Assessment of Urinary Dysfunction After Midurethral Sling Placement: A Comparison of Two Voiding Trial Methods.

STUDY OBJECTIVE: Temporary urinary retention after midurethral sling (MUS) surgery requiring indwelling catheter or self-catheterization usage is common. Different methods for assessment of immediate postoperative urinary retention have been described. This study aimed to compare postoperative voiding trial (VT) success after active vs passive VT in women undergoing MUS surgery. DESIGN: Comparative retrospective cohort study. SETTING: Female pelvic medicine and reconstructive surgery practice at a university-affiliated tertiary medical center. PATIENTS: Patients with stress urinary incontinence who underwent surgical treatment during the study period were eligible for inclusion. Excluded were patients younger than the age of 18 years, combined cases with other surgical services, planned laparotomy, and a history of urinary retention and patients for whom their VT was performed on postoperative day 1. The cohort was divided into 2 groups: (1) patients who underwent an active retrofill of their bladder using a Foley catheter and (2) patients who were allowed to have a spontaneous void. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 285 patients met the inclusion criteria for the study. Of these subjects, 94 underwent an active VT and 191 underwent a passive VT. There were no statistically significant differences in immediate postoperative urinary retention (30.8% vs 29.3%; p = .79) or time from surgery end to VT (233.0 ± 167.6 minutes vs 203.1 ± 147.8 minutes; p = .13) between groups. Urinary retention, as defined by a failed VT, increased from 10% to 29.3% when MUS placement was accompanied by concomitant prolapse repair procedure. Multivariate logistic regression analysis revealed that undergoing a combined anterior and posterior colporrhaphy (odds ratio [OR], 5.13; p <.001) and undergoing an apical prolapse procedure (OR, 2.75; p = .004) were independently associated with immediate postoperative urinary retention whereas increased body mass index (OR, 0.89; p <.001) lowered likelihood of retention. CONCLUSION: The method used to assess immediate postoperative urinary retention did not affect VT success. Concomitant combined anterior and posterior colporrhaphy and apical suspension were correlated with greater likelihood of VT failure whereas increased body mass index decreased odds of retention.

Assessment of patient satisfaction with home vs office indwelling catheter removal placed for urinary retention after female pelvic floor surgery: a randomized controlled trial.

BACKGROUND: Postoperative urinary retention is burdensome for patients. We seek to improve patient satisfaction with the voiding trial process. OBJECTIVE: This study aimed to assess patient satisfaction with location of indwelling catheter removal placed for urinary retention after urogynecologic surgery. STUDY DESIGN: All adult women who were diagnosed with urinary retention requiring postoperative indwelling catheter insertion after undergoing surgery for urinary incontinence and/or pelvic organ prolapse were eligible for this randomized controlled study. They were randomly assigned to catheter removal at home or in the office. Those who were randomized to home removal were taught how to remove the catheter before discharge, and were discharged home with written instructions, a voiding hat, and 10-mL syringe. All patients had their catheter removed 2 to 4 days after discharge. Those patients who were allocated to home removal were contacted in the afternoon by the office nurse. Subjects who graded their force of urine stream 5, on a scale of 0 to 10, were considered to have safely passed their voiding trial. For patients randomized to the office removal group, the voiding trial consisted of retrograde filling the bladder to maximum they could tolerate up to 300 mL. Urinating >50% of instilled volume was considered successful. Those who were unsuccessful in either group had catheter reinsertion or self-catheterization training in the office. The primary study outcome was patient satisfaction, measured based on patients' response to a question, "How satisfied were you with the overall removal process of the catheter?" A visual analogue scale was created to assess patient satisfaction and 4 secondary outcomes. A sample size of 40 participants per group were needed to detect a 10 mm difference in satisfaction between groups on the visual analogue scale. This calculation provided 80% power and an alpha of 0.05. The final number accounted for 10% loss to follow up. We compared the baseline characteristics, including urodynamic parameters, relevant perioperative indices, and patient satisfaction between the groups. RESULTS: Of the 78 women enrolled in the study, 38 (48.7%) removed their catheter at home and 40 (51.3%) had an office visit for catheter removal. Median and interquartile range for age, vaginal parity, and body mass index were 60 (49-72) years, 2 (2-3), and 28 (24-32) kg/m2, respectively, in the overall sample. Groups did not differ significantly in age, vaginal parity, body mass index, previous surgical history, or type of concomitant procedures. Patient satisfaction was comparable between the groups, with a median score (interquartile range) of 95 (87-100) in the home catheter removal group and 95 (80-98) in the office catheter removal group (P=.52). Voiding trial pass rate was similar between women who underwent home (83.8%) vs office (72.5%) catheter removal (P=.23). No participants in either group had to emergently come into the office or hospital due to inadequate voiding afterwards. Within 30 days post operatively, a lower proportion of women in the home catheter removal group (8.3%) had urinary tract infection, compared to patients in the office catheter removal group (26.3%) (P=.04). CONCLUSION: In women with urinary retention after urogynecologic surgery, there is no difference in satisfaction concerning the location of indwelling catheter removal when comparing home and office.

Burden of illness among intermittent catheter users with non-neurogenic urinary retention in Denmark.

BACKGROUND: Urinary retention (UR) caused by non-neurogenic conditions is a frequent disorder often requiring the use of intermittent catheterization (IC). This study examines the burden of illness among subjects with an IC indication due to non-neurogenic UR. METHODS: Health-care utilization and costs were extracted from Danish registers (2002-2016) related to the first year after IC training and compared to matched controls. RESULTS: A total of 4,758 subjects with UR due to benign prostatic hyperplasia (BPH) and 3,618 subjects with UR due to other non-neurological conditions were identified. Total health-care utilization and costs per patient-year were significantly higher compared to matched controls (BPH: 12,406 EUR vs 4,363, p < 0.000; other non-neurogenic causes: 12,497 EUR vs 3,920, p < 0.000) and driven mainly by hospitalizations. Urinary tract infections (UTIs) were the most frequent bladder complications often requiring hospitalization. The inpatient costs per patient-year for UTIs were significantly higher for cases than controls (BPH: 479 EUR vs 31, p < 0.000; other non-neurogenic causes: 434 EUR vs 25, p < 0.000). CONCLUSIONS: The burden of illness caused by non-neurogenic UR with need for IC was high and essentially driven by hospitalizations. Further research should clarify if additional treatment measures may reduce the burden of illness in subjects suffering from non-neurogenic UR using IC.

Long term genitourinary toxicity following curative intent intensity-modulated radiotherapy for prostate cancer: a systematic review and meta-analysis.

BACKGROUND: Recent studies have shown that radiation-induced pelvic toxicity often requires urological consultation. However, the 10-year incidence of genitourinary toxicity following intensity-modulated radiotherapy (IMRT) amongst patients with localised prostate cancer remains unclear. Hence, we conducted a systematic review and meta-analysis to determine the incidence of late genitourinary toxicity relying on Radiation Therapy Oncology Group (RTOG) and Common Terminology Criteria for Adverse Events (CTCAE) grade as well as the incidence of specific genitourinary toxicity. Secondary objectives involved quantifing the number of studies reporting 120-month follow-up endpoints, time to event analysis, predictive factors or economic evaluation. METHODS: Articles published from January 2008 to December 2021 describing prospective studies were systematically searched in MEDLINE, EMBASE and Cochrane (PROSPERO protocol CRD42019133320). Quality assessment was performed by use of the Cochrane Risk of Bias 2 Tool for RCTs and the Newcastle Ottowa Scale for non-RCTs. Meta-analysis was performed on the 60-month incidence of RTOG and CTCAE Grade ≥2 genitourinary toxicity, haematuria, urinary retention and urinary incontinence. RESULTS: We screened 4721 studies and six studies met our inclusion criteria. All included studies involved normofractionation, three included a hypofractionation comparator arm and none involved nodal irradiation. The pooled 60-month cumulative incidence of RTOG and CTCAE Grade ≥2 genitourinary toxicity were 17% (95% CI: 5-20%, n = 678) and 33% (95% CI: 27-38%, n = 153), respectively. The pooled 60-month cumulative incidence of Haematuria was 5% (95% CI: -4-14%, n = 48), Urinary incontinence 12% (95% CI: 6-18%, n = 194), Urinary retention 24% (95% CI: 9-40%, n = 10). One study reported time to event analyses, one reported predictive factors, no studies reported economic analysis or 120-month toxicity. There was considerable heterogeneity amongst the studies. CONCLUSION: There are few high-quality studies reporting 60-month toxicity rates after IMRT. Conservative estimates of 60-month toxicity rates are high and there is need for longer follow-up and consistent toxicity reporting standards.

The efficacy of force of stream assessment for post-operative catheter management: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Postoperative urinary retention is common after urogynecologic procedures. Our objective is to determine the efficacy of force of stream (FOS) assessment without a visual analog scale for postoperative catheter management. METHODS: We conducted a retrospective cohort study of 110 women undergoing an inpatient gynecologic procedure. They were asked to subjectively assess FOS after surgery without a visual analog scale. If it was 50% or better than the usual preoperative void, they were discharged home without a catheter. If < 50%, the catheter was replaced and the patients were sent home and asked to follow up in 3 to 5 days for another void trial. RESULTS: Average age was 56.9 ± 10.2 years; 63.6% underwent surgery for pelvic organ prolapse, 23.6% underwent sling for urinary incontinence, and 12.7% underwent a combination of both. Force of stream was > 50% in 93.6% of the patients; 6.4% had force of stream < 50% and hence were discharged home with a Foley catheter. Only two patients (1.8%) were discharged without a Foley catheter and returned to the emergency department for signs of urinary retention. Sensitivity, specificity, positive and negative predictive values were 77.8%, 100%, 100% and 98.1%, respectively. CONCLUSION: The subjective assessment of flow of stream is a reliable and safe method to assess postoperative voiding. Given it is less invasive than backfilling the bladder and easier than using a bladder scan, it should be the primary method to assess postoperative voiding.

A Cost-Effectiveness Analysis of Post-Void Residual Bladder Scan Thresholds in the Postoperative Setting.

INTRODUCTION AND HYPOTHESIS: To identify the optimal cost-effectiveness threshold of post-void residual (PVR) by bladder scan in postoperative urogynecologic patients. METHODS: A cost-effectiveness analysis was performed as a secondary analysis of a previously published study of patients undergoing urogynecologic procedures with planned voiding trials, setting thresholds for postoperative PVR bladder scan volumes at 100 ml, 150 ml, and 200 ml. Patient-based scenarios were modeled for ambulatory office or emergency department (ED) resource utilization and to determine the cost-effectiveness of each threshold. Costs were obtained from a southeastern academic medical center, only utilizing direct medical costs and hospital costs, not including societal costs. Quality-adjusted life years (QALY's) were used as health outcomes determining the incremental cost-effectiveness ratio (ICER). RESULTS: A total of 151 patients from the original study were included. A willingness to pay threshold of $100,000 per QALY was assumed. A PVR of 100 ml exceeded this at $373,824. A PVR threshold of 150 ml was dominant (-$1,211,716), while minimizing ED visits for postoperative urinary retention (POUR) and unnecessary clinic appointments. While a PVR of 200 ml appeared a cost-effective strategy (-$488,389), there was increased ED utilization and under-detection of postoperative urinary retention (POUR). CONCLUSION: A PVR threshold of 100 ml created a healthcare system burden due to increased office voiding trials. Both PVR thresholds of 150 ml and 200 ml were cost-effective strategies; however, ED utilization for POUR increased with 200 ml. Utilizing 150 ml as the PVR cut-off proved the most cost-effective strategy, avoiding POUR under-detection and undue health costs.

Short-term catheter management options for urinary retention following pelvic surgery: a cost analysis.

BACKGROUND: Several studies have compared short-term catheterization approaches and have demonstrated no difference in patient satisfaction, but no study has evaluated their costs. OBJECTIVE: To evaluate the costs of 3 pathways for short-term catheter management in patients diagnosed with urinary retention following pelvic surgery. STUDY DESIGN: We utilized a Markov decision tree to model costs from the society's perspective. In pathway 1, patients have an indwelling catheter and return to the office for a voiding trial. In pathway 2, patients have an indwelling catheter and discontinue the catheters at home. In pathway 3, patients are taught clean intermittent catheterization postoperatively. We accounted for office visits, emergency department visits, urinary tract infection testing and treatment, transportation, caregiver time, teaching time, and supplies. RESULTS: Clean intermittent catheterization is the least costly catheterization method at $79 per patient, followed by self-removal of the catheter ($128) and office voiding trial ($185). One-way sensitivity analyses showed that the distance between the patient and office and the rates of spontaneous voiding following catheterization had the greatest impact. When patients need to travel >5 miles to the office for catheter removal, self-removal of a catheter is less costly than an office voiding trial. Once it has been determined that patients have urinary retention and require catheterization, clean intermittent catheterization is the most cost-saving option only if the patients are taught clean intermittent catheterization postoperatively. If all patients were to be taught clean intermittent catheterization routinely before surgery, it becomes the most costly option. Based on annual surgical volume, if even $30 were saved per patient with postoperative urinary retention, the estimated total societal savings would be $420,000 to $7.2 million. CONCLUSION: Clean intermittent catheterization as initial management of urinary retention following pelvic surgery is the most cost-saving option when it is only taught postoperatively to patients after determining the need for catheterization. When this is not possible, self-removal of an indwelling catheter is the most cost-saving option, especially as the distance between the patient and provider increases. Choosing the optimal management guided by patient and provider factors can lead to substantial cost savings annually in the United States.

Post-void residual urine ratio: A novel clinical approach to the post-void residual urine in the assessment of males with lower urinary tract symptoms.

PURPOSE: To assess the correlation between post-void residual urine ratio (PVR-R) and pathological bladder emptying diagnosed by pressure-flow studies (PFS) in males with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: PVR-R and PVR urine were evaluated in 410 males underwent PFS for LUTS. PVR-R was the percentage of PVR to bladder volume (voided volume+PVR). Schafer and International Continence Society (ICS) nomograms, Bladder Contractility Index (BCI) were used to diagnose bladder outlet obstruction (BOO) and detrusor underactivity (DUA). We subdivided the cohort in 4 groups: Group I, BOO+/DUA+; Group II, BOO-/DUA+; Group III, BOO+/DUA-; Group IV, BOO-/DUA- (control group). We subdivided the 4 groups according to PVR-R strata: (1) 0%-20%; (2) 21%-40%; (3) 41%-60%; (4) 61%-80%; (5) 81%-100%. RESULTS: Group I had a greater median PVR-R (50%) with a >40% in 61.4% of the cohort. Median PVR-R was 16.6% in Group II, 24% in Group III, and 0% in the control Group. According to ICS nomograms and BCI, median PVR-R and PVR were significantly higher (p<0.001) in obstructed and underactive males. PVR-R threshold of 20% allowed to recognize males with voiding disorders with high sensibility, specificity, PPV, and NPV. A PVR-R cut-off of 40% identified males with associated BOO and DUA and more severe voiding dysfunction. CONCLUSIONS: A higher PVR-R is related to a more severe pathological bladder emptying, and to the association of BOO and DUA. PVR-R may have a clinical role in first assessment of males with LUTS and severe voiding dysfunction.

Can a Simple Geriatric Assessment Predict the Outcome of TURP?

PURPOSE: To determine the impact of a simple preoperative geriatric assessment on the outcome in older patients with recurrent urinary retention who underwent desobstructive surgery. PATIENTS AND METHODS: Patients aged 75 years or older with recurrent urinary retention referred for TURP entered this prospective, multicentre study. Several demographic, intra- and postoperative parameters were assessed. Preoperative geriatric assessment was performed by the 7-item Canadian Study of Health and Ageing (CSHA) frailty scale (1: very fit, 7: severely frail; completion takes less than a minute). The main outcome parameters were successful voiding rates at discharge and 3 months postoperatively. RESULTS: A total of 54 patients were recruited; 42 (77.8%) patients had a CSHA index of 1-3 and were considered as "fit", the remaining 12 (22.2%) formed the "frail" group (CSHA index 4-7). Age was identical in both cohorts (79.5 ± 3.7 vs. 79.7 ± 3.3 years); differences were demonstrable for the American Society of Anesthesiologists (ASA) score (p = 0.001), the number of daily medications (>4: 32 vs. 75%, p = 0.02), falls within the past 6 months (12 vs. 33%), and the necessity of home/nursing care (5 vs. 42%, p = 0.004). Intra- and perioperative complications, duration of postoperative catheterization, and length of hospitalization were identical in both cohorts. The success rate at discharge was 80.6% in fit and 75.0% in frail patients; the respective values at 3 months were 95.2 and 83.3%. CONCLUSIONS: A simple 1-min geriatric assessment tool can predict - to a certain extent - the outcome of desobstructive surgery in older patients with recurrent urinary retention. Fit patients achieve an excellent outcome while frail patients might benefit from a more in-depth urodynamic/geriatric evaluation.

Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

OBJECTIVES: In adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal instrumented fusion (PSIF), we aimed to answer these questions: (1) is there a difference in postoperative urinary retention (UR) rates among patients who had removal of their Foley catheters before vs. after discontinuation of epidural analgesia (EA)? (2) Can the timing of Foley catheter removal be an independent risk factor for postoperative UR requiring recatheterization? (3) Is there an incurred cost related to treating UR? STUDY DESIGN: Retrospective cohort. BACKGROUND: EA has been widely used for postoperative pain control after PSIF for AIS. In these patients, removing the Foley catheter, inserted for intraoperative monitoring of urine output, is indicated in the early postoperative period. However, a controversy exists as to whether it should be removed before or after the EA has been discontinued. METHODS: A single-institution, longitudinally maintained database was queried to identify 297 patients who met specific inclusion and exclusion criteria. Patient characteristics and the order and timing of removing the urinary and epidural catheters were collected. Rates of UR were statistically compared in patients who had early vs. late urinary catheter removal. A univariate and multivariate regression analysis was conducted to identify independent risk factors. Hospital episode costs were analyzed. RESULTS: Patients who had early (n = 66, 22%) vs. late (n = 231, 78%) urinary catheter removal had a significantly higher incidence of UR requiring recatheterization (15 vs. 4.7%, p = 0.007). Patient with early removal were almost 4 times more likely to develop UR requiring recatheterization [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p = 0.005]. UR incurred additional costs averaging $15,000/patient (p = 0.204). CONCLUSION: In patients who had PSIF for AIS, removal of a urinary catheter before discontinuation of EA is an independent risk factor for UR, requiring recatheterization and associated with increased cost. LEVEL OF EVIDENCE: III.

Local VS. other forms of anesthesia for open inguinal hernia repair: A meta-analysis of randomized controlled trials.

BACKGROUND: There is variation in the anesthetic technique for open inguinal hernia repair (OIHR) worldwide. Factors determining the anesthetic technique remains equivocal. We hypothesize that outcomes and operative room times are superior with local anesthesia (LA) compared to AO [all others (general and spinal anesthesia)]. METHODS: Following PRISMA guidelines and set inclusion and exclusion criteria, various databases were reviewed and 18 RCT's were isolated. Using ReviewManager 5.3, multiple parameters were used to test for overall effect between the included studies. RESULTS: Overall complication rate was similar in LA vs. AO (p = 0.06). Wound infection and hematomas were similar between LA vs. OA, but urinary retention was significantly decreased in LA (p = 0.0002). Patient satisfaction was not inferior with LA (p = 0.10). Surgical time was similar in LA vs. AO (p = 0.86), but operating room time was significantly decreased with LA (p < 0.0001). The literature review also showed a decrease in the LOS and cost when LA was used. CONCLUSION: This meta-analysis demonstrates that LA is a well-tolerated for OIHR with OR times and urinary retention being significantly decreased.

Cateter hidrofílico para cateterismo vesical intermitente em indivíduos com lesão medular e bexiga neurogênica / Hydrophilic catheter for intermittent bladder catheterization in individuals with spinal cord injury and neurogenic bladder

CONTEXTO: No Brasil estima-se que a incidência de trauma raquimedular é de 40 casos novos/ano/milhão de habitantes, sendo que 80% das vítimas são homens e 60% se encontram entre os 10 e 30 anos de idade. As repercussões urológicas causadas pela lesão na medula espinhal constituem um dos principais desafios durante a reabilitação, pois o mau funcionamento vesical pode, quando assistido inadequadamente, acarretar complicações que vão desde a infecção urinária, cálculos vesicais, refluxo vesicoureteral, hidronefrose e, em casos extremos, perda da função renal. No indivíduo com bexiga neurogênica em função da lesão medular deve-se garantir esvaziamento vesical a baixa pressão, evitar estase urinária e perdas involuntárias. Na maior parte dos casos, este esvaziamento deverá ser feito por cateterismo vesical intermitente, instituído de forma mandatória desde a alta hospitalar. Infecções do trato urinário são extremamente frequentes nos lesados medulares sendo a principal doença infecciosa que os acom

Ultrasonographic Assessment of Bladder Volumes in Children Undergoing Penile Surgery: Does the Type of Anesthesia Matter?

BACKGROUND: There are scant data reporting postoperative ultrasonographically measured bladder volumes in children undergoing penile surgery. STUDY QUESTION: We studied the effect of various anesthesia techniques on return of micturition after penile surgery in children, using ultrasonographically measured bladder volumes. DATA SOURCES: Ultrasonographically measured postvoiding residual bladder volumes indexed to age-appropriate capacity, and time elapsed between the end of surgery and spontaneous voiding after pediatric circumcision, distal hypospadias repair, or repair of urethrocutaneous fistula, were studied. STUDY DESIGN: Children between 4 months and 12 years were randomized to caudal block, intravenous (IV) fentanyl or penile block, in association with inhaled general anesthesia. Bladder volumes were measured before surgery and immediately after voiding for the first time. Time to first postsurgery void was also recorded. RESULTS: Thirty-one children completed all assessments; 12 underwent caudal block, 9 IV fentanyl anesthesia, and 7 were given penile block. The mean first postvoid bladder residual volumes were highest in the caudal and lowest in the penile block children (27.5 vs. 17.3 mL, P = 0.003). The time elapsing between the end of surgery and first voiding was the longest in the fentanyl group compared with caudal and penile blocks (232, 178, 150 minutes, respectively, P = 0.02). CONCLUSIONS: None of the anesthetic techniques provoked postoperative urinary retention after minor penile surgery in children. The penile block appears superior to caudal block or to IV fentanyl-based anesthesia with regard to postoperative recovery of normal micturition.

Urinary tract infection after acute stroke: Impact of indwelling urinary catheterization and assessment of catheter-use practices in French stroke centers.

INTRODUCTION: Urinary catheterization and acute urinary retention increase the risk of urinary tract infection (UTI). Our study aimed to investigate the incidence of UTI following acute stroke at our stroke center (SC) and to assess urinary catheter-care practices among French SCs. METHODS: Stroke patients hospitalized within 24h of stroke onset were prospectively enrolled between May and September 2013. Neurological deficit level was assessed on admission using the US National Institutes of Health Stroke Scale (NIHSS). Patients were followed-up until discharge. Indwelling urinary catheterization (IUC) was the only technique authorized during the study. An electronic survey was also conducted among French SCs to assess their practices regarding urinary catheterization in acute stroke patients. RESULTS: A total of 212 patients were included, with 45 (21.2%) receiving indwelling urinary catheters. The overall estimated incidence of UTI was 14.2%, and 18% among patients receiving IUC. On univariate analysis, IUC was significantly associated with older age, longer hospital stays and higher NIHSS scores. Of the 30 SCs that responded to our survey, 19 (63.3%) declared using IUC when urinary catheterization was needed. The main argument given to justify its use was that it was departmental policy to adopt this technique. Also, 27 participants (90%) stated that conducting a study to assess the impact of urinary catheterization techniques on UTI rates in acute stroke patients would be relevant. DISCUSSION: Our results are in accord with previously reported data and confirm the high burden of UTI among acute stroke subjects. However, no association was found between IUC and UTI on univariate analysis due to a lack of statistical power. Also, our survey showed high heterogeneity in catheter-use practices among French SCs, but offered no data to help determine the best urinary catheterization technique. CONCLUSION: Urinary catheterization is common after acute stroke and a well-known risk factor of UTI. However, as high heterogeneity in catheter-use practices is found among French SCs, randomized studies comparing the efficacy of urinary catheterization techniques in terms of UTI prevention in acute stroke patients are now warranted.

Unplanned emergency department or urgent care visits after outpatient rotator cuff repair: potential for avoidance.

BACKGROUND: With the cost of health care rising, the potential to avoid costs from an unplanned return to the emergency department (ED) or urgent care center (UC) after elective outpatient rotator cuff repair (RCR) has been discussed but not extensively assessed. METHODS: Outpatient RCR procedures were queried in a closed health care system, and all unplanned ED and UC visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction). Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention. Final tallies of all visits versus visits with ADs were compared. RESULTS: From June 2015 to May 2016, 1306 outpatient RCRs were performed (729 male and 577 female patients; average age, 60 years). Of the patients, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common (P = .007), whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied (P < .001). DISCUSSION AND CONCLUSIONS: Unplanned ED visits within 7 days of outpatient RCR are measurable and in many cases, such as ED or UC visits for pain, are avoidable. Visits for urinary retention are seen more commonly after RCR. Outpatient RCR led to more unplanned ED and UC visits than other common outpatient orthopedic surgical procedures.

A Critical Analysis of Stented and Unstented Tubularized Incised Plate Urethroplasty Through a Prospective Randomized Study and Assessment of Factors Influencing the Functional and Cosmetic Outcomes.

OBJECTIVE: To compare, functionally and aesthetically, stented and unstented tubularized incised plate urethroplasty (TIPU). In addition, predictors of repair success were investigated. MATERIALS AND METHODS: One hundred ten children with distal hypospadias were included in this study. The length and width of the urethral plate (UP) and transverse glans diameter (TGD) were measured. Patients were randomized into two groups: stented and unstented TIPU. Postoperative assessment of pain was done using Face, Legs, Activity, Cry, Consolability (FLACC) scale, and cosmetic outcome was evaluated using hypospadias objective scoring evaluation. Uroflow was assessed at 6 months in toilet-trained boys. Complications were graded by the Clavien classification system. RESULTS: In 93 cases, Face, Legs, Activity, Cry, Consolability score, hospital stay, and dressing time were in favor of the unstented group, whereas hypospadias objective scoring evaluation score and uroflow parameters were comparable. TGD and UP width varied significantly between successful and failed cases. Cutoff values of 13.5 mm and 8.5 mm for TGD and UP width, respectively, are required for successful outcome. Acute urinary retention was 12.8% after unstented repair. Detrusor spasm was 47.8% after stented and 8.5% after unstented repair. In both groups, urethrocutaneous fistula of 5.4%, glanular dehiscence of 1.1%, and meatal stenosis of 5.4% were found in cases with small TGD and narrow UP. CONCLUSION: Unstented TIPU evades the associated drawbacks of the stent along with lower postoperative pain, hospital stay, and dressing time. Even without a postoperative stent, the complication rate in infants with distal hypospadias is low, and short-term functional and aesthetic outcomes were not compromised.

A Nationwide Assessment of the Emergency Department Management of Acute Urinary Retention Due to Urethral Stricture.

OBJECTIVE: To evaluate the nationwide practice patterns of the management of acute urinary retention (AUR) secondary to urethral stricture (US) in an emergency department (ED) setting. MATERIALS AND METHODS: We used the 2006-2010 Nationwide Emergency Department Sample to identify men with US who received treatment for AUR. We excluded patients with benign prostatic hyperplasia, vesicourethral anastomotic stenosis, neurogenic bladder, and bladder cancer. Primary outcome was urethral dilation or suprapubic tube (SPT) placement as initial AUR management. Patient demographics and hospital factors were also examined. Multivariate logistic regression was performed to examine factors associated with initial AUR management. RESULTS: We identified 4794 weighted ED encounters of men with US who underwent urethral dilation or SPT placement for AUR. Mean age was 58.6 ± 0.8 years. A total of 4084 (85%) men received urethral dilation, whereas 710 had SPT (15%) placement. In bivariate analysis, patients who received SPT were likely to be younger (P <.001), treated in recent years (P = .002), and in hospitals in the West region (P = .003). In multivariate analysis, SPT placement was significantly associated with younger age (P = .004), public insurance (P = .03), recent treatment years (P = .02), and hospitals in the West region (P = .02). Income and hospital teaching status did not have significant association with initial treatment choice. CONCLUSION: Urethral dilation remains the most common urologic intervention in the ED for AUR due to US; however, there is an increasing trend toward SPT placement. Patients who are younger, publicly insured, or who receive care in the West region are more likely to receive a SPT for initial treatment of AUR due to US.

Comparing Clinical and Economic Outcomes Associated with Early Initiation of Combination Therapy of an Alpha Blocker and Dutasteride or Finasteride in Men with Benign Prostatic Hyperplasia in the United States.

BACKGROUND: Benign prostatic hyperplasia (BPH) is a common disease in men that is characterized by lower urinary tract symptoms. Pharmacologic treatment with alpha blockers (ABs) and 5-alpha reductase inhibitors (5ARIs) is recommended to alleviate symptoms, prevent disease progression that can lead to complications, and reduce health care costs. OBJECTIVE: To compare clinical, economic, and health care resource utilization outcomes among BPH patients treated with early continuous combination AB and 5ARI therapy (dutasteride vs. finasteride) using administrative claims data from the United States. METHODS: A retrospective analysis of administrative claims data from 2003-2013 was conducted to compare outcomes between patients with claims for early combination therapy with dutasteride + AB and patients with claims for early finasteride + AB. The study population included males aged older than 50 years with at least 1 medical claim with a diagnosis of BPH and pharmacy dispensing for AB and 5ARI therapies. Outcomes included acute urinary retention (AUR), prostate-related surgery, clinical progression, medical and pharmacy costs, and health care resource utilization. Inverse probability of treatment (IPT) weighted Cox proportional hazards, linear, and Poisson regression models were used to assess the association between outcomes and early combination therapy as appropriate. RESULTS: A total of 2,778 patients were included in the early finasteride + AB treatment cohort, and 4,125 patients were included in the early dutasteride + AB cohort. Dutasteride users were younger than finasteride users (mean age: 64.8 vs. 67.5 years, P < 0.001) and had a greater mean number of urologist visits (10.7 vs. 7.9, P < 0.001) during baseline. After adjusting for confounding using IPT weighting, no statistically significant difference was observed between dutasteride and finasteride for AUR (hazard ratio [HR] = 0.845, 95% CI = 0.660-1.070, P = 0.1643), prostate-related surgery (HR = 0.806, 95% CI = 0.568-1.171, P = 0.2525), and clinical progression (HR = 0.834, 95% CI = 0.663-1.043, P = 0.1122). While dutasteride was associated with higher pharmacy costs per month (adjusted monthly cost difference = $79, 95% CI = $45-$105), total all-cause medical costs were not significantly different between the 2 cohorts (adjusted monthly cost difference = -$44, 95% CI = -$110-$22). CONCLUSIONS: Clinical and economic outcomes were similar between the early dutasteride + AB and early finasteride + AB cohorts, with no statistically significant differences detected. DISCLOSURES: Funding for this study was provided by GlaxoSmithKline (HO-14-15325 and AVO110072). Bell and Swensen are employees of GlaxoSmithKline. DerSarkissian, Xiao, Duh, and Lefebvre are employed by Analysis Group, a consulting company that received research grants from GlaxoSmithKline to conduct this study. Study concept and design were contributed by Bell, Swensen, Lefebvre, and Duh. Bell and Duh acquired the data. DerSarkissian and Xiao performed the statistical analysis and interpreted the data along with Lefebvre, Duh, and Bell. DerSarkissian and Bell drafted the manuscript. All authors contributed equally to critically revising the manuscript and providing final approval of the submitted manuscript.

Assessment of perioperative, early, and late postoperative complications of the inside-out transobturator tape procedure in the treatment of stress urinary incontinence..

OBJECTIVE: To evaluate the complications of urinary incontinence surgery with transobturator tape (TVT-O) system and to describe its diagnosis and management. MATERIALS AND METHODS: A total of 156 patients who were diagnosed as having stress incontinence and mixed incontinence with stress predominance underwent a TOT operation under spinal anesthesia by one surgeon or two surgeons (MB, AEY) from the team. TVT-obturator inside out material was used in the operation. Urodynamic tests and pad tests were done on all the patients. This is a prospective and retrospective study of the complications of TVT-O. The operation was performed under regional anesthesia, as described by Deval et al. Patients were excluded from the study if they had been operated under general or local anesthesia, had undergone any vaginal operations except for anterior repair (cystocele), wanted to have a baby, had severe systemic diseases or had been diagnosed as having urge incontinence in urodynamic tests. These situations may affect the rate of complications, the authors also excluded slings that had materials other than monofilament polypropylene, and patients who were suspected of having neurologic bladder conditions. The bladder and urethra were evaluated using cystoscopy. The durations of the TOT procedure, cystoscopy, and if performed, the cystocele operation, were recorded. Perioperative, early, and late postoperative complications were analyzed by follow-up visits (after two months to four years). RESULTS: Of the 156 patients included in the study, 100 (64.1%) had pure stress urinary incontinence and 56 (35.9%) had mixed incontinence, 20 (12.8%) had previous incontinence surgery. The mean duration of follow up was 30.3 ± 7.4 (range 17-42) months. The mean age of the patients was found to be 48.43 ± 6.24 years (range 42-68). The mean parity of the patients was 5.24 ± 2.86 (range 2-13), and mean body mass index was found to be 23.7 ± 4.8. Mean maximum detrusor pressure was 10.30 ± 4.08 and the mean ALP value was 80.80 ± 25.57. Mean operative time was found to be 13.8 ± 5.16 min in patients who underwent only TOT and TOT-anterior repair. Vaginal injury including to the lateral fornix (4.4%), hemorrhaging of more than 200 ml (3.2%), vascular damage (1.9%), hematoma on the leg (1.9%), hemorrhaging of more than 500 ml (0.064%), and bladder perforation (1.2%) were detected as perioperative complications. Urethral injury and perioperative nerve and intestinal injury did not occur. The most common complication in early postoperative period was inguinal pain extending the legs (30.7%), followed by headaches (23.7%), fever (12.8%), urinary tract infection (5.7%), and urinary retention (3.2%), respectively. Late postoperative complications included vaginal erosion (4.4%), de novo urge incontinence (8.9%), de novo dyspareunia (7.1%), perineal pain (4.4%), and worsening urgency (8.9%). CONCLUSION: Although the TVT-O technique is a minimal invasive surgery method applied to treat the urinary incontinence surgically, it does not imply that it is a complication-free surgical procedure. Despite the low incidence of intraoperative complications, there is a mild risk of early and late postoperative complications. Fortunately these complications can be taken under control by either conservative and simple medical treatments or surgical procedures.

Management of lower urinary retention in a limited resource setting.

BACKGROUND: There is a projected increase in lower urinary tract obstruction by 2018, especially in the developing economies of Asia and Africa. However in many of these countries, the problems encountered both by the patients and the clinicians are not well documented. Our aims are, to prospectively analyse the management of urinary retention, the associated difficulties, and complications in our setting, where access to investigative modalities such as Computerize Tomography and Magnetic Resonance Imaging are not available. PATIENTS AND METHODS: The study was approved by the University Of Calabar Teaching Hospital ethical committee. A validated Proforma was used to collect data from all patients who were clinically diagnosed with urinary retention based on history, and physical examination, from July 2009 to June 2010. Data collected from the 1st of July 2009 to the 30th of June 2010, include demographics, findings on physical examination, previous medical history and co-morbid conditions. The results of investigations done such as: urinalysis, full blood count, electrolytes, urea and creatinine, intravenous urography, trans- abdominal ultrasonography, chest X-ray and histology of trans-rectal biopsies of the prostate . The total number of new patients seen, including those with urinary retention during the study was documented. The retentions were also classified into acute and chronic. All the patients were followed up throughout the study. The data was analysed using Epi-Info statistical program version 3.4 of 2007 to analyse the data, estimating averages, mean, median and percentages. RESULTS: The total number of new patients seen, including those with urinary retention was Seventy thousand, one hundred and thirty nine (70,139).Of this number, hundred and fifty nine (0.23%), presented with urinary retention; 145 (91.2%) were acute, and14 (8.8%) were chronic. The male: female ratio was 39:1.The patients ages ranged from 4 to 94 years, with a mean of 53.7±11.2. Seventy seven [48.4%] of them were in the 6(th) and 7(th) decades of life. The common causes were; prostatic diseases [BPH and cancer of the prostate] 77.0%, infections 75.8%, trauma 12.1%, and congenital 12.1%. Urinary retention was relieved by: indwelling urethral catheterization [IUC] 120 patients (75.5%), supra- pubic cystostomy [SC] 34 (21.4%) and intermittent urethral catheterization [IC] 5 (3.1%). The most frequently encountered complications include pyuria (18.2%), pericatheter sepsis 17.5%, and haemorrhage during change of catheter 16.8% [figure 2]. Figure 2Complication after one week bladder drainage. CONCLUSION: Lower urinary retention is common in our environment. The management is appropriate and standard. The man power and facilities are inadequate, and requires urgent improvement.