The Role of Frailty on Surgical Outcomes Following Pelvic Organ Prolapse Surgery in Medicare Beneficiaries: A National Study.

OBJECTIVE: To evaluate the association of frailty with surgical outcomes following pelvic organ prolapse (POP) surgery in Medicare beneficiaries. METHODS: This is a retrospective cohort study of female Medicare beneficiaries ≥65 years of age undergoing POP surgery between 2014 and 2016. Primary outcomes were hospital length-of-stay (LOS) ≥3 days, 30-day post-operative complications (excluding urinary tract infections (UTI)), and 30-day UTI. Frailty was quantified using the validated Claims-Based Frailty Index (CFI) and categorized into not frail (CFI<0.15), pre-frail (0.15≤CFI<0.25), mildly frail (0.25≤CFI<0.35), and moderately to severely frail (0.35≤CFI≤1). RESULTS: Among the 107,890 women included (mean age, 73.3±6 years), 91.3% were White as and 4.3% were classified as mildly or moderately to severely frail. Rates of hospital LOS≥3 days and 30-day UTI increased over 7-fold and rates of 30-day complications increased over 3-fold as CFI increased from not frail to moderately to severely frail (all P values <.001). Compared to women who were not frail, women who were moderately to severely frail demonstrated an increased relative risk of hospital LOS≥3 days (aRR 3.1 [95% CI 2.5-3.8,P <.001]), 30-day complications (aRR 2.8 [95% CI 2.2-3.6, P <.001]), and 30-day UTI (aRR 2.5 [95% CI 2.2-3.0, P <.001]). CONCLUSION: Among Medicare beneficiaries undergoing POP surgery in the United States, frailty is strongly associated with increased risk of prolonged hospital stay and 30-day complications. Frailty should be considered in the preoperative assessment for POP surgeries to improve patient outcomes.

Frailty Is Associated with an Increased Risk of Complications and Need for Repeat Procedures after Sling Surgery in Older Adults.

PURPOSE: Sling surgery is the gold standard treatment for stress urinary incontinence in women. While data support the use of sling surgery in younger and middle-aged women, outcomes in older, frail women are largely unknown. MATERIALS AND METHODS: Data were examined for all Medicare beneficiaries ≥65 years old who underwent sling surgery with or without concomitant prolapse repair from 2014 to 2016. Beneficiaries were stratified using the Claims-Based Frailty Index (CFI) into 4 categories: not frail (CFI <0.15), prefrail (0.15 ≤CFI <0.25), mildly frail (0.25 ≤CFI <0.35) and moderately to severely frail (CFI ≥0.35). Outcomes included rates and relative risk of 30-day complications, 1-year mortality and repeat procedures for persistent incontinence or obstructed voiding at 1 year. RESULTS: A total of 54,112 women underwent sling surgery during the study period, 5.2% of whom were mildly to moderately to severely frail. Compared to the not frail group, moderately to severely frail beneficiaries demonstrated an increased adjusted relative risk (aRR) of 30-day complications (56.5%; aRR 2.5, 95% CI: 2.2-2.9) and 1-year mortality (10.5%; aRR 6.7, 95% CI: 4.0-11.2). Additionally, there were higher rates of repeat procedures in mildly to severely frail beneficiaries (6.6%; aRR 1.4, 95% CI: 1.2-1.6) compared to beneficiaries who were not frail. CONCLUSIONS: As frailty increased, there was an increased relative risk of 30-day complications, 1-year mortality and need for repeat procedures for persistent incontinence or obstructed voiding at 1 year. While there were fewer sling surgeries in performed frail women, the observed increase in complication rates was significant. Frailty should be strongly considered before pursuing sling surgery in older women.

African American Men have Increased Risk of Prostate Cancer Detection Despite Similar Rates of Anterior Prostatic Lesions and PI-RADS Grade on Multiparametric Magnetic Resonance Imaging.

OBJECTIVE: To determine whether the frequency of anterior prostate lesions (APL) on multiparametric magnetic resonance imaging (mpMRI) prior to biopsy differed between African American (AA) and non-AA men and evaluate implications of race and tumor location for prostate cancer (PCa) detection. METHODS: Patients from the Prospective Loyola University mpMRI (PLUM) Prostate Biopsy Cohort (January 2015-December 2020) without prior diagnosis of PCa were evaluated for APLs by race. Multivariable logistic regression models evaluated predictors of APLs and associations of APLs and race with detection of any PCa (grade group 1+) and clinically significant PCa (csPCa; grade group 2+). Additional stratified and propensity score matched analyses were conducted. RESULTS: Of 1,239 men included, 190 (15.3%) were AA and 302 (24.4%) had at least one APL with no differences by race on multivariable analysis. While men with APLs were twice as likely to harbor PCa or csPCa, the unadjusted proportion of targeted biopsy-confirmed APL PCa (12.6% vs 12.0%) or csPCa (8.4% vs 8.9%) were similar for AA and non-AA men. AA men had higher risk of prostate cancer on targeted cores (OR 1.66 (95%CI 1.06 - 2.61), P = 0.026) which was independent of lesion location or PI-RADS. CONCLUSION: AA men were found to have similar rates of APLs on mpMRI to non-AA men indicating access to mpMRI may mitigate some of the historical racial disparity based on lesion location. AA men have increased risk of PCa detection compared to non-AA men independent of anterior location or lesion grade on mpMRI reinforcing the importance of identifying genetic, biologic, and socioeconomic drivers.

Male Bladder Microbiome Relates to Lower Urinary Tract Symptoms.

BACKGROUND: In women, compelling evidence associates lower urinary tract microbiota (LUTM) with lower urinary tract symptoms (LUTS); a similar association in men with benign prostate enlargement (BPE) is not established. OBJECTIVE: To determine whether associations exist between LUTM and LUTS. DESIGN, SETTING, AND PARTICIPANTS: Forty-nine male volunteers, aged 40-85 yr, were recruited from one academic tertiary care center. Twenty-eight patients undergoing BPE/LUTS surgery and 21 undergoing non-BPE/LUTS surgery were stratified by International Prostate Symptom Score (IPSS), and paired voided/catheterized urine specimens were collected for expanded quantitative urine culture (EQUC) and 16S ribosomal RNA gene sequencing. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary and secondary outcomes were presence of detectable LUTM and specific bacterial members of the LUTM, respectively. Baseline data were compared. Univariable logistic regression models were used to calculate odds ratios (ORs) for IPSS category associated with the presence of bladder microbiota. Relative LUTM proportions were compared with IPSS using chi-square tests. RESULTS AND LIMITATIONS: Thirty-nine percent of catheterized and 98% of voided specimens contained LUTM. Catheterized and voided LUTM differed significantly. LUTM was detected in catheterized urine of 22.2% of men with mild LUTS, 30.0% with moderate LUTS, and 57.1% with severe LUTS (p=0.024). Increased IPSS category was associated with significantly higher odds of detectable bacteria (OR: 2.21, 95% confidence interval: 1.09-4.49). Small sample size limited this study, making it unable to identify significant differences in specific bacterial taxa based on IPSS. CONCLUSIONS: Voided urine does not adequately characterize the male bladder microbiome. In males with and without BPE, IPSS severity was associated with detectable bacteria in catheterized urine, which samples the bladder. Additional studies are needed to identify specific bladder bacteria associated with LUTS. PATIENT SUMMARY: To study bladder bacteria, urine should be collected with a catheter. Men with severe urinary symptoms are more likely to have detectable bladder bacteria than those with less severe symptoms.

Impact of preoperative urodynamics on women undergoing pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Preoperative urodynamic studies (UDS) are frequently performed before pelvic organ prolapse (POP) surgery to assess urethral and bladder function. The primary goal of this study is to examine how preoperative UDS are utilized and what value these studies have in patient treatment and/or counseling. METHODS: We retrospectively reviewed patients who underwent prolapse surgery and had preoperative UDS between June 2010 and February 2015. Indications for UDS were classified into four categories: (1) occult stress urinary incontinence only, (2) overactive bladder symptoms, (3) mixed or insensible urinary incontinence, and (4) voiding symptoms and/or elevated post-void residual. We identified changes in management or counseling that were directly attributable to UDS results prior to surgery. RESULTS: Three hundred ninety-two patients underwent urodynamic testing for indications 2-4 above, and 316 met the inclusion criteria. Fifty-seven percent (180/316) had OAB symptoms (34.4% wet, 65.6% dry), 40.2% (127/316) had mixed incontinence, and 17.1% (54/316) had voiding symptoms and/or elevated PVR. A total of 3.5% (11/316) patients had alteration in their management or counseling based on the results of the UDS; 29.4% (50/170) of the women evaluated for occult SUI alone or with other symptoms demonstrated it and 41 underwent sling placement. CONCLUSIONS: UDS did not have a significant impact on preoperative management or counseling in POP surgery if demonstration of occult SUI was not the indication for preoperative study in women committed to POP surgery. Major alterations in treatment were rare and occurred mostly in women with stress incontinence that also had concomitant voiding symptoms and/or elevated PVR.

Vaginal Dehiscence and Evisceration After Robotic-assisted Radical Cystectomy: A Case Series and Review of the Literature.

OBJECTIVE: To describe a rare complication in 5 women who had vaginal prolapse, dehiscence, and/or evisceration after having undergone robotic-assisted radical cystectomy with creation of ileal conduit urinary diversion. Radical cystectomy is the standard of care in the extirpative treatment for muscle invasive urothelial carcinoma. Anterior exenteration in the female patient requires removal of the anterior vaginal wall, urethra, uterus, and adnexa which results in significant changes to the pelvic floor. METHODS: Retrospective identification of all women having undergone robotic-assisted radical cystectomy for urothelial carcinoma who ultimately represented with vaginal prolapse, dehiscence, and/or evisceration between January 2012 and April 2019. We identified patient characteristics detailing their presentation. A review of the available literature highlighted the lack of available information in this uncommon cohort. RESULTS: Five women with vaginal dehiscence and/or evisceration who had previously undergone robotic-assisted radical cystectomy, anterior vaginectomy with urethrectomy, pelvic lymph node dissection, and creation of ileal conduit by 4 surgeons were identified. Mean interval time to initial presentation of prolapse or dehiscence was 44.4 weeks (range 11-120). In the 2 patients that eviscerated prior to repair, this occurred at 5 and 25 weeks after initial outpatient consultation. All reconstructive efforts were approached transvaginally. Two patients underwent 2 or more repairs. Management options included expectant management, pessary, and immediate vs delayed transvaginal surgical repair. CONCLUSION: Our case series describes the unique and potentially devastating complication of vaginal dehiscence and bowel evisceration in women with history of robotic-assisted radical cystectomy.

Role of Multiparametric Magnetic Resonance Imaging Prostate Specific Antigen Density and PI-RADS™ Score in Predicting Up Staging in Men on Active Surveillance.

INTRODUCTION: Using a combination of magnetic resonance imaging of the prostate and prostate specific antigen density, we determined which men on active surveillance are at risk for up staging and which men could avoid repeat biopsy while remaining on surveillance. METHODS: We reviewed the records of 110 men on active surveillance with Gleason 6 disease who underwent magnetic resonance imaging followed by UroNav fusion biopsy (Invivo, Gainesville, Florida). Using univariable and multivariable logistic regression analyses we examined the effect of age, race, prostate specific antigen, prostate specific antigen density, prostate volume, PI-RADS (Prostate Imaging Reporting and Data System) score, number and size of target lesions, and time on surveillance to determine the likelihood of up staging to Gleason 7 or greater disease. RESULTS: A total of 33 cases (30%) were up staged. On multivariable analysis prostate specific antigen density and PI-RADS score were significant predictors of up staging with adjusted odds ratios of 3.97 for prostate specific antigen density of 0.16 or more (CI 1.31-12.00, p <0.05), 13.8 for a PI-RADS 4 lesion (CI 2.3-81.3, p <0.01) and 25 for a PI-RADS 5 lesion (CI 3.8-163.5, p <0.01). When cross-tabulating these factors, men with a PI-RADS score of 3 or greater with a prostate specific antigen density of 0.16 ng/ml/cc or more had a 61.2% chance of up staging. Conversely, in men with PI-RADS score 3 or less and prostate specific antigen density less than 0.15, no up staging was seen. CONCLUSIONS: A combination of PI-RADS score and prostate specific antigen density predicts patients at risk for up staging at surveillance biopsy. Conversely, this combination may help determine which men may safely forgo biopsy.

Molecular targets of nutraceuticals derived from dietary spices: potential role in suppression of inflammation and tumorigenesis.

Despite the fact cancer is primarily a preventable disease, recent statistics indicate cancer will become the number one killer worldwide in 2010. Since certain cancers are more prevalent in the people of some countries than others, suggests the role of lifestyle. For instance cancer incidence among people from the Indian subcontinent, where most spices are consumed, is much lower than that in the Western World. Spices have been consumed for centuries for a variety of purposes-as flavoring agents, colorants, and preservatives. However, there is increasing evidence for the importance of plant-based foods in regular diet to lowering the risk of most chronic diseases, so spices are now emerging as more than just flavor aids, but as agents that can not only prevent but may even treat disease. In this article, we discuss the role of 41 common dietary spices with over 182 spice-derived nutraceuticals for their effects against different stages of tumorigenesis. Besides suppressing inflammatory pathways, spice-derived nutraceuticals can suppress survival, proliferation, invasion, and angiogenesis of tumor cells. We discuss how spice-derived nutraceuticals mediate such diverse effects and what their molecular targets are. Overall our review suggests "adding spice to your life" may serve as a healthy and delicious way to ward off cancer and other chronic diseases.