Urinary Analysis of FGFR3 and TERT Gene Mutations Enhances Performance of Cxbladder Tests and Improves Patient Risk Stratification.

PURPOSE: Cxbladder tests are urinary biomarker tests for detection of urothelial carcinoma. We developed enhanced Cxbladder tests that incorporate DNA analysis of 6 single nucleotide polymorphisms for the FGFR3 and TERT genes, in addition to the current 5 mRNA biomarkers and clinical risk factors. MATERIALS AND METHODS: Two multicenter, prospective studies were undertaken in: (1) U.S. patients with gross hematuria aged ≥18 years and (2) Singaporean patients with gross hematuria or microhematuria aged >21 years. All patients provided a midstream urine sample and underwent cystoscopy. Samples were retrospectively analyzed using enhanced Cxbladder-Triage (risk stratifies patients), enhanced Cxbladder-Detect (risk stratifies patients and detects positive patients), and the combination enhanced Cxbladder-Triage × Cxbladder-Detect. RESULTS: In the pooled cohort (N=804; gross hematuria: n=484, microhematuria: n=320), enhanced Cxbladder-Detect had a sensitivity of 97% (95% CI 89%-100%), specificity of 90% (95% CI 88%-92%), and negative predictive value of 99.7% (95% CI 99%-100%) for detection of urothelial carcinoma. Overall, 83% of patients were enhanced Cxbladder-Detect-negative (ie, needed no further work-up). Of 133 enhanced Cxbladder-Detect-positive patients, 59 had a confirmed tumor, of which 19 were low-grade noninvasive papillary carcinoma or papillary urothelial neoplasm of low malignant potential. In total, 40 tumors were high-grade Ta, T1-T4, Tis, including concomitant carcinoma in situ. Of the 74 patients with normal cystoscopy, 41 were positive by single nucleotide polymorphism analysis. Enhanced Cxbladder-Triage and enhanced Cxbladder-Detect had significantly better specificity than the first-generation Cxbladder tests (P < .001). CONCLUSIONS: This study in ethnically diverse patients with hematuria showed the analytical validity of the enhanced Cxbladder tests.

Autologous Pubovaginal Sling for the Treatment of Stress Urinary Incontinence in a Patient With High Risk of Mesh Erosion.

OBJECTIVE: Autologous pubovaginal sling is a surgical option for patients with stress urinary incontinence (SUI), either as primary treatment, or in those who have failed synthetic sling placement.1,2 It is also favorable for patients at high risk of mesh erosion, for example, in those who are immunocompromised or postradiation.3-5 This video reviews the technical considerations in performing an autologous pubovaginal sling fashioned from rectus fascia in an immunocompromised patient with multiple previous abdominal surgeries. METHODS: The patient is a 63-year-old woman with SUI refractory to conservative management, with a background of Behcet's disease on long-term steroids. First, a 12  ×  2 cm rectus sheath graft was harvested through a Pfannenstiel incision. Stay sutures were placed to aid in subsequent sling placement. A vertical incision was made in the anterior vaginal wall after hydro-dissection with lignocaine/adrenaline solution and the plane was developed with a combination of blunt and sharp dissection. The trocars with the attached fascial sling were passed retropubically. Sling tensioning was assessed with a Q-tip test. An inadvertent bladder perforation was noted during the passage of the left trocar on intraoperative cystoscopy, which was managed conservatively with urinary catheterization for one week postoperatively. RESULTS: The patient was discharged well on postoperative day 2 and underwent a successful trial off catheter on postoperative day 7. At 1-month follow-up, the patient reported complete resolution of her SUI with no de-novo urgency or voiding dysfunction. CONCLUSION: Autologous pubovaginal slings are an effective treatment option for SUI with minimal morbidity especially in patients with high risk of mesh erosion.