Urologic Consultations for Urethral Catheter Placement: A Cost Analysis.

OBJECTIVE: To comprehensively analyze the cumulative costs associated with Foley consultations throughout their event lifespan. Urologic consultation for Foley catheter (Foley) management is common. Such consultations are heterogeneous, with some requiring only simple catheter placement. Others (eg, traumatic Foley) necessitate more complex procedural intervention and may also result in downstream care and/or intervention needs. METHODS: This study analyzed a retrospective database of consecutive urologic Foley consultations at a single academic institution (2017-2019), collecting comprehensive data on patient characteristics, related procedures/materials, and downstream care (eg, hospitalization, laboratory/radiology testing, evaluation and management services). A process map and related modeling were used to assess categorical and cumulative event costs. Allocated costs and charges were utilized for materials/institutional resources and for services rendered, respectively. Statistical analysis performed using SAS and statistical inferences were based on significance level of 10%. RESULTS: A total of 244 patient encounters were included in the analysis. The mean overall cost of all care related to Foley consultation was $2389.23 (±$4045.89). A total of 62 (25.4%) patients required only consultation/Foley without additional intervention, with a total cost of $738.90 (±$94.10). The remaining 182 (75.6%) patients required additional intervention and related cost (total cost $3413.27 (±$4850.41)). Traumatic catheterization was associated with higher cost compared with atraumatic cases ($3201.50 (±$6158.4) vs $1926.40 (±$1776.20), respectively, P = .05). Downstream care comprised a significant portion of overall cost. In 61 (25%) cases no nurse attempt was performed prior to consultation. CONCLUSION: Urologic Foley consultation is associated with significant health system cost. Quality initiatives to optimizing Foley placement and management are critical to improving quality of care and associated downstream costs.

Predictors of pelvic pain in a general urology clinic population.

Objectives: To assess the prevalence and predictors of chronic pelvic pain in a general urology population presenting for evaluation of unrelated non-painful complaints.Generalized pelvic pain is estimated to afflict between 6% and 26% of women and is often multifactorial in aetiology. A paucity of prospective research exists to characterize chronic pelvic pain patterns and to understand related predictors. Materials and Methods: This is a prospective, cross-sectional survey-based study of female patients presenting to a general urology clinic over a 10-month period (7/2018-5/2019). Patients completed a 32-item survey with questions pertaining to demographics, comorbidities and chronic pelvic pain characteristics. Comparison tests (chi-squared, Fisher's exact) and stepwise multivariable logistic modelling were performed to assess for predictors of chronic pelvic pain. Results: A total of 181 women completed the survey, with a mean age of 56 years. Overall, 75 (41%) women reported chronic pelvic pain. Those with chronic pelvic pain were younger compared to those without (52 vs 59 years, p = 0.001). Univariable logistic regression analysis identified BMI, depression, fibromyalgia, overactive bladder and any bowel symptoms as possible positive predictors of chronic pelvic pain. Final best-fit multivariable model found overactive bladder, fibromyalgia and presence of bowel symptoms as independent positive predictors of chronic pelvic pain. Conclusions: Our study is one of the few studies that has prospectively analysed chronic pelvic pain and its predictors. The present study identified significant associations with overactive bladder, fibromyalgia and bowel symptoms. Further research is needed to better understand the aetiologies of chronic pelvic pain and the possible relationship with identified clinical predictors.

Comparison of microwave ablation and partial nephrectomy for T1a small renal masses.

OBJECTIVE: To compare the oncological and renal function outcomes of microwave ablation (MWA) compared to partial nephrectomy (PN) in two small renal mass (SRM) tumor size cohorts, <3 cm and 3-4 cm. MATERIALS AND METHODS: This study included retrospective data from 2009 to 2015 and prospective data since 2015 from a single-institution database. Patient demographics, renal mass characteristics, and treatment outcomes were collected. Survival curves and hazard analysis were used to assess oncological outcomes. Changes in eGFR and CKD stage following surgery were used to assess renal function outcomes. RESULTS: A total of 80 PN and 126 MWA patients were analyzed. Median age and Charlson Comorbidity Index (CCI) of MWA patients were greater than PN for each tumor size cohort. Cumulative progression free survival at 36-months was 91% for MWA and 90% for PN. Preoperative renal function was significantly lower in patients undergoing MWA for both tumor sizes, however there was no significant difference in the postoperative change in renal function between MWA and PN for tumors up to 4 cm. CONCLUSIONS: Oncological outcomes and renal preservation were comparable between MWA and PN cohorts for SRMs <3cm and 3-4cm despite the MWA cohort being older and having more comorbidities. Our findings suggest that MWA can be used as a safe and effective alternative to PN for T1a renal tumors up to 4 cm.

Do patients with Peyronie's disease perceive penile curvature in adults and children differently than the general population?

BACKGROUND: As perception of penile curvature varies widely, we sought to understand how adults perceive curvature and how these opinions compare with those of patients with curvature, specifically Peyronie's disease (PD). AIM: To investigate the perspectives of curvature correction from adults with and without PD, as well as differences within demographics. METHODS: A cross-sectional survey was administered to adult patients and nonpatient companions in general urology clinics at 3 institutions across the United States. Men, women, and nonbinary participants were recruited. Patients were grouped as having PD vs andrology conditions without PD vs general urology conditions plus companions. The survey consisted of unlabeled 2-dimensional images of penis models with varying degrees of curvature. Participants selected images that they would want surgically corrected for themselves and their children. Univariable and multivariable analyses were performed to identify demographic variables associated with willingness to correct. OUTCOMES: Our main outcome was to detect differences in threshold to correct curvature between those with and without PD. RESULTS: Participants were grouped as follows: PD (n = 141), andrology (n = 132), and general (n = 302) . Respectively, 12.8%, 18.9%, and 19.9% chose not to surgically correct any degree of curvature (P = .17). For those who chose surgical correction, the mean threshold for correction was 49.7°, 51.0°, and 51.0° (P = .48); for their children, the decision not to correct any degree of curvature was 21.3%, 25.4%, and 29.3% (P = .34), which was significantly higher than correction for themselves (P < .001). The mean threshold for their children's correction was 47.7°, 53.3°, and 49.4° for the PD, andrology, and general groups (P = .53), with thresholds no different vs themselves (P = .93). On multivariable analysis, no differences were seen in demographics within the PD and andrology groups. In the general group, participants aged 45 to 54 years and those who identified as LGBTQ (lesbian, gay, bisexual, transgender, queer) had a higher threshold for correction as compared with their counterparts when factoring other demographic variables (63.2° vs 48.8°, P = .001; 62.1° vs 50.4°, P = .05). CLINICAL IMPLICATIONS: With changing times and viewpoints, this study stresses the importance of shared decision making and balancing risks and benefits to correction of penile curvature. STRENGTHS AND LIMITATIONS: Strengths include the broad population surveyed. Limitations include the use of artificial models. CONCLUSION: No significant differences were seen in the decision to surgically correct curvature between participants with and without PD, with participants being less likely to choose surgical correction for their children.

International Iohexol Shortage: Alternative Contrast Agents and Imaging Procedures for the Urologist.

INTRODUCTION: In April 2022, GE Healthcare announced a COVID-19-related interruption in iohexol manufacturing, leading to an international iodinated contrast shortage. The shortage greatly impacted urological practice, highlighting the value of alternative contrast agents and imaging/procedure alternatives. These alternatives are reviewed in this work. METHODS: A review of existing literature describing the use of alternative contrast agents, alternative imaging procedures, and contrast conservation strategies in urological care was performed using the PubMed database. The review was not performed systematically. RESULTS: Older iodinated contrast agents such as ioxaglate and diatrizoate can replace iohexol for intravascular imaging in patients without renal impairment. These agents, along with gadolinium-based agents such as Gadavist, have been used intraluminally for urological procedures and diagnostic imaging. Several lesser-known imaging and procedure alternatives are described and include air contrast pyelography, contrast-enhanced ultrasound, voiding urosonography, and low tube voltage CT urography. Conservation strategies include contrast dose reductions and use of contrast management devices for contrast vial splitting. CONCLUSIONS: The COVID-19-related iohexol shortage caused significant hardship for urological care internationally, leading to delayed contrasted imaging studies and urological procedures. Alternative contrast agents, imaging/procedure alternatives, and conservation strategies are reviewed in this work with the goal of equipping the urologist to mitigate the current iodinated contrast shortage and to prepare in the event of a future shortage.

Complex Foley Catheter Placement After Radical Prostatectomy.

OBJECTIVE: To describe a method for replacement of a dislodged critical urethral foley catheter following a robotic- assisted laparoscopic radical prostatectomy. BACKGROUND: Following robotic-assisted laparoscopic radical prostatectomy (RALP), a bladder drainage via catheter is necessary to allow for proper healing of the urethrovesical anastomosis. In most cases, this is done using a transurethral foley catheter.1,2 Early traumatic loss of the urethral catheter following RALP is consider a urologic emergency and can lead to vesicourethral anastomotic urine leak, ileus, infection or abscess, and future anastomotic stenosis.3 Replacing the urethral catheter in this situation can be difficult even in experienced hands and often requires imaging assistance. METHOD: A 53-year-old male with Grade Group 4 (Gleason 4 + 4) prostate cancer underwent an uncomplicated RALP. During his post-operative course, his urethral foley catheter fell out or was traumatically removed three times resulting in disruption of the posterior anastomosis. To replace the urethral catheter and prevent it from being dislodged again, a transabdominal approach under ultrasound and cystoscopic guidance was employed to replace the catheter into the bladder and secure it trans abdominally using a single G-tube safety Pexy T fastener. CONCLUSION: This case reports describes a technique used to replace and secure a urethral foley catheter in a patient who suffered from a posterior anastomotic disruption following repeated loss and traumatic removal of his urethral foley catheter during his RALP post-operative course. While replacement of a dislodged urethral foley catheter following a RALP can be challenging, the catheter can safely be placed and secured trans abdominally in these rare but serious situations where the conventional catheter secure devices and patient education alone are not sufficient to prevent removal.

Cost-effectiveness analysis: percutaneous microwave ablation vs robotic-assisted partial nephrectomy for small renal masses.

PURPOSE: The majority of newly diagnosed renal tumors are masses < 4 cm in size with treatment options, including active surveillance, partial nephrectomy, and ablative therapies. The cost-effectiveness literature on the management of small renal masses (SRMs) does not account for recent advances in technology and improvements in technical expertise. We aim to perform a cost-effectiveness analysis for percutaneous microwave ablation (MWA) and robotic-assisted partial nephrectomy (RA-PN) for the treatment of SRMs. METHODS: We created a decision analytic Markov model depicting management of the SRM incorporating costs, health utilities, and probabilities of complications and recurrence as model inputs using TreeAge. A willingness to pay (WTP) threshold of $100,000 and a lifetime horizon were used. Probabilistic and one-way sensitivity analyses were performed. RESULTS: Percutaneous MWA was the preferred treatment modality. MWA dominated RA-PN, meaning it resulted in more quality-adjusted life years (QALYs) at a lower cost. Cost-effectiveness analysis revealed a negative Incremental Cost-Effectiveness Ratio (ICER), indicating dominance of MWA. The model revealed MWA had a mean cost of $8,507 and 12.51 QALYs. RA-PN had a mean cost of $21,521 and 12.43 QALYs. Relative preference of MWA was robust to sensitivity analysis of all other variables. Patient starting age and cost of RA-PN had the most dramatic impact on ICER. CONCLUSION: MWA is more cost-effective for the treatment of SRM when compared with RA-PN and accounting for complication and recurrence risk.

Upper pole pathologies in duplex kidneys: an analysis of predictive factors for surgery and urinary tract infections from the Mid-Atlantic Pediatric Academic Consortium.

BACKGROUND/OBJECTIVE: While there is significant data on the natural history and outcomes for prenatal hydronephrosis in simplex kidneys, duplex kidneys tend to be less studied. Management can be quite variable based on provider preference. We aimed to describe practice patterns from several tertiary academic institutions, identify clinical predictors for surgical intervention and urinary tract infection (UTI) for upper pole pathology, and demonstrate the natural history of lower pole vesicoureteral reflux (VUR). METHODS: We conducted a retrospective review of patients from 4 Mid-Atlantic institutions between 2015 and 2020. Inclusion criteria included patients with a duplex kidney with upper pole pathology and/or lower pole VUR. The primary outcome was predictive factors for surgical intervention and UTI. The secondary outcome was to assess the natural history of lower pole VUR including resolution rates by grade. Linear regression identified clinical predictors for UTI events. Multivariate logistic regression identified predictors of surgical intervention, UTI, and lower pole VUR resolution. Descriptive statistics and regression modeling analyses were performed using SAS. RESULTS: Two hundred forty-two patients were included with a total of 271 duplex renal units. Hydronephrosis grade (both SFU and UTD grading) and number of prior UTI events were statistically significant predictors for surgical intervention (p = 0.03/0.001 and p = 0.002 respectively). Ectopic ureter (p = 0.004), ureterocele (p = 0.02), and obstruction (p = 0.04) were the only pathologies predictive for surgery. Male gender and circumcision were significantly associated with decreased UTI risk (p = 0.03 and p = 0.01). On linear regression modeling, antibiotic prophylaxis after the first year of life was associated with decreased risk of further UTI events (p = 0.03); however, antibiotic prophylaxis within the first year of life did not decrease UTI risk (p = 0.14). For VUR outcomes, 65.0% of grades 1-3 VUR and 52.2% of grades 4-5 had resolution/improvement at mean time of 2.1 years. There were no predictive factors for resolution/improvement of VUR. CONCLUSIONS: Hydronephrosis grade and UTI events were significant predictors for surgical intervention for upper pole pathology. Pathologies that were predictive for surgery included ectopic ureter, ureterocele and obstruction. Male gender, circumcision and antibiotic prophylaxis after the first year of life were associated with a decreased UTI risk. Roughly 58% of lower pole VUR spontaneously improved/resolved. Identification of these risk factors aids in standardization of care practices to reduce long-term UTI risk and inform counseling with families about possible need for surgical intervention and expectations for long term outcomes.

Inferior Vena Cava Thrombus Secondary to Ureteropelvic Junction Obstruction with Severe Hydronephrosis.

BACKGROUND: Benign external compression of the Inferior Vena Cava (IVC) with distal thrombus formation is seldomly described in the medical literature. CASE PRESENTATIONS: We report a case of external IVC compression by a dilated right renal pelvis and hydronephrotic kidney secondary to longstanding Ureteropelvic Junction (UPJ) obstruction found in a 68-year-old male. Management included therapeutic anticoagulation, IVC filter placement, attempted thrombectomy by interventional radiology, and interval repeats imaging. This patient demonstrated complete resolution of the caval thrombus on repeat imaging 2 months following discharge. This case highlights the importance of interdisciplinary team coordination, a crucial component of patient's management and eventual treatment plan. It is reasonable to manage patients with IVC thrombus with anticoagulation alone. CONCLUSION: In the modern era, angiointerventional techniques provide minimally invasive approaches to the management of vascular disorders and minimize morbidity.

Economic Impact of Urological Conditions in Men and Women in Belize.

INTRODUCTION: Urological disease is prevalent in low- and middle-income countries. Concurrently, the inability to maintain employment or provide family care contributes to poverty. We assessed the microeconomic impacts of urological disease in Belize. METHODS: We conducted a prospective survey-based assessment of patients evaluated during surgical trips by the charity Global Surgical Expedition. Patients completed a survey focusing on impact of urological disease on work and caretaker responsibilities, as well as its economic impact. The primary study outcome was income loss resulting from work impairment or work time missed related to urological disease. Income loss was calculated using the validated Work Productivity and Activity Impairment Questionnaire. RESULTS: A total of 114 patients completed surveys. Overall, 87.7% and 37.2% of respondents reported a negative impact of urological disease on job and caretaking responsibilities, respectively. Nine (7.9%) patients were unemployed secondary to their urological disease. Sixty-one (53.5%) patients provided financial data sufficient for analysis. In this cohort, median weekly income was $250 Belize dollars (approximately $125 United States Dollars), while median weekly cost for urological disease treatment was $25 Belize dollars. Among the 21 (34.5%) patients who missed work due to urological disease, median weekly income loss was $35.6 Belize dollars, representing 55% of their total income. A vast majority (88.6%) of patients reported that cure of urological disease would increase ability to work and/or care for family. CONCLUSIONS: In Belize, urological disease results in significant impairment of work and caretaking responsibilities, as well as income loss. Efforts are necessary to provide urological surgeries in low- and middle-income countries as urological disease impacts not only quality of life, but also financial health.

Prevalence and characterization of dyspareunia in a general urology clinic population.

INTRODUCTION: To assess the character and prevalence of dyspareunia in a general urology population presenting for evaluation of unrelated non-painful complaints. MATERIALS AND METHODS: This is an IRB-approved, prospective, cross-sectional survey-based assessment of dyspareunia in a general cohort of female patients presenting to a urology clinic over a 10-month period (7/2018-5/2019). Patients presenting specifically for acute painful complaints were excluded. Participating patients completed an original 23-item survey with questions pertaining to dyspareunia. Specific focus was placed on pain characteristics, including location, quality, frequency, severity, and quality of life. Descriptive analysis, pain mapping, and plotting analyses were performed to assess pain patterns. RESULTS: A total of 181 women completed the survey, with a mean age of 56 years. Overall, 53 (29%) women reported dyspareunia. However, among currently sexually active women the prevalence of dyspareunia was 46% (38/83). Patients reported a significant variety of pain locations and qualities. Women most commonly reported multiple pain locations (median 2 (IQR 1,4)), with 33 distinct combinations identified. The majority (70%) of women endorsed only one pain quality, although eight unique combinations were nonetheless seen. A significant proportion (34%) reported high or very high pain severity, with 45% having pain most or all times of sexual activity. A majority (53%) of patients indicated moderate to severe dissatisfaction with their sexual activity. Despite this finding, a significant proportion (33%) of patients with dyspareunia reported having at least weekly sexual activity. CONCLUSIONS: A significant percentage of women presenting to a general urology clinic experience dyspareunia. Notably, patient-reported pain characteristics, including location and quality, varied significantly across women assessed. Further study is needed to understand how these characteristics may relate to different and specific etiologies of sexual pain and directed treatment options.

Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis.

BACKGROUND: Ureteroenteric stricture incidence has been reported as high as 20% after urinary diversion. Many patients have undergone prior radiotherapy for prostate, urothelial, colorectal, or gynecologic malignancy. We sought to evaluate the differences between ureteroenteric stricture occurrence between patients who had radiation prior to urinary diversion and those who did not. METHODS: An IRB-approved cystectomy database was utilized to identify ureteroenteric strictures among 215 patients who underwent urinary diversion at a single academic center between 2016 and 2020. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Strictures due to malignant ureteral recurrence were excluded (3 patients). Statistical analysis was performed using chi squared test, t-test, and Wilcoxon Rank-Sum Test, logistic regression, and Kaplan-Meier analysis of stricture by cancer type. RESULTS: 65 patients had radiation prior to urinary diversion; 150 patients did not have a history of radiation therapy. Benign ureteroenteric stricture rate was 5.3% (8/150) in the non-radiated cohort and 23% (15/65) in the radiated cohort (p = < 0.001). Initial management of stricture was percutaneous nephrostomy (PCN) in 78% (18/23) and the remaining 22% (5/23) were managed with primary retrograde ureteral stent placement. Long term management included ureteral reimplantation in 30.4% (7/23). CONCLUSIONS: Our study demonstrates a significant increase in rate of ureteroenteric strictures in radiated patients as compared to non-radiated patients. The insult of radiation on the ureteral microvascular supply is likely implicated in the cause of these strictures. Further study is needed to optimize surgical approach such as utilization of fluorescence angiography for open and robotic approaches.

Perioperative Cost Comparison between Percutaneous Microwave Ablation and Partial Nephrectomy for Localized Renal Masses.

INTRODUCTION: We sought to determine and compare the perioperative cost associated with percutaneous microwave ablation (MWA) and robot-assisted partial nephrectomy (RA-PN) for treatment of localized renal masses (LRMs). METHODS: We conducted a retrospective cohort analysis of a prospectively maintained IRB-approved LRM database. The database was queried for patients treated with microwave ablation or partial nephrectomy from 2015 to 2020. Allocated costs related to the procedural encounter and related to complications were collected. Allocated cost was calculated using ratio of cost-to-charges cost accounting methodology. Total cost was the sum of medical center cost and physician related cost. Statistical analysis was performed in SAS using Student's t-test and the Wilcoxon rank-sum test. RESULTS: A total of 279 patients were identified, of whom 165 underwent percutaneous MWA and 114 underwent RA-PN. All partial nephrectomies were robot-assisted. The mean total cost was $20,536 for RA-PN and $6,470 for percutaneous MWA (p <0.0001). Five patients (3%) who underwent MWA and 7 (6%) who underwent RA-PN experienced complications. Patients who underwent MWA and did not have a major complication had an average medical center cost of $5,174, compared to $8,990 for those with a major complication (p=0.36). Among patients who underwent RA-PN, those who did not have a major complication had an average medical center cost of $15,138, compared to $28,940 for those who did have a major complication (p=0.008). CONCLUSIONS: MWA demonstrates lower perioperative cost and lower cost of complications than RA-PN for treatment of LRM. Further cost-effectiveness studies for LRM treatment should be performed with this updated cost information.

Characterization and Prevalence of Female Pelvic Pain in a General Outpatient Urology Population.

OBJECTIVE: To assess the character and prevalence of female pelvic pain in a general urology population presenting for evaluation of unrelated non-painful complaints. METHODS: This is an IRB-approved, prospective, cross-sectional survey-based assessment of pelvic pain in a general cohort of female patients presenting to a urology clinic over a 10-month period (7/2018-5/2019). Patients presenting specifically for acute painful complaints (eg, kidney stones) were excluded. Participating patients completed an original 22-item survey with questions pertaining to pelvic pain. Specific focus was placed on pain characteristics, including location, quality, frequency, exacerbating factors, and severity. Descriptive analysis, pain mapping, and plotting analyses were performed to assess pain patterns. RESULTS: A total of 181 women (mean age 56 years) completed the survey. Overall, 75 (41%) women reported pelvic pain. Two-thirds reported experiencing pain "often" to "always" over the preceding month. Patients described a significant variety of pain locations and qualities. The most common sites of pain were lower back (73%) and bladder (72%), while "dull/aching" was the most common pain quality. A majority (84%) of patients had multiple concurrent pain locations, with 40 unique pain location combinations being reported. Similarly, 13 and 10 unique combinations were seen with pain quality and eliciting activity, respectively. CONCLUSION: A significant percentage of women presenting to a general urology clinic experience pelvic pain. There was wide variety of pain characteristics and unique patterns. Further research is needed to comprehensively assess pain characteristics and develop related diagnostic pathways.