Urinalysis is predictive for absence of urinary tract infection in men with and without catheters.

OBJECTIVES: To determine accuracy of negative urinalysis (UA) for predicting negative urine culture and the absence of urinary tract infection (UTI), and optimal urine culture growth cutoff for UTI diagnosis in men with and without urinary catheters. SUBJECTS AND METHODS: UAs with urine cultures within 1 week from adult men were identified and evaluated. Predictive values for the absence of UTI (absence of ≥1 of the following criteria: documentation of UTI diagnosis, antibiotic prescription, uropathogen presence on culture) were calculated. RESULTS: In total, 22 883 UAs were included. Negative UA had a high predictive value for negative urine culture (0.95, 95% confidence interval [CI]: 0.94-0.95) and absence of UTI (0.99, CI: 0.99-0.995) in the overall cohort. Negative UA also had a high predictive value for negative urine culture (0.93, CI: 0.90-0.95) and absence of UTI (0.99, CI: 0.98-0.999) in those with indwelling urinary catheters. The traditional threshold of culture growth of 100 000 colony-forming units (CFU)/mL did not capture 22% of UTIs. CONCLUSION: UA exhibits high predictive value for negative urine culture and absence of UTI in men, supporting a protocol wherein culture is only performed in the context of abnormal UA. The traditional 100 000 CFU/mL cut-off may have not captured a subset of UTI in the male population, and warrants further investigation.

First in Human Subjects Testing of the UroMonitor: A Catheter-free Wireless Ambulatory Bladder Pressure Monitor.

PURPOSE: Urodynamics is the standard method of diagnosing bladder dysfunction, but involves catheters and retrograde bladder filling. With these artificial conditions, urodynamics cannot always reproduce patient complaints. We have developed a wireless, catheter-free intravesical pressure sensor, the UroMonitor, which enables catheter-free telemetric ambulatory bladder monitoring. The purpose of this study was twofold: to evaluate accuracy of UroMonitor pressure data, and assess safety and feasibility of use in humans. MATERIALS AND METHODS: Eleven adult female patients undergoing urodynamics for overactive bladder symptoms were enrolled. After baseline urodynamics, the UroMonitor was transurethrally inserted into the bladder and position was confirmed cystoscopically. A second urodynamics was then performed with the UroMonitor simultaneously transmitting bladder pressure. Following removal of urodynamics catheters, the UroMonitor transmitted bladder pressure during ambulation and voiding in private. Visual analogue pain scales (0-5) were used to assess patient discomfort. RESULTS: The UroMonitor did not significantly alter capacity, sensation, or flow during urodynamics. The UroMonitor was also easily inserted and removed in all subjects. The UroMonitor reproduced bladder pressure, capturing 98% (85/87) of voiding and nonvoiding urodynamic events. All subjects voided with only the UroMonitor in place with low post-void residual volume. Median ambulatory pain score with the UroMonitor was rated 0 (0-2). There were no post-procedural infections or changes to voiding behavior. CONCLUSIONS: The UroMonitor is the first device to enable catheter-free telemetric ambulatory bladder pressure monitoring in humans. The UroMonitor appears safe and well tolerated, does not impede lower urinary tract function, and can reliably identify bladder events compared to urodynamics.

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

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

Surgical Management and Oncologic Outcomes of Renal Cell Carcinoma and Inferior Vena Caval Thrombi With Aggressive Histologic Variants.

OBJECTIVE: To characterize the surgical management, perioperative, and cancer-specific outcomes, and the influence of aggressive histologic variants (AHV) on operative management among patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus. RCC with rhabdoid and/or sarcomatoid differentiation, which we defined as AHV, portends a worse prognosis. AHV can be associated with a desmoplastic reaction which may complicate resection. METHODS: We reviewed patients undergoing radical nephrectomy and IVC thrombectomy between 1990 and 2020. Comparative statistics were employed as appropriate. Survival analysis was performed according to the Kaplan-Meier method, and intergroup analysis performed with log-rank statistics. Multivariable cox proportional hazards regression was used to assess the effect of AHV, age, thrombus level, vena cavectomy, metastases, and medical comorbidities on recurrence and overall survival (OS). RESULTS: Ninety-four of 403 (23.3%) patients had AHV, including 43 (46%) rhabdoid, 39 (41%) sarcomatoid, and 12 (13%) with both. AHV were more likely to present with advanced disease; however, increased perioperative complications or decreased OS were not observed. Median (IQR) survival was 16.7 (4.8-47) months without AHV and 12.6 (4-29) months with AHV (P = .157). Sarcomatoid differentiation was independently associated with worse OS (HR = 2.016, CI 1.38-2.95, P <.001), whereas rhabdoid alone or with sarcomatoid demonstrated similar OS (P = 0.063). CONCLUSION: RCC and IVC thrombus with AHV are more likely to present with metastatic disease, and sarcomatoid differentiation is associated with a worse OS. Resection of tumors with and without AHV have similar perioperative complications, suggesting that surgery can be safely accomplished in patients with RCC and IVC thrombus with AHV.

Urinalysis Exhibits Excellent Predictive Capacity for the Absence of Urinary Tract Infection.

OBJECTIVE: To assess predictive value of urinalysis for negative urine culture and absence of urinary tract infection, re-evaluate the microbial growth threshold for positive urine culture result, and describe antimicrobial resistance features. Urine culture is associated with 27% of U.S. hospitalizations, and unnecessary antibiotic prescription is a main antibiotic resistance contributor. METHODS: Urinalyses with urine culture from women ages 18-49 from 2013 to 2020 were studied. Clinically diagnosed urinary tract infection (CUTI) was defined as (1) uropathogen growth, (2) documented diagnosis of urinary tract infection, and (3) antibiotic prescription. Sensitivity, specificity, and diagnostic predictive values were used to assess urinalysis performance in predicting isolation of a uropathogen by culture and in detection of CUTI. RESULTS: Total 12,252 urinalyses were included. Forty-one percent of urinalyses were associated with positive urine culture and 1287 (10.5%) with CUTI. Negative urinalysis exhibited high predictive accuracy for negative urine culture (specificity 90.3%, PPV 87.3%) and absence of CUTI (specificity 92.2%, PPV 97.4%). Twenty-four percent of patients not meeting the CUTI definition were still prescribed antibiotics. Twenty-two percent of cultures associated with CUTI exhibited growth less than 100,000 CFU/mL. Escherichia coli was implemented as causing 70% of CUTIs, and 4.2% of these produced an extended spectrum beta-lactamase. CONCLUSION: Negative urinalysis exhibits high predictive accuracy for absence of CUTI. A reporting threshold of 10,000 CFU/mL is more clinically appropriate than a 100,000 CFU/mL cutpoint. Reflex culture based on urinalysis results could complement clinical judgement and improve laboratory and antibiotic stewardship in premenopausal women.

Extensive dystrophic calcification of eroded artificial urinary sphincter cuff-a rare cause of urethral obstruction: a case report.

Background: Despite a high technical success rate and satisfaction, complications of an artificial urinary sphincter (AUS) can occasionally occur and vary in severity from transient urinary retention to unrecognized urethral injury or urethral erosion. Infection usually occurs when urine comes into contact with the device and necessitates explant of the cuff followed by delayed device replacement. In rare cases, however, the device can remain in contact with urine for long periods of time without the sequelae normally associated with acute infection. Case Description: Here we present a case report of two patients with intraurethral migration of AUS cuffs associated with calcification resulting in urethral obstruction precluding catheterization. With extensive calcification around the cuff and longstanding complete erosion into the urethra, the urologist can expect obliteration of normal tissue planes and intense fibrosis during cuff explantation. Following excision of the cuff and stones, assessment of the urethral lumen should be performed to determine whether repair of the urethra is required. After surgery, urinary diversion with a urethral catheter is important to allow for urethral healing. Prior to considering AUS replacement, cystoscopic assessment of the urethra is critical to assess for stricture or other abnormality. Conclusions: Extensive calcification following AUS erosion into the urethra requires the expertise of a urologist with experience in urethral surgery in order to optimize outcomes. Urologists should be aware of this uncommon, but dramatic presentation of urethral obstruction due to a chronically eroded AUS cuff.

The Timing and Frequency of Infectious Complications after Radical Cystectomy: An Opportunity for Rescue Antibiotic Treatment.

INTRODUCTION: We evaluated the timing, frequency and antibiotic sensitivity of post-radical cystectomy urinary tract infections to guide an infection reduction initiative. METHODS: A combined review was performed of all patients undergoing radical cystectomy in the 2011 to 2013 American College of Surgeons NSQIP® database and 100 consecutive patients from our institution. We evaluated the rates and timing of postoperative urinary tract infection and sepsis as well as associations with hospital readmissions. Specific culture data and treatment interventions were assessed and an institution specific urinary tract infection antibiogram was created. RESULTS: Among the 3,495 patients identified in the NSQIP database the 30-day rates of urinary tract infection and sepsis were 9.5% and 9.4%, respectively, and median days to urinary tract infection and sepsis were 15 and 13. Median length of stay after radical cystectomy was 10.4 days. Overall 61.5% of urinary tract infections and 52.1% of sepsis episodes occurred after discharge home. At our institution the rates of urinary tract infection and sepsis were 15% and 9%, and occurred at a median of 14 and 18 days, respectively. The 30-day readmission rate was 21%, with 10 readmissions for infections including 7 for urinary tract infection and 5 for bacteremia. We identified 9 patients with positive urine or blood cultures for yeast requiring antifungal therapy. Of the urinary tract infections 88% were sensitive to oral agents and 79% were sensitive to nitrofurantoin or ciprofloxacin. CONCLUSIONS: The timing of urinary tract infections/sepsis after radical cystectomy is predictable on the national and institutional level. At our hospital, cultured organisms are likely to respond to well tolerated oral therapies. This information can be used to implement an outpatient antibiotic protocol to prevent infectious complications after radical cystectomy.

Inconsistent Adoption of World Health Organization V (2010) Semen Analysis Reference Ranges in the United States Eight Years After Publication.

OBJECTIVE: To determine the percentage of laboratories in the United States that have adopted the World Health Organization 2010 (WHO 5) semen analysis (SA) reference values 6years after their publication. METHODS: Laboratories were identified via 3 approaches: using the Clinical Laboratory Improvement Amendments (CLIA) website, the CDC's 2015 Assisted Reproductive Technology Fertility Clinical Success Rate Report, and automated web searches. Laboratories were contacted by phone or email to obtain de-identified SA reports and reference ranges. RESULTS: We contacted 617 laboratories in 46 states, of which 208 (26.7%) laboratories in 45 states were included in our analysis. 132 (63.5%) laboratories used WHO 5 criteria, 57 (27.4%) used WHO 4 criteria, and 19 (9.1%) used other criteria. WHO 5 criteria adoption rates varied by geographic region, ranging from 87.5% (35/40) in the Midwest to 50.0% (33/66) in the West. There was a greater adoption rate of WHO 5 reference values in academic affiliated (23/26, 88.5%) compared to non-academic affiliated laboratories (110/182, 60.4%) (P = .028). CONCLUSION: While the majority of laboratories have adopted WHO 5 criteria following its release 6years ago, a large percentage (36.5%) use what is now considered outdated criteria. This variability could result in the characterization of a male's semen values as being "within reference range" at one center and "outside of reference range" at another. This inconsistency in classification may result in confusion for the both patient and physician and potentially shift the burden of infertility evaluation and treatment to the female partner.

Intraoperative Nerve Blocks Fail to Improve Quality of Recovery after Tissue Expander Breast Reconstruction: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Clinical Trial.

BACKGROUND: The authors' study represents the first level I evidence to assess whether intraoperative nerve blocks improve the quality of recovery from immediate tissue expander/implant breast reconstruction. METHODS: A prospective, randomized, double-blinded, placebo-controlled clinical trial was conducted in which patients undergoing immediate tissue expander/implant breast reconstruction were randomized to either (1) intraoperative intercostal and pectoral nerve blocks with 0.25% bupivacaine with 1:200,000 epinephrine and 4 mg of dexamethasone or (2) sham nerve blocks with normal saline. The 40-item Quality of Recovery score, pain score, and opioid use in the postoperative period were compared statistically between groups. Power analysis ensured 80 percent power to detect a 10-point (clinically significant) difference in the 40-item Quality of Recovery score. RESULTS: Forty-seven patients were enrolled. Age, body mass index, laterality, mastectomy type, and lymph node dissection were similar between groups. There were no statistical differences in quality of recovery, pain burden as measured by visual analogue scale, opioid consumption, antiemetic use, or length of hospital stay between groups at 24 hours after surgery. Mean global 40-item Quality of Recovery scores were 169 (range, 155 to 182) for the treatment arm and 165 (range, 143 to 179) for the placebo arm (p = 0.36), indicating a high quality of recovery in both groups. CONCLUSION: Although intraoperative nerve blocks can be a safe adjunct to a comprehensive postsurgical recovery regimen, the authors' results indicate no effect on overall quality of recovery from tissue expander/implant breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Clinical symptoms that predict the presence of Obstructive Sleep Apnea.

OBJECTIVE: To determine if a set of clinical symptoms can help in determining the presence and severity of OSA. SETTING: Tertiary urban pediatric hospital. METHODS: Parents of children undergoing an overnight PSG answered a 56 item questionnaire based on their child's symptoms. The responses to the questionnaire were compared between patients with different severities of OSA (s determined by PSG) and those without OSA. Responses to questionnaire were also analyzed between obese and non-obese patients. RESULTS: 235 children were included (140 male and 95 female) with a mean age of 5.76 ± 2.78 years. The mean Apnea Hypopnea Index (AHI) was 7.78 ± 14.50 events/hour (range 0-110 events/h). 74 (31.5%) children had mild-OSA (AHI between 1 and 4.99 events/h), 31 (13.19%) had moderate-OSA (AHI between 5 and 9.99 events/h), 58 (24.7%) had severe-OSA (AHI≥10events/h) and the remaining 72 (30.64%) had No-OSA (AHI≤1event/h). 87 (37%) patients were obese. Eight clinical symptoms in non-obese and six clinical symptoms in obese patients predicted the mild to severe OSA. Sixteen symptoms in non-obese patients and nine symptoms in obese patients predicted the presence of severe OSA in these patients. CONCLUSION: Clinical symptoms reported in this study are useful to predict the presence of and the severity of OSA in children. Clinical symptoms can also predict the presence and severity of OSA in children who are obese, however, the symptoms required to make the prediction are different in obese children.

Donor-site Morbidity of Medial and Lateral Thigh-based Flaps: A Comparative Study.

BACKGROUND: Free and pedicled medial and lateral thigh-based flaps are common reconstructive procedures. However, there have been no comparative studies of morbidity between medial and lateral donor sites. METHODS: We conducted an Enterprise Data Warehouse-based review of all the senior authors' (R.D.G., G.A.D., and M.S.A.) thigh-based free and pedicled flaps. Patient demographic data, donor-site complications, drain duration, and number of postoperative visits were collected and compared. Complications were also compared between fasciocutaneous flaps and muscle or myocutaneous flaps, and skin grafted donor sites. RESULTS: We analyzed 352 flap donor sites, with 155 medial and 197 lateral. Two hundred seventeen (217) flaps were pedicled. Flap types included 127 gracilis, 27 rectus femoris, 134 anterolateral thigh, and 36 vastus lateralis-only flaps. There were no significant differences in complications between medial (17.4%) and lateral thigh (21.3%) donor sites, although lateral thigh flaps had a mean of 1 additional postoperative visit. Rates of wound dehiscence/healing issues were significantly higher in both gracilis myocutaneous flaps (25.9%) and flaps requiring a skin grafted donor site (31.2%). Postoperative therapeutic anticoagulation was the only significant risk factor for a donor-site complication. Flap complications resulted in increased drain duration and postoperative office visits. CONCLUSIONS: Donor-site morbidity is similar in both lateral and medial thigh-based flaps. The inclusion of muscle in the flap from either donor site does not seem to increase complications, but the inclusion of a skin paddle with gracilis muscle, or a skin grafted lateral thigh donor site, results in increased wound healing complications.

A systems modeling approach to the study of retinoid function: implications for evaluation of retinoids in cancer chemoprevention and/or chemotherapy.

We have used a mathematical/compartmental modeling approach along with a number of rationally designed complementary in vivo and in vitro systems to investigate the effects of administration of various retinoids and/or drug combinations on normal physiological metabolism of native retinoids. The present paper focuses on our studies of the synthetic retinoid 4-HPR and our use of fairly simple mathematical/compartmental modeling techniques to investigate how this retinoid affects the metabolism of native retinoid overall, as well as in two specific tissues, the prostate and the eyes. We have presented our work with this particular retinoid and these tissues as an example of the type of studies we have been doing and to present some of the information that one can obtain using this approach. In addition, an important objective of this paper is to highlight the fact that a great deal of critical information can be derived from fairly simple mathematical/compartmental models. When used appropriately, such models provide a powerful tool to direct the design, conduct, and interpretation of experiments. The models we developed for the prostate and the eyes were used as hypotheses to direct our research efforts in both in vivo and in vitro systems. In the case of the eyes, we were able to elucidate the possible mechanisms involved in one of the most commonly reported complications (i.e., visual function abnormalities) associated with administration of an important chemopreventive and/or chemotherapeutic agent. We are in the process of further expanding our studies with the prostate as well as several other tissues in a similar manner. The immediate clinical relevance and application of our work with the eyes demonstrate the high translational potential of our approach. Without the use of the type of mathematical/compartmental modeling approach we used, which provided the basis for much of this work, we are not aware of any other way that we could have obtained the critical information that we did. We hope that the work presented here demonstrates the usefulness, power, and potential clinical applicability of a modeling approach to investigate different retinoid-based treatments as well as a variety of other chemopreventive and/or chemotherapeutic agents.