Active Compared With Passive Voiding Trials After Midurethral Sling Surgery: A Systematic Review.

OBJECTIVE: To compare active with passive voiding trials on the rate of passing a trial of void and discharge rates with catheter in women who have undergone midurethral sling for treatment of stress urinary incontinence (SUI). DATA SOURCES: MEDLINE, EMBASE, and ClinicalTrials.gov were searched through February 24, 2023. METHODS OF STUDY SELECTION: Our population included women undergoing midurethral sling, with or without anterior or posterior repair, for treatment of SUI. Our two primary outcomes were rate of passing voiding trial and rate of discharge with a catheter. Our secondary outcome was the rate of delayed postoperative urinary retention, when a patient initially passes a trial of void but then subsequently presents in retention. TABULATION, INTEGRATION, AND RESULTS: Abstracts were doubly screened; full-text articles were doubly screened; and accepted articles were doubly extracted. In single-arm studies evaluating either passive or active voiding trial, random-effects meta-analyses of pooled proportions were used to assess outcomes. Of 3,033 abstracts screened, 238 full-text articles were assessed, and 26 met inclusion criteria. Ten studies including 1,370 patients reported active trial of void. Sixteen studies including 3,643 patients reported passive trial of void. We included five randomized controlled trials, five comparative retrospective studies, five prospective single group studies, and 11 retrospective single group studies. Five of the studies included patients with a concomitant anterior or posterior colporrhaphy. On proportional meta-analysis, the active trial of void group was less likely to pass the voiding trial (81.0%, 95% CI, 0.76-0.87% vs 89.0%, 95% CI, 0.84-0.9%3, P =.029) with high heterogeneity ( I2 =93.0%). Furthermore, there were more discharges with catheter in active trial of void compared with passive trial of void (19.0%, 95% CI, 0.14-0.24% vs 7.0%, 95% CI, 0.05-0.10%, P <.01). The rates of delayed postoperative urinary retention were low and not different between groups (0.6%, 95% CI, 0.00-0.02% vs 0.2%, 95% CI, 0.00-0.01%, P =.366) with low heterogeneity ( I2 =0%). Sling revisions were statistically lower in the active trial of void group (0.5%, 95% CI, 0.00-0.01% vs 1.5%, 95% CI, 0.01-0.02%, P =.035) with low heterogeneity ( I2 =10.4%). CONCLUSION: Passive trial of void had higher passing rates and lower discharge with catheter than active trial of void. Rates of most complications were low and similar between both groups, although passive trial of void had higher sling revisions. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022341318.

Adverse Events for Overactive Bladder Medications From a Public Federal Database.

IMPORTANCE: Clinical data on the use of overactive bladder (OAB) medications are limited by the physician interpretation of adverse effects rather than those that are patient reported. OBJECTIVE: The aim of the study was to evaluate the association between OAB medications and adverse drug events (ADEs) through the self-reporting U.S. Food and Drug Administration Adverse Event Report System database. STUDY DESIGN: The U.S. Food and Drug Administration Adverse Event Report System (FAERS) database was queried from 2004 to 2019. Adverse drug events were recategorized. Disproportionality analysis was used to detect the risk signals for each OAB medication and ADEs. χ 2 values were calculated to assess the association between ADEs and dosage. RESULTS: A total number of 14,102 reports were identified. The most frequently reported OAB medications were mirabegron (35%), transdermal oxybutynin (27%), and solifenacin (25%). Neuropsychiatric (NP) ADEs were highest with tolterodine and fesoterodine usage (16% and 15.6%, respectively) and transdermal oxybutynin had the lowest (6.5%). Increasing the dose of tolterodine or fesoterodine was not associated with increased NP ADEs. Oxybutynin had the highest risk of affect/mood disorder, agitation, and balance/movement disorder; however, it had the lowest risk of headache/migraine compared with all OAB medications. Mirabegron compared with all other OAB medications had the lowest risk of affect/mood disorder and agitation; however, it had the highest risk of headache and migraines. CONCLUSIONS: The FAERS database not only is a repository of ADEs but also may represent evolving prescribing habits for OAB medications. Transdermal oxybutynin had the lowest NP ADEs and may be appropriate for selected individuals.

No pelvic exam, no problem: patient satisfaction following the integration of comprehensive urogynecology telemedicine.

INTRODUCTION AND HYPOTHESIS: The COVID-19 pandemic revolutionized the practice of medicine, requiring rapid adoption of telemedicine. However, patient satisfaction has not been well characterized for telemedicine visits for a broad range of urogynecologic conditions. METHODS: We performed a cross-sectional survey study following a retrospective review of all urogynecologic telemedicine visits from March 1, 2020, to March 31, 2021, at a tertiary care center. The survey queried patient satisfaction using the Likert scale. Descriptive statistics and Fisher's exact analyses were performed. RESULTS: There were 256 telemedicine visits at our institution during the study period, and 88 patients (34% unadjusted response rate) completed the survey. The average age of study participants was 55 (SD 17; 24, 84) years old. The majority of patients were white (69%), lived within the five boroughs of NYC (81%), and had higher levels of education (72% with a bachelor's or professional degree). Most visits were for urinary complaints (68%), with those patients reporting greater fulfillment of urogynecologic needs compared to patients presenting with pelvic complaints (p = 0.02). There were no significant differences in satisfaction among other demographics (p > 0.05). Altogether, high satisfaction rates were noted for scheduling (99%), technology (90%), provider interaction (96%), fulfillment of personal needs (91%), and overall satisfaction (94%). CONCLUSIONS: We demonstrate high patient satisfaction for telemedicine visits in a tertiary urogynecology clinic for a variety of indications, with greater fulfillment of urogynecologic needs observed for those visits which may not necessitate an in-person exam (e.g., urinary complaint).

Can Women Accurately Predict Their Voided Volumes?

IMPORTANCE: Voiding diaries can be onerous, we sought to investigate if some women can predict their voided volumes. OBJECTIVES: The objective of this study is to determine the accuracy of estimated voided volumes and characteristics most predictive of accuracy. STUDY DESIGN: We prospectively collected data on 101 women undergoing urodynamics for lower urinary tract symptoms and/or prolapse at a tertiary care facility. Data collection included postvoid residual volume, urodynamic diagnosis, flow time and rate, and a 1-time measurement of voided volume into a blinded uroflow. Linear and logistic regression analyses were performed to examine predictors of estimated voided volume (mL). RESULTS: Mean age was 58.2 years (standard deviation, 12.8 years). The median estimated voided volume and actual voided volume were 240 and 215 mL, respectively. The average percent error was 15% (63% of patients being within a 30% margin of error and 32.7% being within a 20% margin of error). On linear regression analysis, smaller voids of 101 to 200 mL were associated with greater accuracy (R2 = 0.37 P = 0.001) and diagnosis of anxiety was associated with a higher voided volume percent error (P = 0.028). Logistic regression analysis revealed that for every 1 year increase in age, there was a 3% decrease in odds of predicting voiding volume within 30% (odds ratios, 0.97; P = 0.041). CONCLUSIONS: Nearly two-thirds of women estimated their voided volume within 30% of the actual void and one-third of women could predict within 20%. This should be taken into consideration when obtaining patient history, particularly with age and diagnosis of anxiety, and may substantiate use of voiding diaries for accurate measurement in specific populations.

Trends in Reported Case Logs of OnabotulinumtoxinA and Sacral Neuromodulation.

INTRODUCTION: We investigated current trends in reported case logs of third line treatments for primarily overactive bladder including sacral neuromodulation, percutaneous tibial nerve stimulation and chemodenervation. METHODS: Data on third line overactive bladder procedure volume was obtained from the American Board of Urology annualized case logs between 2010 and 2016. Entries from certifying, recertifying, and female pelvic medicine and reconstructive surgery applying urologists were considered. Statistical analysis was then performed to identify trends and surgeon characteristics that predicted the number of procedures performed. RESULTS: Case log reported procedures of third line therapies increased from 1,822 in 2010 to a peak of 6,143 in 2013. From 2010 to 2016, 25% (1,375/5,499) of all urologists logged at least 1 chemodenervation or neuromodulation procedure, while only 2 urologists logged percutaneous tibial nerve stimulation cases. In total, 26,874 neuromodulation or chemodenervation procedures were logged. Neuromodulation usage peaked in 2013, the year of U.S. Food and Drug Administration approval for chemodenervation, and has since been declining. Chemodenervation procedures increased each year after 2013 until declining in 2016. Female pelvic medicine and reconstructive surgery surgeons performed significantly more procedures than all other specialty categories (p ≤0.01). Gender, practice region, practice size and practice setting were also significant predictors of the number of procedures performed. CONCLUSIONS: Chemodenervation and neuromodulation have increased considerably in the past 6 years. There are differences in the types of procedures being performed based on gender, subspecialty, certification status, practice region, practice size and practice setting.

Patient Satisfaction With Telemedicine During the COVID-19 Pandemic: Retrospective Cohort Study.

BACKGROUND: New York City was the international epicenter of the COVID-19 pandemic. Health care providers responded by rapidly transitioning from in-person to video consultations. Telemedicine (ie, video visits) is a potentially disruptive innovation; however, little is known about patient satisfaction with this emerging alternative to the traditional clinical encounter. OBJECTIVE: This study aimed to determine if patient satisfaction differs between video and in-person visits. METHODS: In this retrospective observational cohort study, we analyzed 38,609 Press Ganey patient satisfaction survey outcomes from clinic encounters (620 video visits vs 37,989 in-person visits) at a single-institution, urban, quaternary academic medical center in New York City for patients aged 18 years, from April 1, 2019, to March 31, 2020. Time was categorized as pre-COVID-19 and COVID-19 (before vs after March 4, 2020). Wilcoxon-Mann-Whitney tests and multivariable linear regression were used for hypothesis testing and statistical modeling, respectively. RESULTS: We experienced an 8729% increase in video visit utilization during the COVID-19 pandemic compared to the same period last year. Video visit Press Ganey scores were significantly higher than in-person visits (94.9% vs 92.5%; P<.001). In adjusted analyses, video visits (parameter estimate [PE] 2.18; 95% CI 1.20-3.16) and the COVID-19 period (PE 0.55; 95% CI 0.04-1.06) were associated with higher patient satisfaction. Younger age (PE -2.05; 95% CI -2.66 to -1.22), female gender (PE -0.73; 95% CI -0.96 to -0.50), and new visit type (PE -0.75; 95% CI -1.00 to -0.49) were associated with lower patient satisfaction. CONCLUSIONS: Patient satisfaction with video visits is high and is not a barrier toward a paradigm shift away from traditional in-person clinic visits. Future research comparing other clinic visit quality indicators is needed to guide and implement the widespread adoption of telemedicine.

Nocturia in female patients: Current clinical features, treatment patterns and outcomes at a tertiary referral centre.

Objective: To report the current clinical features, treatment patterns and outcomes of female patients who were seen at a tertiary referral centre with a primary diagnosis of nocturia, and to assess the predictive factors of therapeutic management failure. Patients and methods: A retrospective chart review of all new female patients seen in a single-centre functional urology practice with the diagnosis of nocturia was performed. Up to three visits within a 12-month period from the time of presenting were reviewed. The primary endpoint was patient-reported improvement assessed at each follow-up visit and the change in the number of nocturia episodes. Results: In all, 239 female patients were included for analysis. The prevalence of nocturnal polyuria, reduced bladder capacity, and global polyuria were 75%, 40.2%, and 18.1%, respectively. Within the first two visits, 72.7% of patients had started a treatment beyond behavioural therapies. Anticholinergics were the most commonly initiated treatment (47.2% of patients). At the latest considered visit, 80 patients reported improvement in nocturia (45.5%) and there was a mean - 0.8 decrease in the number of nocturia episodes from 4 to 3.2, which was statistically significant (P < 0.001). There was no statistically significant association between any of the bladder diary findings and treatment outcomes. A smaller number of nocturia episodes was the only predictive factor of therapeutic management failure in multivariate analysis (odds ratio 0.10; P = 0.01). Conclusions: Whilst the prevalence of nocturnal polyuria in women with nocturia is high, the therapeutic management until 2016 seemed to rely mostly upon overactive bladder medications with a relatively low success rate. Abbreviations: BD: bladder diary; BPS: bladder pain syndrome; ICD(-9)-(10): International Classifications of Disease (ninth revision) (10th revision); NPI: Nocturnal Polyuria Index; OAB: overactive bladder; OR: odd ratio; POP: pelvic organ prolapse.

Diagnosis and management of nocturia in current clinical practice: who are nocturia patients, and how do we treat them?

OBJECTIVE: To characterize the current evaluation, and efficacy of treatments in patients with the primary complaint of nocturia. METHODS: A retrospective chart review was performed of new patient encounters seen in a tertiary urology practice from May 2010 to September 2016 with the primary diagnosis of nocturia (ICD-9 788.43 and ICD-10 R35.1). RESULTS: 595 patients were identified. 403 met inclusion criteria. The median patient reported that nocturia episodes were 4 (1-20). 192 patients (48%) reported previous treatment for nocturia. After the index visit, a bladder diary (BD) was utilized in 50% of patients, with a 62% (n = 124) completion rate at follow-up visit. On BD analysis, the most common etiologies of nocturia were nocturnal polyuria 76% (n = 90) and overactive bladder in 21% (n = 26). Patient reported improvement with therapy after BD completion was 46% (n = 34), similar to patients without voiding diaries (43% improvement, n = 153). Anticholinergics and alpha blockers were the most commonly recommended drug, but no specific medication was associated with nocturia improvement. Oral desmopressin was used in 5% of patients. CONCLUSION: Nocturia is a common condition and very commonly patients have sought treatment prior to presentation. Bladder diaries were recommended to half of the patients. Patient reported that improvement did not seem to correlate with completion of a bladder diary. Though most patients had NP the use of desmopressin was very low. Current treatments used in managing nocturia may lack efficacy.

Quantifying downstream impact of inappropriate staging imaging in a cohort of veterans with low- and intermediate-risk incident prostate cancer.

INTRODUCTION: According to current National Comprehensive Cancer Network guidelines, routine imagining for staging low-risk prostate cancer is not recommended. However, extensive overuse of guideline-discordant imaging continues to persist. Incidental findings are common on imaging and little is known about the optimal management. Rates of incidental findings vs. false positive diagnosis from inappropriate imaging are poorly understood and have yet to be quantified for low- and intermediate-risk prostate cancer patients. OBJECTIVE: To determine the frequency of positive radiologic findings in patients with low- and intermediate-risk prostate cancer during initial staging at VA New York Harbor Healthcare System. METHODS: We retrospectively reviewed all low- and intermediate-risk prostate cancer patients' medical records from the VA New York Harbor Healthcare System for diagnosis from 2005 to 2015. We reviewed each individual's prebiopsy prostate specific antigen (PSA), Gleason score, and clinical stage. We also determined if imaging obtained yielded a false positive, incidental finding, or if metastatic disease occurred within the 6 months following initial diagnosis. RESULTS: There were 414 men, who were classified as low- to intermediate-risk prostate cancer and underwent inappropriate staging imaging of 4,306 men diagnosed with prostate cancer. Of these 414 men, 178 (43%) had additional follow-up imaging for positive findings. We calculated an incidental finding rate of 10% and a false positive rate of 38% for patients. Five (1%) patients had metastatic disease. CONCLUSION: Despite guideline recommendations, imaging overuse remains an issue for low-intermediate-risk prostate cancer patients. The false positive rate found in this analysis is alarmingly high at 38%. This use of scans is burdensome to the healthcare system and patient. This study highlights the frequency of inappropriate imaging and its negative consequences.

Restrictive transfusion in radical cystectomy is safe.

INTRODUCTION AND OBJECTIVE: Perioperative blood transfusion (PBT) is commonplace in radical cystectomy (RC) and has been linked to poorer oncologic outcomes. Limiting PBT in this largely elderly and comorbid population has not been studied. Herein, we first investigate the safety of a restrictive transfusion protocol (RTP) in patients undergoing RC for urothelial carcinoma and then compare oncologic outcomes between patients who did and did not receive PBT. METHODS: Outcomes for 173 consecutive patients meeting inclusion criteria undergoing RC for urothelial carcinoma from April 2010 to June 2014 by a single surgeon employing RTP were analyzed from an institutional review board-approved, prospectively collected database. Pairwise matching to a cohort undergoing RC during an earlier era of more liberal PBT was performed, and 90-day outcomes were compared. RESULTS: Median follow-up for the RTP cohort was 3.1 years (range: 0-5.1y). Median age was 70 years (range: 38-93y). Forty-six patients (26.6%) received PBT. Eighty-seven matched pairs were generated from RTP cohort and liberal era where PBT rate was 94%. There were no differences in 90-day complication rates, mortality, or readmission rates (P>0.05). In the RTP cohort, patients who underwent PBT had higher estimated blood loss (500 vs. 350, P = 0.001), lower baseline hematocrit (28.9 vs. 33.3, P = 0.005), and similar operative time (5.8 vs. 5.3h, P = 0.01) and length of stay (5.5 vs. 5, P = 0.07). At discharge and 3-week follow-up, there was no difference in hematocrit (P>0.05). In the no-PBT group, 90-day (65.6% vs. 86.7%, P = 0.007) and high-grade (15.6% vs. 34.8%, P = 0.003) complication rates were lower. On multivariable analysis, predictors of PBT were age (odds ratio [OR] = 1.06, 95% CI [1.01-1.11]), Charlson comorbidity index≥2 (OR = 2.68, CI [1.09-7.04]), neoadjuvant chemotherapy (OR = 3.74, CI [1.46-10.19]),≥pT3 (OR = 5.5, CI [2.33-13.73]), baseline hematocrit (OR = 0.95, CI [0.87-1.00]), and estimated blood loss (OR = 1.001, CI [1-1.003]). PBT was associated with lower recurrence-free survival (hazard ratio = 2.16; CI [1.13-41.12]; P = 0.02) and overall survival (hazard ratio =2.25; CI [1.25-4.88]; P = 0.01). CONCLUSIONS: The use of RTP in RC is safe. PBT was associated with poorer recurrence-free survival and overall survival independent of clinicopathologic characteristics.

Current Trends in Renal Surgery and Observation for Small Renal Masses.

There has been a rising incidence of small renal masses and concomitant downward stage migration. This has led to an evolution in the management of kidney cancer from radical nephrectomy to nephron-sparing treatment options including observation. The adoption of partial nephrectomy continues to increase but is still incomplete leading to significant disparities in the delivery of care throughout the country. Surgical excision remains the treatment of choice for small kidney cancers; however, ablative therapies and active surveillance are emerging as reasonable options for select patients. With continued refinements in treatment options and improvements in ability to risk stratify SRMs, the current treatment trends will likely continue to evolve.

Percutaneous cholecystostomy versus laparoscopic cholecystectomy in patients with acute cholecystitis and failed conservative management: a matched-pair analysis.

INTRODUCTION: The role of percutaneous cholecystostomy (PC) or laparoscopic cholecystectomy (LC) in the management of patients with acute cholecystitis presenting beyond 72 hours from the onset of symptoms is unclear and undefined. The aim of this study was to examine and compare the outcomes of PC or LC in the management of these patients, who failed 24 hours of initial nonoperative management. PATIENTS AND METHODS: A retrospective chart review between January 1999 and October 2010 revealed 261 patients with acute calculus cholecystitis beyond 72 hours from onset of symptoms who failed initial nonoperative management. Twenty-three of 261 (8.8%) underwent PC and were compared with a similar 1:1 matched cohort of LC, matched using sex, age, race, BMI, diabetes, and sepsis to minimize the influence of treatment selection bias. RESULTS: There was no significant difference between PC versus LC regarding morbidity [4/23 (17%) vs. 2/23 (9%), P=0.665] and mortality [3/23 (13%) vs. 0/23 (0%), P=0.233]. The length of hospital stay was significantly longer in the PC group (15.9±12.6 vs. 7.6±4.9 d, P=0.005). CONCLUSION: In this matched cohort analysis, PC failed to show a significant reduction in morbidity compared with LC and was associated with a significantly longer hospital stay.

Argon beam coagulation versus fibrin sealant for hemostasis following liver resection: a randomized study in a porcine model.

BACKGROUND/AIMS: Bleeding from the raw liver surface represents a significant surgical complication after elective liver resection or hepatic trauma. The application of argon beam coagulation (ABC) has been proposed to improve hemostasis, but is associated with significant necrosis of the liver parenchyma. Topical hemostatic agents, i.e. fibrin sealant (FS), have also been recommended, yet the optimal management is under debate. This study compares the efficacy and safety of both methods following liver resection in an animal model. METHODOLOGY: Twenty pigs underwent liver resection, and were then randomized into ABC or FS group for treatment of raw liver surfaces. Intraoperative and postoperative parameters were studied. Animals were sacrificed at day 12, and extent of necrosis was assessed using a scoring system and morphometry. RESULTS: Intraoperative parameters did not show any significant difference between two groups except for shorter time of application in the FS group. Postoperatively, animals in the FS group showed significantly higher hemoglobin levels (p=0.0001). Histologically, FS showed a smaller depth of necrosis than ABC (p=0.022). CONCLUSIONS: The use of FS is superior to ABC for management of the raw liver surface after liver resection, in terms of application time, postoperative bleeding and the extent of liver tissue necrosis.