PROPOSED REVISION OF THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA RENAL TRAUMA ORGAN INJURY SCALE: SECONDARY ANALYSIS OF THE MULTI-INSTITUTIONAL GENITOURINARY TRAUMA STUDY.

BACKGROUND: This study updates the American Association for Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. METHODS: This was a secondary analysis of a multi-center retrospective study including patients with high grade renal trauma from 7 Level-1 trauma centers from 2013-2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells (PRBCs) transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the receiver-operator curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST organ injury scale. RESULTS: based on the 2018 OIS grading system, we included 549 patients with AAST Grade III-V injuries and CT scans (III: 52% (n = 284), IV: 45% (n = 249), and V: 3% (n = 16)). Among these patients, 89% experienced blunt injury (n = 491) and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC = 0.805, revised AUC = 0.883; p = 0.001) and number of units of PRBCs transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. CONCLUSIONS: A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. LEVEL OF EVIDENCE: II.

The Use of Metformin in Overactive Bladder: A Retrospective Nested Case-control, Population-based Analysis.

OBJECTIVE: To determine if metformin use is associated with a lower rate of overactive bladder (OAB) medication use. Metformin facilitates the proliferation and migration of stem cells, which have been shown to improve bladder overactivity in animal models. METHODS: We conducted a retrospective nested case-control cohort study using population-based health-care administrative databases. Our cohort included patients with diabetes mellitus type 2 (DM2) ≥69years. Cases received a prescription for an OAB medication, matched with up to 4 controls based on age, sex, and DM2 diagnosis date. Exposure was a new prescription for metformin prior to receiving an OAB medication. Adjusted odds ratios were estimated using conditional logistic regression. Sensitivity analysis was done to assess the relationship between cumulative days' supply of metformin and use of OAB medications. RESULTS: Within our cohort of 2,233,084 patients with DM2, there were 16,549 case subjects who received a prescription for an OAB medication, and 64,171 matched controls. We found a positive association between OAB medication use and metformin use (adjusted odds ratios=1.07, 95% CI=1.03-1.12). Summed days' supply of metformin was also associated with OAB medication use, except when summed metformin days was >2220. CONCLUSION: Older patients with DM2 exposed to metformin had a slightly higher rate of OAB medication use, until 2220+ days' metformin supply, whereafter no association was found. This suggests no protective role for metformin in the prevention of OAB in this patient population.

Impact of Prostate Cancer-related Genitourinary Radiation Injury on Mental Health Diagnosis and Treatment: Assessment of 55,425 Men.

OBJECTIVE: To investigate the association of low-grade radiation injury (LGRI) and high-grade radiation injury (HGRI) following prostate cancer treatment with mental health diagnoses and therapy. METHODS: A retrospective study of men diagnosed with prostate cancer who were treated with radiotherapy. Men were followed to assess for LGRI or HGRI using IBM MarketScan. Cohorts included: no injury (no-RI), LGRI, HGRI, and controls. Mental health diagnoses and related treatment (medication/therapy) were identified using ICD-10 codes, CPT codes, and national drug codes. A multivariable Cox proportional hazards model from time of radiation to first instance of mental health diagnosis was modeled against injury group, age, and comorbidities. RESULTS: Between 2011 and 2020 we identified 55,425 men who received radiotherapy for prostate cancer. 22,879 (41.3%) experienced a LGRI while 4128 (7.4%) experienced a HGRI. Prior to radiation therapy, mental health diagnoses were equally distributed across cohorts (P > .05). Every marker of mental health showed a step-wise increase in incidence from no-RI to LGRI to HGRI except for alcohol abuse. Use of mental health medications and therapy visits were slightly more likely in the LGRI and HGRI groups prior to radiation, however, this difference was greatly increased postradiation therapy. LGRI (HR 1.38; P < .001) and HGRI (HR 2.1; P < .001) were independently associated with an increased likelihood of mental health diagnoses. CONCLUSION: LGRI and HGRI following prostate cancer radiotherapy are associated with increased risk of mental health diagnosis, medication use, and therapy need compared to men who do not develop injuries. The most common mental health diagnoses were depression and anxiety.

Management of pediatric renal trauma - Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study (Mi-PARTS).

BACKGROUND: Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A non-operative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury is not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This manuscript describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. METHODS: Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010-2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management and outcomes. RESULTS: In total 1216 cases were included in this study. 67.2% were male, and 93.8% had a blunt injury mechanism. 29.3% had isolated renal injuries. 65.6% were high-grade (AAST Grade III-V) injuries. The mean Injury Severity Score (ISS) was 20.5. Most patients were managed non-operatively (86.4%) 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in polytrauma. The rate of avoidable transfer was 28.2%. CONCLUSION: The management and outcomes of pediatric renal trauma lacks data to inform evidence-based guidelines. Non-operative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population, and highlights opportunities for further investigation. With data made available through Mi-PARTS we aim to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. LEVEL OF EVIDENCE: IV, Epidemiological (prognostic/epidemiological, therapeutic/care management, diagnostic test/criteria, economic/value-based evaluations, and Systematic Review and Meta-Analysis).

Treatment Patterns in Men Prescribed Benign Prostatic Obstruction or Overactive Bladder Medications in Canada: A Retrospective Population-based Study.

OBJECTIVE: To characterize first therapeutic change and healthcare resource utilization in older men initiating an overactive bladder (OAB) or benign prostatic obstruction (BPO) medication. METHODS: A retrospective cohort study using health administrative data from ICES in Ontario, Canada (from April 01, 2010 to December 31, 2018) was conducted in men aged ≥66 years with ≥1 OAB (ß3 agonist, antimuscarinic) or BPO (α-blocker, 5-α-reductase inhibitor) prescription and ≥1-year postindex data (index=first observed dispensation). EXCLUSIONS: prescriptions for these drugs ≤1 year preindex, a related procedure ≤5 years. Patients were grouped by condition based on index prescription. Treatment changes in relation to OAB and BPO were characterized by type. Costs and healthcare resource utilization pre- and post-index were compared. RESULTS: Age, geographic region, and income were similar between groups. The most common initial treatments were antimuscarinics (78.1%) in the OAB group and alpha-blockers (86.4%) in the BPO group. The OAB group was more likely to experience a therapeutic change and had a shorter time to first change in therapy (78 [30,231] vs 104 [30,350] days) and higher mean healthcare costs both pre- ($12,354 vs $11,497) and postindex ($14,423 vs $12,852). The most common first therapeutic change in both groups was discontinuing treatment (OAB: 75.6%; BPO: 69.9%). CONCLUSION: Men initiating OAB medications changed therapy sooner than those initiating BPO medications. Most discontinued first-line therapy without initiating further treatment, suggesting unmet need in this population.

Genitourinary Radiation Injury Following Prostate Cancer Treatment: Assessment of Cost and Health Care System Burden.

OBJECTIVE: To evaluate the healthcare resource impact of radiation injury following prostate cancer treatment. METHODS: Using IBM MarketScan, we performed a retrospective study of men with prostate cancer who were treated with radiotherapy and subsequently developed low-grade (LGRI) and high-grade radiation injury (HGRI). Radiation injury diagnoses included bladder neck stenosis, hematuria/cystitis, fistula, ureteral stricture, and incontinence. LGRI and HGRI included injury diagnosis without intervention and with intervention, respectively. Health care visits and costs were measured over 5 time periods including 2 years before radiation, 1 year before radiation, radiation to injury diagnosis, injury diagnosis to first intervention (LGRI), and following first intervention (HGRI). Negative binomial regression modeling was used to assess the effect of radiation injury on average cost adjusting for demographics and comorbidities. RESULTS: Between 2008 and 2017, we identified 121,027 men who received radiotherapy following prostate cancer diagnosis of which 10,057 (8.3%) experienced a HGRI. The frequency of urologic visits and average costs were similar in those without injury and LGRI. However, men with HGRI experienced higher visit frequency and monthly costs. Amongst high-grade injuries, urinary fistula had the highest frequency of visit utilization at 378 visits before first intervention and 245 visits after first intervention. Following radiation injury diagnosis, the average monthly cost was twice as high in those with HGRI ($85.78) compared to LGRI ($38.66). CONCLUSIONS: HGRI was associated with increased urologic health care use and average monthly cost when compared to those who experienced LGRI or no injury. Urinary fistula was associated with the largest resource burden.

Predicting Mirabegron Treatment Response in Patients with Overactive Bladder: A Post Hoc Analysis of Data from Clinical Trials.

BACKGROUND: Many patients discontinue overactive bladder (OAB) treatment because of unmet treatment expectations and/or tolerability issues. OBJECTIVE: To develop a model for predicting the individual treatment response to mirabegron using patient baseline characteristics. DESIGN, SETTING, AND PARTICIPANTS: This was a post hoc analysis of data from eight global phase 2/3, double-blind, randomized, placebo- or active-controlled trials of mirabegron in adult patients with OAB. INTERVENTION: Mirabegron 50 mg once-daily monotherapy for ≥12 wk. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary efficacy outcomes were the change in the mean number of micturitions and the number of incontinence episodes/24 h after 12 wk of treatment. Secondary efficacy outcomes were the change in the mean number of urgency episodes/24 h and the change in Symptom Bother score after 12 wk of treatment. Baseline demographic characteristics, OAB-related characteristics, and intrinsic and extrinsic factor variables were used to create multivariable linear regression models to predict the primary and secondary outcomes. RESULTS AND LIMITATIONS: Data for 3627 patients were included. The predicted effect of mirabegron 50 mg was an average of 2.5 fewer micturition episodes/24 h (95% confidence interval -2.85 to -2.14) and 0.81 fewer incontinence episodes/24 h (95% confidence interval -1.15 to -0.46) from baseline to week 12. A higher number of urgency episodes was predictive of a larger reduction in micturition episodes; body mass index (BMI) ≥30 kg/m2, OAB symptoms for ≥12 mo, and incontinence at baseline were predictive of a smaller reduction. Mixed stress/urgency incontinence and more than five urgency episodes per day were predictive of greater reductions in incontinence episodes. Reductions in urgency episodes and Symptom Bother score were also predicted with mirabegron. Limitations include the exclusion of placebo groups from the analysis and the use of clinical trial rather than real-world data. CONCLUSIONS: Data from the predictive models provide new insights into the effects of modifiable factors (such as BMI) and nonmodifiable factors on treatment outcomes with mirabegron 50 mg. PATIENT SUMMARY: This study aimed to identify factors that could predict how patients with overactive bladder respond to mirabegron treatment to help doctors effectively treat this condition. Mirabegron treatment was associated with a lower number of urinations and occurrences of urinary incontinence per day. Factors associated with worse responses to the medication included being obese.

Prior COVID-19 infection associated with increased risk of newly diagnosed erectile dysfunction.

We sought to assess if COVID-19 infection recovery is associated with increased rates of newly diagnosed erectile dysfunction. Using IBM MarketScan, a commercial claims database, men with prior COVID-19 infection were identified using ICD-10 diagnosis codes. Using this cohort along with an age-matched cohort of men without prior COVID-19 infection, we assessed the incidence of newly diagnosed erectile dysfunction. Covariates were assessed using a multivariable model to determine association of prior COVID-19 infection with newly diagnosed erectile dysfunction. 42,406 men experienced a COVID-19 infection between January 2020 and January 2021 of which 601 (1.42%) developed new onset erectile dysfunction within 6.5 months follow up. On multivariable analysis while controlling for diabetes, cardiovascular disease, smoking, obesity, hypogonadism, thromboembolism, and malignancy, prior COVID-19 infection was associated with increased risk of new onset erectile dysfunction (HR 1.27; 95% CI 1.1-1.5; P = 0.002). Prior to the widespread implementation of the COVID-19 vaccine, the incidence of newly diagnosed erectile dysfunction is higher in men with prior COVID-19 infection compared to age-matched controls. Prior COVID-19 infection was associated with a 27% increased likelihood of developing new-onset erectile dysfunction when compared to those without prior infection.

Healthcare utilization during transition to adult care in patients with spina bifida A population-based, longitudinal study in Ontario, Canada.

INTRODUCTION: Individuals with spina bifida (SB) may experience negative health outcomes because of an informal transition from pediatric to adult care that results in using the emergency room (ER ) for non-acute health problems. METHODS: We conducted a retrospective, population-based cohort study of all people with SB in Ontario, Canada turning 18 years old between 2002 and 2011. These patients were followed for five years before and after age 18. Primary outcome was the annual rate of ER visits. Secondary outcomes included rates of hospitalization, surgery, primary care, and specialist outpatient care. We estimated the association between age and primary and secondary outcomes using negative binomial growth curve models, adjusting for patient-level baseline covariates. RESULTS: Among the 1215 individuals with SB, there was no trend of ER visits seen with increasing age (relative risk [RR ] 0.99, 95% confidence interval [CI] 0.98-1.02); however, there was a significant increase in the rate of ER visits associated with turning 18 years (RR 1.14, 95% CI 1.03-1.27). Turning 18 years old was also associated with a decreased rate of hospital admissions (RR 0.79, 95% CI 0.66-0.95) and no change in surgeries (RR 0.80, 95% CI 0.64-1.02). Visits to primary care physicians remained stable over the same period (RR 0.96, 95% CI 0.90-1.01), while visits to SB-focused specialists decreased after age 18 (RR 0.81, 95% CI 0.75-0.87). CONCLUSIONS: In patients with SB, the rate of ER visits increased significantly at 18 years old, while hospital admissions and specialist physician visits decreased at the same time. Models of transitional care can aim to reduce non-urgent ER visits and facilitate regular specialist care.

Variation in Provider Practice Patterns and the Perceived Need for a Shared Decision-making Tool for Neurogenic Lower Urinary Tract Dysfunction.

OBJECTIVE: To evaluate neurogenic lower urinary tract dysfunction (NLUTD) care providers' current practice patterns, their perceived need for a shared decision-making tool for NLUTD management. METHODS: We developed an electronic survey to assess multiple factors surrounding NLUTD management including practice patterns, perceived need for a decision aid and willingness to use it. Prior to survey dissemination, a panel of expert NLUTD care providers reviewed and provided a critique of the survey. It was delivered via email to the members of the Genitourinary Reconstructive Surgeons, and the Society of Urodynamics, female pelvic medicine and urogenital reconstruction between March and May 2022. RESULTS: A total of 117 NLUTD care providers from 11 countries participated in this survey. Most participants were urologists (n: 109, 93%) working at academic teaching hospitals (n: 82, 70%). The most common treatments the providers had provided for stress urinary incontinence and detrusor overactivity were sling procedures (n: 76, 65%) and anticholinergics (n: 111, 95%). Participants believed that NLUTD management can be highly patient-specific and extensively vary from one individual to another. Most participants believed that patients performing clean intermittent catheterization have better QoL compared to those utilizing indwelling urinary catheters (n: 81, 69%). Participants believed there is a need for a NLUTD decision aid, and they expressed their willingness to use one if available. CONCLUSION: We found discordances between guideline recommendations, provider practice patterns, and patient-reported outcome measures and essential attributes that indicated the need for a decision aid to improve patient-provider communication and shared decision-making in NLUTD management.

Patient Selection and Outcomes of Urinary Diversion.

Urinary diversion selection depends highly on surgeon experience, patient comorbidities, operative indication, and preoperative risk assessment. Navigating this process in the setting of emerging surgical approaches, new operative technology, and evolving perioperative care plans can be difficult for general and reconstructive urologists alike. In this article, we highlight considerations for urinary diversion selection and review new updates in the literature regarding preoperative patient assessment and nutrition optimization. In addition, we review unique perioperative considerations including role of preoperative bowel prep and intraoperative maneuvers in the setting of obesity and prior radiation. Last, we examine postoperative expectations, long-term outcomes, and emerging technology to mitigate postoperative risk associated with urinary diversions.

Risk of Postoperative Thromboembolism in Men Undergoing Urological Prosthetic Surgery: An Assessment of 21,413 Men.

PURPOSE: We assessed venous thromboembolism (VTE) and associated risk factors following artificial urinary sphincter (AUS) and inflatable penile prosthesis (IPP) surgery. MATERIALS AND METHODS: Using IBM® MarketScan, a commercial claims database, patients undergoing AUS and IPP surgery were identified using CPT® and ICD (International Classification of Diseases)-10 procedure codes between 2008 and 2017. ICD-9 and -10 codes were used to identify health care visits associated with lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) within 90 days of surgery. Covariates were assessed using a multivariable model to determine association with outcome of DVT and/or PE. RESULTS: A total of 21,413 men underwent AUS (4,870) or IPP (16,543) surgery between 2008 and 2017 with a median age of 62 years and 68 years, respectively. DVT and PE events following AUS and IPP surgery occurred in 1.54% and 1.04%, respectively. A history of varicose veins (HR 2.76; 95% CI 1.11-6.79), prior history of DVT (HR 13.65; 95% CI 7.4-25.19), or PE (HR 7.65; 95% CI 4.01-14.6) in those undergoing AUS surgery was highly associated with development of postoperative VTE. Likewise, prior history of DVT (HR 12.6; 95% CI 7.99-19.93) and PE (HR 8.9; 95% CI 5.6-14.13) was strongly associated with a VTE event following IPP surgery. CONCLUSIONS: In a large cohort of men undergoing AUS and IPP surgery, 1.54% and 1.04% of men experienced a VTE event within 90 days of surgery, respectively. Prior history of varicose veins, DVT, and PE was associated with an increased likelihood of developing a postoperative DVT or PE.

National Trends and Outcomes in the Use of Intravesical Botulinum Toxin and Enterocystoplasty Among Patients With Myelomeningocele.

OBJECTIVE: To compare trends in the treatment of patients with myelomeningocele receiving intravesical Botulinum (IVB) toxin and enterocystoplasty. METHODS: We identified patients with myelomeningocele in a commercial insurance database from 2008-2017 and stratified them into adult and pediatric samples. Index procedure was identified as either IVB toxin injection or enterocystoplasty. The annual rate of treatments was measured and a change in treatment rate was identified. Time to enterocysplasty was calculated using survival analysis and factors associated with clinical outcomes up to 10 years after index procedure were determined using multivariate Poisson regression. RESULTS: We identified 60,983 patients with myelomeningocele. Nearly twice as many pediatric patients had an enterocystoplasty (n = 317) compared to IVB (n = 138). Very few adult patients underwent enterocystoplasty (n = 25) compared to IVB (n = 116). We identified a significant increase in the annual rate of IVB use around mid-2010 among pediatric patients and around mid-2009 among adults. Twelve pediatric patients (8.6%) and 5 adults (4.3%) went on to receive an enterocystoplasty. Patients who received IVB as the index procedure experienced significantly lower rates of hospitalization days (RR 0.64; 95% CI 0.53-0.78), emergency department visits (RR 0.72; 95% CI 0.63-0.82), and an increased rate of urologic procedures (RR 1.44; 95% CI 1.28-1.62). CONCLUSION: The annual rate of IVB use has increased among patients with myelomeningocele. Nearly 1 in 10 pediatric patients and 1 in 20 adults go on to receive enterocystoplasty. Patients who receive IVB experience lower rates of hospitalization and emergency department visits compared to patients who receive enterocystoplasty.

Receipt of Overactive Bladder Drugs and Incident Dementia: A Population-based Case-control Study.

BACKGROUND: The differential risk of incident dementia associated with receiving various overactive bladder (OAB) drugs is unknown. OBJECTIVE: To estimate the association of antimuscarinic OAB drug (exposure), compared with a ß-3 agonist (mirabegron), and incident dementia. DESIGN, SETTING, AND PARTICIPANTS: A population-based nested case-control study was conducted in patients treated with OAB medications in Ontario, Canada. A total of 11 392 patients aged ≥66 yr with a new diagnosis of dementia between 2010 and 2017, and 29 881 age- and sex-matched controls without dementia were included in the study. INTERVENTION: Receipt of an antimuscarinic OAB drug or receipt of mirabegron, within the previous 6-12 mo. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cases developed dementia and Alzheimer's disease. Controls were derived from the general population and matched to cases based on important baseline characteristics. Odds ratios (ORs) for incident dementia, adjusted for demographic and health-related characteristics, were determined. RESULTS AND LIMITATIONS: Patients receiving solifenacin (OR 1.24; 95% confidence interval 1.08-1.43) and darifenacin (OR 1.30; 95% CI 1.08-1.56) in the prior 6 mo had increased odds of incident dementia compared with those receiving mirabegron. In the 6 mo to 1 yr prior to diagnosis, receipt of solifenacin (OR 1.34; 95% CI 1.11-1.60), darifenacin (OR 1.49; 95% CI 1.19-1.86), tolterodine (OR 1.21; 95% CI 1.02-1.45), and fesoterodine (OR 1.39; 95% CI 1.14-1.71) was associated with increased odds of incident dementia compared with receipt of mirabegron. No effect was seen with oxybutynin or trospium. Limitations included misclassification of the outcome and residual confounding associated with the use of health administrative databases. CONCLUSIONS: Older adults receiving solifenacin and darifenacin in the 6 mo prior to diagnosis, and those receiving solifenacin, darifenacin, tolterodine, or fesoterodine in the year prior to diagnosis, have increased odds of incident dementia, compared with those receiving mirabegron. Oxybutynin and trospium were not associated with dementia, likely due to a protopathic bias. Careful drug selection is warranted when treating patients with OAB. PATIENT SUMMARY: In a large Canadian cohort of patients who developed dementia after starting an overactive bladder (OAB) medication, those taking some anticholinergic medications for OAB have an increased risk of dementia compared with those taking mirabegron.

Association between chronic bladder catheterisation and bladder cancer incidence and mortality: a population-based retrospective cohort study in Ontario, Canada.

OBJECTIVES: To compare the risk of bladder cancer and bladder cancer mortality among patients with chronic bladder catheterisation (indwelling or intermittent) to patients from the general population. DESIGN: Retrospective cohort study. SETTING: Population-based study in Ontario, Canada between 2003 and 2018. PARTICIPANTS: Adult patients 18-90 years of age with chronic bladder catheterisation were hard matched to patients from the general population without a history of bladder catheterisation. INTERVENTIONS: The presence of a chronic catheter was defined as a minimum of two physician encounters for bladder catheterisation, suprapubic tube insertion or home care for catheter care separated by at least 28 days. Urinary tract infection (UTI) rates were collected. MAIN OUTCOME MEASURES: Bladder cancer and bladder cancer-specific mortality after a 1-year lag period were compared between groups. RESULTS: We identified 36 903 patients with chronic catheterisation matched to 110 709 patients without a history of catheterisation. Patients were followed for a median of 8.8 years (IQR: 5.2-11.9 years). The median age was 62 years (IQR: 50-71) and 52% were female. More patients in the catheter group developed bladder cancer (393 (1.1%) vs 304 (0.3%),p<0.001). There were 106 (0.3%) bladder cancer deaths in the catheter group and 59 (0.1%) in the comparison group (p<0.001). Chronic catheterisation (adjusted subdistribution HR (sdHR)=4.80, 95% CI: 4.26 to 5.42,p<0.001) and the number of UTIs (adjusted sdHR=1.04 per UTI, 95% CI: 1.04 to 1.05,p<0.001) were independent predictors of bladder cancer. The relative rate of bladder cancer-specific death was more than eightfold higher among patients with chronic catheterisation (adjusted sdHR=8.68, 95% CI: 6.97 to 10.81,p<0.001). Subgroup analysis among patients with neurogenic bladder and bladder calculi similarly revealed an increased risk of bladder cancer diagnosis and mortality. Bladder cancer risk was highest among patients in the two longest catheter duration quintiles (2.9-5.9 and 5.9-15.5 years). CONCLUSIONS: This is the first study to quantify the increase in bladder cancer incidence and mortality in a large, diverse cohort of patients with chronic indwelling or intermittent bladder catheterisation. The risk was highest among patients with a chronic catheter beyond 2.9 years.

The top 100 cited articles in pediatric urology: A bibliometric analysis.

INTRODUCTION: In the last 120 years, the field of pediatric urology has seen an exponential growth. In this time, there has not been a comprehensive review of top cited articles within the field. OBJECTIVES: We aim to identify and categorize the top 100 most cited peer-reviewed articles in pediatric urology using citation analysis. STUDY DESIGN: We searched for articles in the Web of Science™ Core Collection between 1900 and 2020 using terms specific to pediatric urology. We identified relevant pediatric urology articles and selected the top 100 most cited articles. We analysed trends over time for topics and categories and we evaluated the relatedness of these articles using citation analysis software. RESULTS: The top 100 most cited articles in pediatric urology were published between 1958 and 2016 in 26 countries, across 181 institutions, and in 46 journals. The median number of citations per article was 268 (IQR 225.75-394.25). Clinical manuscripts were the most common among the top 100 cited articles (n = 64) and the most common topic was genital conditions (e.g., penile, inguinal, or testis but not including hypospadias) (n = 19; 16.5%; total citations = 6591). When using bibliometric software to analyse relatedness among the top 100 articles based on citation of one another, we identified 11 clusters of 3 or more articles which corresponded to topics like those we defined a priori (Summary Figure). We found that a greater proportion of articles describing surgical techniques were published prior to 1987 (n = 6, 38%) as compared to after 1987 (n = 11, 13%), while the proportion of basic science articles has increased. DISCUSSION: This is the first study to analyse the most cited articles in pediatric urology. There was a lower median citation per article and fewer prospective studies in this list compared to other urologic sub-specialties. Similar to other clinical specialties, the focus has moved from describing and comparing operative techniques to exploring mechanisms of disease. This study is limited by using a single parameter (citation rate) and a single citation database. CONCLUSION: The list of top 100 most cited articles in pediatric urology is an important resource for clinicians and trainees to understand the body of knowledge and trajectory of this field. It charts the evolution of the field and highlights areas of potential investigation. This objective approach to literature review can facilitate future research and education efforts.

Impact of Delayed Recognition of Iatrogenic Ureteral Injury in a Retrospective Population-Based Study.

INTRODUCTION: Iatrogenic ureteral injuries (IUIs) are rare but can lead to significant consequences if unrecognized at the time of injury. We compare the impact of immediate vs delayed recognition of IUIs on clinical, cost and health care utilization outcomes. METHODS: We conducted a population-based retrospective cohort study on patients who had a diagnosis of an IUI between 2003 and 2018. The primary independent variable was the time of diagnosis of IUI. The primary clinical outcomes evaluated included renal impairment and a composite outcome: hydronephrosis or stricture. Secondary outcomes included total direct health care costs and health care utilization. RESULTS: We identified 1,193 patients who experienced an IUI, 25.2% of whom had a delay in recognition. Delayed recognition of IUI was associated with hydronephrosis or stricture within 1 year following treatment of IUI (OR 2.27, 95% CI 1.69-3.04, p <0.0001) and renal impairment within 2 years following treatment of IUI (OR 2.69, 95% CI 1.84-3.94, p <0.0001) compared to immediate diagnosis. Total health care costs (incident rate ratio [IRR] 2.06, 95% CI 1.89-2.24, p <0.0001), emergency department visits (IRR 2.07, 95% CI 1.77-2.43, p <0.0001), hospitalizations (IRR 1.62, 95% CI 1.48-1.78, p <0.0001) and outpatient urology visits (IRR 1.45, 95% CI 1.31-1.60, p <0.0001) were significantly higher in those with delayed recognition compared to immediate. Previous radiation was significantly associated with delayed recognition of IUI (OR 0.64, 95% CI 0.42-0.97, p=0.04). CONCLUSIONS: Delayed recognition of IUI is associated with significant clinical, cost and health care utilization consequences.