Evaluation of the efficacy of sacral neuromodulation in the treatment of voiding dysfunction after endometriosis surgery.

Pelvic surgery for endometriosis is associated with a risk of bladder and digestive sequelae. Sacral neuromodulation (SNM) has been shown to be effective in the treatment of overactive bladder (OAB) and voiding dysfunction (VD). This study aimed to evaluate the efficacy of sacral neuromodulation (SNM) in treating voiding dysfunction (VD) following endometriosis surgery. A retrospective analysis was conducted on data from women who underwent SNM testing for persistent VD after endometriosis surgery. The study included 21 patients from a French tertiary referral center. Patient characteristics, lower urinary tract symptoms, urodynamic findings, SNM procedures, and outcomes were assessed. The primary outcome was the success of SNM treatment for VD. After a median follow-up of 55 months, 60% of patients achieved successful outcomes, with significant improvements of VD and quality of life. Moreover, more than half of patients who required clean intermittent self-catheterization (CISC) before SNM were able to wean off CISC. Complications such as infections and paraesthesia were observed, but overall, SNM was found to be effective and well tolerated. Age and the interval between endometriosis surgery and SNM testing were associated with treatment success. This study adds to the limited existing literature on SNM for VD after endometriosis surgery and suggests that SNM can be a valuable therapeutic option for these patients. Further research is needed to identify predictive factors and mechanisms underlying the effectiveness of SNM in this context. MRI-compatible and rechargeable devices, has improved the feasibility of SNM for these patients. In conclusion, SNM offers promise as a treatment option for persistent VD after endometriosis surgery, warranting further investigation. LEVEL OF EVIDENCE: 4.

Hot Topics of the Past Decade: Evolutions and Revolutions in Lower Urinary Tract Symptoms.

The past decade has seen the emergence of numerous alternatives to traditional surgery for benign prostatic obstruction. Further trials are ongoing and will probably change our views on management of male lower urinary tract symptoms.

Contemporary rates of adherence to international guidelines for pelvic lymph node dissection in radical cystectomy: a population-based study.

OBJECTIVE: To examine the rates of adherence to guidelines for pelvic lymph node dissection (PLND) in patients treated with radical cystectomy (RC) and to identify predictors of omitting PLND. MATERIALS AND METHODS: We relied on 66,208 patients treated with RC between 2004 and 2013 within the National Inpatients Sample (NIS) database. We examined the rates of PLND according to year of surgery, patient and hospital characteristics. Univariate and multivariate logistic regression analyses assessed the probability of PLND use, after adjusting for year of surgery, age, gender, race, comorbidities, hospital location, teaching status and hospital surgical volume. RESULTS: Overall, PLND was performed on 54,223 (81.9%) RC patients. The rates PLND at RC significantly increased over the study period from 72.3% in 2004 to 85.9% in 2013, (p < 0.001). Barriers to PLND at RC consisted of female gender (OR: 1.31; 95% CI 1.25-1.38; p < 0.001), African American race (OR: 1.21; 95% CI 1.10-1.32; p < 0.001), intermediate (OR: 1.78; 95% CI 1.68-1.88; p < 0.001) or low surgical volume institutions (OR: 2.59; 95% CI 2.44-2.74; p < 0.001), non-teaching institution status (OR: 1.21; 95% CI 1.15-1.27; p < 0.001) and rural hospital location (OR: 1.13; 95% CI 1.01-1.25; p = 0.03). CONCLUSIONS: It is encouraging to note increasing rates of PLND at RC over time. Both patients and hospital characteristics influence PLND rates. More efforts should be aimed at reducing inequalities in PLND at RC due to these highly modifiable variables.

Location of Metastatic Bladder Cancer as a Determinant of In-hospital Mortality After Radical Cystectomy.

BACKGROUND: A recent study of a highly select cohort suggested a survival benefit when local treatment is delivered in patients with metastatic bladder cancer (BCa). OBJECTIVE: We examined in-hospital mortality (IHM) rates according to the presence, absence, and location of metastatic disease in a similar highly select cohort of BCa patients treated with radical cystectomy (RC). DESIGN, SETTING, AND PARTICIPANTS: We used data for 25 004 BCa patients included in the National Inpatients Sample (NIS) database between 1998 and 2013. INTERVENTION: Radical cystectomy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We tested postoperative IHM rates according to the presence of metastases and the location of metastatic disease (exclusive nodal vs distant metastases). Multivariable logistic regression analyses were adjusted for age, gender, race, comorbidities, length of hospitalization, hospital location, teaching status, hospital surgical volume, and bed size. RESULTS AND LIMITATIONS: Among 25 004 BCa patients treated with RC, 3830 (14.4%) had nonregional lymph node metastases (NRNM), 693 (2.8%) had distant metastases (DM), and 19 965 (79.8%) had nonmetastatic disease. Virtually all patients with metastatic BCa had a single metastatic focus (n=4020; 93.7%). In multivariable logistic regression analyses, DM (odds ratio [OR] 2.31, 95% confidence interval [CI] 1.57-3.28; p<0.001) but not NRNM (OR 0.88, 95% CI 0.66-1.15; p=0.4) was associated with higher risk of IHM. The absence of information on preoperative chemotherapy and the retrospective study design may limit our findings. CONCLUSIONS: The risk of IHM for highly select individuals with NRNM treated with RC is similar to that for patients with nonmetastatic BCa. Conversely, patients with DM are at higher risk of IHM compared to patients with NRNM. PATIENT SUMMARY: According to existing data, radical cystectomy in the metastatic bladder cancer setting should be limited to patients with nonregional lymph node metastases, if at all indicated.

Local Therapy Improves Survival in Metastatic Prostate Cancer.

BACKGROUND: Treatment of the primary, termed local therapy (LT), may improve survival in metastatic prostate cancer (mPCa) versus no local therapy (NLT). OBJECTIVE: To assess cancer-specific mortality (CSM) after LT versus NLT in mPCa. DESIGN, SETTING, AND PARTICIPANTS: Within the Surveillance, Epidemiology and End Results database (2004-2013), 13 692 mPCa patients were treated with LT (radical prostatectomy [RP] or radiation therapy [RT]) or NLT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable competing risk regression analyses (MVA CRR) tested CSM after propensity score matching (PSM) in two analyses, (1) NLT versus LT and (2) RP versus RT, and were complemented with interaction, sensitivity, unmeasured confounder, and landmark analyses. RESULTS AND LIMITATIONS: Of 13 692 mPCa patients, 474 received LT: 313 underwent RP and 161 RT. In MVA CRR, after PSM, LT (n=474) results in lower CSM (subhazard ratio [SHR] 0.40, 95% confidence interval [CI] 0.32-0.50) versus NLT (n=1896). In MVA CRR after PSM, RP (n=161) results in lower CSM (SHR 0.59, 95% CI 0.35-0.99) versus RT (n=161). Invariably, lowest CSM rates were recorded for Gleason ≤7, ≤cT3, and M1a substage. Interaction and sensitivity analyses confirmed the robustness of results, and landmark analyses rejected the bias favouring LT. A strong unmeasured confounder (HR=5), affecting 30% of NLT patients, could obliterate LT benefit. Data were retrospective. CONCLUSIONS: In mPCa, LT results in lower mortality relative to NLT. Within LT, lower mortality is recorded after RP than RT. Patients with most favourable grade, local stage, and metastatic substage derive most benefit from LT. They also derive most benefit from RP, when LT types are compared (RP vs RT). It is important to consider study limitations until ongoing clinical trials confirm the proposed benefits. PATIENT SUMMARY: Individuals with prostate cancer that spreads outside of the prostate might still benefit from prostate-directed treatments, such as radiation or surgery, in addition to receiving androgen deprivation therapy.

Population-Based External Validation of the Updated 2012 Partin Tables in Contemporary North American Prostate Cancer Patients.

OBJECTIVE: To externally validate the updated 2012 Partin Tables in contemporary North American patients treated with radical prostatectomy (RP) for localized prostate cancer (PCa) at community institutions. MATERIALS AND METHODS: We examined records of 25,254 patients treated with RP and pelvic lymph node dissection (PLND) between 2010 and 2013, within the surveillance, epidemiology, and end results database. The ROC derived AUC assessed discriminant properties of the updated 2012 Partin Tables of organ confined disease (OC), extracapsular extension (ECE), seminal vesical invasion (SVI), and lymph node invasion (LNI). Calibration plots focused on calibration between predicted and observed rates. RESULTS: Proportions of OC, ECE, SVI, and LNI at RP were 69.8%, 18.4%, 7.4%, and 4.4%, respectively. Accuracy for prediction of OC, ECE, SVI, and LNI was 70.4%, 59.9%, 72.9%, and 77.1%, respectively. In subgroup analyses in patients with nodal yield >10, accuracy for LNI prediction was 76.0%. Subgroup analyses in elderly patients and in African American patients revealed decreased accuracy for prediction of all four endpoints. Last but not least, SVI and LNI calibration plots showed excellent agreement, versus good agreement for OC (maximum underestimation of 10%) and poor agreement for ECE (maximum overestimation of 12%). CONCLUSION: Taken together, the updated 2012 Partin Tables can be unequivocally endorsed for prediction of OC, SVI, and LNI in community-based patients with localized PCa. Conversely, ECE predictions failed to reach the minimum accuracy requirements of 70%. Prostate 77:105-113, 2017. © 2016 Wiley Periodicals, Inc.

Contemporary rates of pathological features and mortality for adenocarcinoma of the urinary bladder in the USA.

OBJECTIVES: To examine contemporary rates of pathological features and mortality for adenocarcinoma of the urinary bladder in the USA using population-based data analysis. METHODS: We relied on 10 024 patients with non-metastatic bladder cancer diagnosed between 2004 and 2013 within the Surveillance, Epidemiology and End Results registries. Logistic regression analyses focused on grade and stage. Kaplan-Meier analyses assessed cancer-specific mortality rates in adenocarcinoma and urothelial carcinoma of the bladder. Cox regression analyses assessed the impact of histological subtype on cancer-specific mortality. RESULTS: Overall, 215 (2.1%) adenocarcinoma and 9809 (97.9%) urothelial carcinoma patients were identified. The rate of non-organ-confined disease was higher in adenocarcinoma (64.7% vs 50.8%, P < 0.001). In multivariable logistic regression analyses, adenocarcinoma patients had a 2.2-fold higher risk of harboring non-organ-confined disease (95% confidence interval 1.7-3.0; P < 0.001) than urothelial carcinoma patients. Cancer-specific mortality-free survival rates were lower in adenocarcinoma (P < 0.01). This disadvantage only applied to non-organ-confined disease (P = 0.044), and not to organ-confined disease (P = 0.9). In multivariable Cox regression analyses, adenocarcinoma conferred a 1.3-fold higher rate of cancer-specific mortality (hazard ratio 1.30, 95% confidence interval 1.05-1.60; P = 0.01). Among adenocarcinoma patients, 30.7% harbored signet-ring cell adenocarcinoma and portended particularly poor cancer-specific mortality rates. CONCLUSIONS: In bladder cancer, adenocarcinoma presents at higher stages than urothelial carcinoma. However, cancer-specific mortality rates do not differ. A more unfavorable stage at diagnosis and higher cancer-specific mortality apply to the signet-ring cell variant.

Predicting preterm birth in twin pregnancy: was the previous birth preterm? A Canadian experience.

OBJECTIVE: Most studies determining risk of preterm birth in a twin pregnancy subsequent to a previous preterm birth are based on linkage studies or small sample size. We wished to identify recurrent risk factors in a cohort of mothers with a twin pregnancy, eliminating all known confounders. METHODS: We conducted a retrospective cohort study of twin births at a tertiary care centre in Montreal, Quebec, between 1994 and 2008, extracting information, including chorionicity, from patient charts. To avoid the effect of confounding factors, we included only women with a preceding singleton pregnancy and excluded twin-to-twin transfusion syndrome, fetal chromosomal/structural anomalies, fetal demise, and preterm iatrogenic delivery for reasons not encountered in both pregnancies. We used multiple regression and sensitivity analyses to determine recurrent risk factors. RESULTS: Of 1474 twin pregnancies, 576 met the inclusion criteria. Of these, 309 (53.6%) delivered before 37 weeks. Preterm birth in twins was strongly associated with preterm birth of the preceding singleton (adjusted OR 3.23; 95% CI 1.75 to 5.98). The only other risk factors were monochorionic twins (adjusted OR 1.82; 95% CI 1.21 to 2.73) and oldest or youngest maternal ages. Chronic or gestational hypertension, preeclampsia, and insulin-dependent diabetes during the singleton pregnancy did not significantly affect risk. CONCLUSION: Preterm birth in a previous singleton pregnancy was confirmed as an independent risk factor for preterm birth in a subsequent twin pregnancy. This three-fold increase in risk remained stable regardless of year of birth, inclusion/exclusion of pregnancies following assisted reproduction, or defining preterm birth as < 34 or < 37 weeks' gestational age. Until the advent of optimal preventive strategies, close obstetric surveillance of twin pregnancies is warranted.

Objectif : La plupart des études qui cherchent à déterminer le risque d'accouchement préterme dans le cadre d'une grossesse gémellaire se déroulant à la suite d'un accouchement préterme sont fondées sur des études de liaison ou des échantillons de faible envergure. Nous souhaitions identifier les facteurs de risque récurrents au sein d'une cohorte de mères connaissant une grossesse gémellaire, en éliminant toutes les variables de confusion connues. Méthodes : Nous avons mené une étude de cohorte rétrospective qui portait sur les grossesses gémellaires ayant donné lieu à un accouchement au sein d'un centre de soins tertiaires de Montréal, au Québec, entre 1994 et 2008; nous avons extrait les données requises (dont la chorionicité) des dossiers des patientes. Pour éviter l'effet des facteurs de confusion, nous n'avons inclus que des femmes ayant déjà connu une grossesse monofœtale et avons exclu les cas de syndrome transfuseur-transfusé, d'anomalies chromosomiques / structurelles fœtales, de décès fœtal et d'accouchement préterme iatrogène pour des motifs n'ayant pas été constatés au cours des deux grossesses. Nous avons fait appel à des analyses de régression multiple et de sensibilité pour déterminer les facteurs de risque récurrents. Résultats : Parmi les 1 474 grossesses gémellaires recensées, 576 ont satisfait aux critères d'inclusion. Parmi celles-ci, 309 (53,6 %) accouchements ont eu lieu avant 37 semaines. L'accouchement préterme dans le cadre d'une grossesse gémellaire à été fortement associé au fait d'avoir connu un accouchement préterme dans le cadre de la grossesse monofœtale précédente (RC corrigé, 3,23; IC à 95 %, 1,75 - 5,98). Les seuls autres facteurs de risque ont été les jumeaux monozygotes (RC corrigé, 1,82; IC à 95 %, 1,21 - 2,73) et les âges maternels les plus vieux ou les plus jeunes. La présence d'une hypertension chronique ou gestationnelle, d'une prééclampsie et d'un diabète insulino-dépendant au cours de la grossesse monofœtale n'a pas exercé un effet significatif sur le risque. Conclusion : Le fait d'avoir connu un accouchement préterme dans le cadre d'une grossesse monofœtale précédente a été confirmé comme étant un facteur de risque indépendant d'accouchement préterme dans le cadre d'une grossesse gémellaire subséquente. Ce triplement du risque est demeuré stable, peu importe l'année de naissance, l'inclusion / exclusion des grossesses attribuables à la procréation assistée ou la définition de l'accouchement préterme comme étant < 34 ou < 37 semaines de gestation. Jusqu'à ce que des stratégies de prévention optimales soient mises au point, la mise en œuvre d'une étroite surveillance obstétricale s'avère justifiée dans les cas de grossesse gémellaire.