravesical Electromotive Botulinum Toxin Type A (Dysport) Administration in Children With Myelomeningocele.

OBJECTIVE: Electromotive drug administration (EMDA) presents a minimally invasive method of intravesical instillation of therapeutic agents without the need for general anesthesia.1 It employs a combination of iontophoresis, electrophoresis, and electroporation to deliver drugs into deep tissue layers using an electrical current created between 2 electrodes.2 This video shows feasibility of botulinum toxin type A (BoNTA) EMDA in myelomeningocele children with urinary incontinence secondary to neuropathic detrusor overactivity. METHODS: In this technique (Video 1), catheterization was performed with a 10-Fr (CE-DAS, UROGENICS/Ag 9900 (pediatric), Mirandola, Italy) catheter electrode, after providing a local transurethral anesthesia with 2% lidocaine gel. The cuff of the catheter was filled by 2 cc saline solution. The bladder was then drained and irrigated with 0.9% saline solution until the catheter outflow became clear. The bladder was subsequently filled with sterile water to its maximal capacity. BoNTA (Dysport) at a dose of 10 IU/kg was added to the intravesical solution. Negative electrode as 2 dispersive electrodes was placed on the abdomen. Positive electrode was connected to the intravesical catheter. A pulsed current generator (Physionizer 30, Physion srl, Mirandola, Italy), delivered a current with frequency of 2,800 Hz, interval of 50 µs and amplitude of 10-20 mA for 20 minutes. At the end of the procedure, the bladder was emptied. RESULTS: For the first time, BoNTA/EMDA was performed on myelomeningocele patients with urinary incontinence in our center.3 According to our prior reports, urinary incontinence improved in 75% of the patients between 2 consecutive clean intermittent catheterizations at 1-year follow-up.4 Mean maximal cystometric capacity significantly increased from 148 ± 62 mL at baseline to 239 ± 73 mL 1 year after the treatment.4 CONCLUSION: This technique is a feasible, safe, reproducible, cost effective, long lasting, and pain free method, on an outpatient basis with long-term duration of effects and without anesthesia or cystoscopy procedure.

Pelvic floor electrical stimulation and muscles training: a combined rehabilitative approach for management of non-neuropathic urinary incontinence in children.

PURPOSE: To assess the efficacy of combined transcutaneous interferential (IF) electrical stimulation and pelvic floor muscle training through biofeedback on non-neuropathic urinary incontinence in children. METHODS: This prospective study comprised of 46 anatomically and neurologically normal children (9 boys, 37 girls; mean age of 8.4 ±â€¯2.2 years old) with non-neuropathic urinary incontinence. All children were evaluated by kidney and bladder ultrasounds, uroflowmetry with electromyography (EMG), a complete voiding diary and a dysfunctional voiding scoring questionnaire at the baseline. Children were randomly allocated into two treatment groups including group A (n = 23) who underwent biofeedback therapy in addition to IF electrical stimulation and group B (n = 23) who received only biofeedback therapy. Re-evaluation was performed 6 months and one year after completion of the treatment sessions. RESULTS: Improvement of non-neuropathic urinary incontinence was significantly higher in group A in comparison to group B at two follow ups (P < 0.05). Daytime incontinence was improved in 19/23(82%) and 13/23(56.5%) of children in groups A and B respectively after the treatment (P < 0.01). There was no significant difference in uroflowmetry measures between two groups after the treatment. CONCLUSIONS: Combination of biofeedback therapy and transcutaneous IF electrical stimulation is a potential effective modality in treating non-neuropathic urinary incontinence in children. LEVEL OF EVIDENCE: Type of study: Treatment study. Level I: Randomized controlled trials with adequate statistical power to detect differences (narrow confidence intervals) and follow up >80%.

Pelvic floor electromyography and urine flow patterns in children with vesicoureteral reflux and lower urinary tract symptoms

ABSTRACT Objective: To determine the different urine flow patterns and active pelvic floor electromyography (EMG) during voiding in children with vesicoureteral reflux (VUR) as well as presenting the prevalence of lower urinary tract symptoms in these patients. Materials and Methods: We retrospectively reviewed the charts of children diagnosed with VUR after toilet training from Sep 2013 to Jan 2016. 225 anatomically and neurologically normal children were included. The reflux was diagnosed with voiding cystourethrography. The study was comprised an interview by means of a symptom questionnaire, a voiding diary, uroflowmetry with EMG and kidney and bladder ultrasounds. Urine flow patterns were classified as bell shape, staccato, interrupted, tower and plateau based on the current International Children's Continence Society guidelines. Results: Of 225 children with VUR (175 girls, 50 boys), underwent uroflowmetry + EMG, 151 (67.1%) had an abnormal urine flow pattern. An active pelvic floor EMG during voiding was confirmed in 113 (50.2%) children. The flow patterns were staccato in 76 (33.7 %), interrupted in 41 (18.2%), Plateau in 26 (11.5%), tower in 12 (5.3%) and a bell shape or normal pattern in 70 (31.5%). Urinary tract infection, enuresis and constipation respectively, were more frequent symptoms in these patients. Conclusions: Bladder/bowel dysfunction is common in patients with VUR that increases the risk of breakthrough urinary tract infections in children receiving antibiotic prophylaxis and reduces the success rate for endoscopic injection therapy. Therefore investigation of voiding dysfunction with primary assessment tools can be used prior to treating VUR.