Pelvic Floor Distress Inventory Scores Improve After Prolapse Surgery Regardless of Surgical Approach but Not After Observation Alone.

OBJECTIVE: To evaluate the effect of different surgical procedures on Pelvic Floor Distress Inventory (PFDI) scores in women with pelvic organ prolapse. MATERIALS AND METHODS: Women with prolapse were enrolled from 2008 to 2014. Baseline data and outcomes at 1 year were collected including subscales of the PFDI. Patients who had surgery (SGY) within the first year were compared to those who did not (N-SGY). Subanalyses of SGY included vaginal vs abdominal, with or without concurrent hysterectomy (HYST, N-HYST), placement of mesh (MESH, N-MESH), and concurrent posterior repair/perineorrhaphy (POST, N-POST). RESULTS: A total of 233/239 patients underwent surgery in the first year. For SGY vs N-SGY, SGY had significant improvements in PFDI and all subscale scores at 1 year while N-SGY did not. When comparing vaginal to abdominal approach, MESH to N-MESH and HYST to N-HYST, there were no differences between any scores at baseline or 1 year between the groups. However, all within group symptom scores improved from baseline to 1 year (P <.0001 for all). In comparing POST to N-POST, there were no differences between groups at 1 year in PFDI and Urogenital Distress Inventory and Pelvic Organ Prolapse Distress Inventory subscale scores. Colorectal-Anal Distress Inventory scores were significantly higher at baseline for POST (P <.0001) but not at 1 year (P = 0.37). All within group scores statistically significant improved at 1 year. CONCLUSION: Women who underwent surgical repair for prolapse had significantly improved overall PFDI and subscale scores regardless of surgical approach and concurrent procedures.

Recovery of urinary function after robotic-assisted laparoscopic prostatectomy versus radical perineal prostatectomy for early-stage prostate cancer.

INTRODUCTION: Robotic-assisted laparoscopic prostatectomy (RALP) has largely replaced open radical prostatectomy in many centers. Radical perineal prostatectomy (RPP) is another less invasive approach that has not been widely adopted. RPP offers excellent exposure of the urinary sphincter and bladder neck that may provide good urinary function outcomes. We evaluate urinary function after RALP and RPP. METHODS: Retrospective review of a prospective radical prostatectomy database was performed. Urinary modules from the Expanded Prostate Cancer Index Composite-Urinary Function (EPIC-UF) questionnaire were used to determine urinary symptoms at baseline and at 6, 12, 18, and 24 months after surgery. RESULTS: 753 men underwent RALP (n = 623) or RPP (n = 130). Of these, 558 had complete data and were included in our study (RALP: n = 458, RPP: n = 100). A higher number of patients undergoing RALP than RPP had pelvic lymph node dissection (20.2% vs. 0%, p < 0.0001) and cavernosal neurovascular bundle sparing (79.2% vs. 68.4%, p < 0.0001). 558 patients had complete EPIC-UF data. Overall urinary recovery was greater for RALP than RPP at 6 months (p = 0.028). Urinary incontinence and function were also more improved after RALP compared to RPP at 6 months (p = 0.021, p = 0.006). However, no differences in overall, urinary incontinence, or urinary function scores were seen at 12, 18, or 24 months. There was no difference between groups in urinary bother or irritative/obstructive symptoms at any time point. CONCLUSIONS: RALP had more rapid recovery of urinary function at 6 months vs. RPP; at 12-24 months, however, RALP and RPP had similar urinary function recovery in all urinary subdomains.

Additional treatments, satisfaction, symptoms and quality of life in women 1 year after vaginal and abdominal pelvic organ prolapse repair.

OBJECTIVES: To evaluate additional treatments, symptoms, satisfaction and quality of life 1 year after vaginal and abdominal pelvic organ prolapse (POP) repair. METHODS: Adult women enrolled in a prospective POP database were reviewed. Baseline and outcomes data 1 year after surgery were collected including the Pelvic Floor Distress Inventory (PFDI) and mailed surveys. Data were analyzed with descriptive statistics, Fisher's exact tests and t tests. RESULTS: Of 222 women, 147 (66%) had vaginal and 75 (34%) had abdominal repair. Vaginal group patients were older (64.1 vs. 59.7 years; p = 0.003), but other demographic characteristics did not differ. Vaginal group patients had lower baseline anterior and apical prolapse grades (anterior 2.7 vs. 3.1, p = 0.003; apical 2.1 vs. 3.1, p < 0.001). Baseline PFDI scores were similar. Scores improved significantly for both groups after 1 year, but 1-year PFDI scores were significantly higher in the vaginal group (45.6 vs. 32.6, p = 0.032). Scores were not different when adjusted for age and prolapse grade (p = 0.24). At 1 year, most patients in the vaginal and abdominal groups reported moderately/markedly improved overall symptoms (72/108 vs. 50/60, p = 0.030) and quality of life (89/101 vs. 54/59, p = 0.601). Most were satisfied with surgery (68/101 vs. 48/59, p = 0.067). Retreatment rates (pelvic floor physical therapy, medications, coping strategies, surgical procedures) were similar (34/109 vs. 15/62, p = 0.381). Vaginal mesh use did not affect additional treatments, patient satisfaction or symptoms. CONCLUSIONS: Although symptoms improve and most women are satisfied with surgery, about one in four women have additional therapy in the first year after POP repair.

Does sex matter? A matched pairs analysis of neuromodulation outcomes in women and men.

AIMS: To evaluate whether baseline symptoms and outcomes are influenced by gender in a matched cohort undergoing neuromodulation. METHODS: Patients in our prospective neuromodulation database that had a tined lead placed were reviewed. Those that had implantable pulse generator (IPG) placed were matched on age and urologic diagnosis. History, voiding diaries, satisfaction, Interstitial Cystitis Symptom/Problem Index (ICSIPI), and overactive bladder symptom severity (OABq ss)/health-related quality of life (HRQOL) preimplant and over 3 years were evaluated using descriptive statistics, repeated measures, and matched pair GEE or mixed analyses. RESULTS: Of 590 patients in the database, more women than men received an IPG (450/488; 92.2 vs. 84/102; 82.4%; p = 0.0011). Eighty matched pairs (n = 160; 81% ≥ 50 years old; 56.25% had urgency/frequency with urge incontinence-UI) were identified and evaluated. On voiding diaries, volume/void was greater in women only at baseline (p = 0.040); both groups improved over time (p < 0.0001). Urinary frequency improved in both women and men (p = 0.0010; p = 0.0025). Over 3 years, UI episodes/day improved only in men (p = 0.017) and UI severity improved only in women (p < 0.0001). ICSIPI, OABq ss, and HRQOL scores improved similarly in both groups (p < 0.0001 for all measures in both groups), and although more women were satisfied at 3 months (p = 0.027), groups did not differ at other time points. CONCLUSIONS: More women undergo neuromodulation and have initial success and subsequent IPG implantation. UI episodes improved only in men, and UI severity improved only in women. Both women and men experienced similar levels of symptom improvement on other measures.

The Risks and Benefits of Cavernous Neurovascular Bundle Sparing during Radical Prostatectomy: A Systematic Review and Meta-Analysis.

PURPOSE: We summarize published data on associations between cavernous neurovascular bundle preservation (nerve sparing) during prostatectomy and positive surgical margins, erectile function, urinary function and other patient reported outcomes. MATERIALS AND METHODS: A systematic literature search of MEDLINE®, Embase® and Cochrane Reviews databases was performed for interventional or observational studies published between 2000 and 2014. English language articles that compared clinical outcomes of patients undergoing nerve sparing and nonnerve sparing radical prostatectomy were included. Meta-analyses were performed to calculate pooled relative risk estimates for positive surgical margins, erectile dysfunction and urinary incontinence in nerve sparing and nonnerve sparing groups. Sensitivity analyses compared outcomes among unilateral and bilateral nerve sparing vs nonnerve sparing groups. RESULTS: Of the 1,883 articles identified, 124 studies (73,448 patients) were included in the analysis. Nerve sparing did not increase the risk of positive surgical margins in patients with pT2 (RR 0.92, 95% CI 0.75-1.13) or pT3 disease (RR 0.83, 95% CI 0.71-0.96), potentially due to appropriate patient selection. The risk of incontinence was lower in nerve sparing cases (RR 0.75, 95% CI 0.65-0.85 and RR 0.61, 95% CI 0.44-0.84) at 3 and 12 months, respectively. The relative risk of erectile dysfunction with nerve sparing was 0.77 (95% CI 0.70-0.85) at 3 months and 0.53 (95% CI 0.39-0.71) at 12 months. Subgroup analyses of unilateral and bilateral nerve sparing approaches demonstrated similar results. CONCLUSIONS: Among cohort studies nerve sparing was not associated with worse cancer outcomes. Nerve sparing is associated with better urinary and erectile function. These results should be interpreted with caution given the potential for selection bias and unadjusted confounding factors.

Prostate volume estimations using magnetic resonance imaging and transrectal ultrasound compared to radical prostatectomy specimens.

INTRODUCTION: We sought to evaluate the accuracy of prostate volume estimates in patients who received both a preoperative transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) in relation to the referent pathological specimen post-radical prostatectomy. METHODS: Patients receiving both TRUS and MRI prior to radical prostatectomy at one academic institution were retrospectively analyzed. TRUS and MRI volumes were estimated using the prolate ellipsoid formula. TRUS volumes were collected from sonography reports. MRI volumes were estimated by two blinded raters and the mean of the two was used for analyses. Pathological volume was calculated using a standard fluid displacement method. RESULTS: Three hundred and eighteen (318) patients were included in the analysis. MRI was slightly more accurate than TRUS based on interclass correlation (0.83 vs. 0.74) and absolute risk bias (higher proportion of estimates within 5, 10, and 20 cc of pathological volume). For TRUS, 87 of 298 (29.2%) prostates without median lobes differed by >10 cc of specimen volume and 22 of 298 (7.4%) differed by >20 cc. For MRI, 68 of 298 (22.8%) prostates without median lobes differed by >10 cc of specimen volume, while only 4 of 298 (1.3%) differed by >20 cc. CONCLUSIONS: MRI and TRUS prostate volume estimates are consistent with pathological volumes along the prostate size spectrum. MRI demonstrated better correlation with prostatectomy specimen volume in most patients and may be better suited in cases where TRUS and MRI estimates are disparate. Validation of these findings with prospective, standardized ultrasound techniques would be helpful.

Development and incorporation of hybrid simulation OSCE into in-training examinations to assess multiple CanMEDS competencies in urologic trainees.

INTRODUCTION: As residency training requirements increasingly emphasize a competency-based approach, novel tools to directly evaluate Canadian Medical Education Directives for Specialists (CanMEDS) competencies must be developed. Incorporating simulation allows residents to demonstrate knowledge and skills in a safe, standardized environment. We describe a novel hybrid simulation station for use in a urology resident in-training Objective Structured Clinical Exam (OSCE) to assess multiple CanMEDS competencies. METHODS: An OSCE station was developed to assess Communicator, Health Advocate, Manager, and Medical Expert (including technical skills) CanMEDS roles. Residents interviewed a standardized patient, interacted with a nurse, performed flexible cystoscopy and attempted stent removal using a novel bladder/stent model. Communication was assessed using the Calgary-Cambridge Observational Guide, knowledge was assessed using a checklist, and technical skills were assessed using a previously validated global rating scale. Video debriefing allowed residents to review their performance. Face and discriminative validity were assessed, and feasibility was determined through qualitative post-examination interviews and cost analysis. RESULTS: All 9 residents (postgraduate years [PGY] 3, 4, 5) completed the OSCE in 15 minutes. Communicator and knowledge scores were similar among all PGYs. Scores in technical skills were higher in PGY-5 compared with PGY-3/4 reside nts (mean score 79% vs. 73%). Residents and exam personnel felt the OSCE station allowed for realistic demonstration of competencies. Equipment cost was $218 for the exam station. CONCLUSIONS: We developed and implemented a hybrid simulation-based OSCE station to assess multiple CanMEDS roles. This approach was feasible and cost-effective; it also provided a framework for future development of similar OSCE stations to assess resident competencies across multiple domains.

Adolescent users of an online contraception selection tool: how user preferences and characteristics differ from those of adults.

STUDY OBJECTIVE: The objective of this study was to report user statistics of an online contraception selection tool over a 6-month period, comparing preferences and characteristics of adolescents to those of adults. SETTING: Choosing Wisely, available on the website www.SexualityandU.ca, is an interactive program that helps women select an ideal birth control method. DESIGN: Answers to the online questionnaire were logged for a 6-month period. Answers of adolescent users were retrospectively reviewed for responses to questions regarding personal preferences and compared with those of adults. PARTICIPANTS: Participants of the study included users who self-identified as first-time users of Choosing Wisely. RESULTS: 3178 adolescents (age ≤19) and 4206 adults self-identified as new users and completed the software module. Adolescents less commonly reported weighing over 198 pounds or to be smokers. 61% of adolescents would prefer to avoid menses (vs 52% of adults) and 83% of adolescent would find a pregnancy devastating (vs 64% of adults). 1720 (54%) of the adolescents had menstrual complaints; of these 500 (29%) did not believe they could reliably take a pill daily. The majority of both adolescents (73%) and adults (71%) claimed to be willing to use a contraceptive method that required interruption of intercourse. CONCLUSIONS: Choosing Wisely is attracting large numbers of teens and adults, whose responses provide insight into the characteristics of those seeking contraception. Our data corroborate the need for contraceptive options such as combined contraceptives that do not require daily pill-taking and contraceptives that offer menstrual management. However, the magnitude of these statistically significant differences was not always as impressive clinically.

Seasonal trends in adolescent pregnancy conception rates.

STUDY OBJECTIVE: The objectives of this study were to determine if a seasonal trend exists in adolescent pregnancies and to compare the teen conception rate per month to an adult population. SETTING: The study was conducted in a tertiary care Canadian hospital that has a one-site model of care. DESIGN: A retrospective chart review of all adolescent pregnancies over a 5-year period (N = 838) was undertaken. From the 13,554 adult pregnancies over the same time period, a random sample of 838 pregnancies was chosen for similar chart review. A chi-square test was used to compare the proportion of pregnancies conceived in each calendar month between the two groups. PARTICIPANTS: Pregnancies ending in spontaneous abortions, elective terminations, ectopic pregnancies, as well as obstetrical deliveries, were included. RESULTS: There was a significantly different monthly trend seen in adolescent pregnancy conceptions when compared with the adult group (χ² = 24.38, df = 11, P = 0.0112). The adolescent group was observed to have a unique peak in the number of pregnancies conceived in March (10.5% of pregnancies conceived compared to 7.3% in adults). In addition, 8.5% of conceptions in adolescents occurred in December compared to 10.4% in adults. CONCLUSIONS: There are several plausible explanations for the modest but real differences identified in this study including trends in fecundity/fertility or social/school events that lead to increased sexual activity. Peaks in conception indicate times when a greater need for health care services exists, and when preventive education can be most effective.

Characteristics and concerns of women choosing an online contraception selection tool ("choosing wisely").

BACKGROUND: Choosing Wisely, a user-friendly and interactive application developed and tested at Queen's University, is a self-administered computer-based questionnaire that aims to assist women, their partners, and their health care providers in deciding among contraceptive options. The application asks specific, direct questions regarding a patient's preferences, health, and lifestyle, and it then generates three lists: (1) indicated contraceptive methods, (2) options that may be suitable, and (3) contraindicated methods. OBJECTIVE: To report statistics on the users of Choosing Wisely in the first 13 months since the launch of the program on the award-winning SOGC website Sexualityandu.ca in June, 2007. METHODS: At the end of the program module, each user's answers were logged anonymously in a Microsoft Excel spreadsheet along with the time and date of completion. Descriptive statistics were generated in SPSS version 16.0. RESULTS: Between June 21, 2007, and July 25, 2008, 9775 users completed the Choosing Wisely program. Of these users, 8942 (91.5%) were female, and 8745 (89.5%) were under 35. At least one concern regarding contraceptive options was reported by 7359 users (75.3%), and the most common of these was weight gain, selected by 4806 (65.3%). CONCLUSION: Choosing Wisely has attracted an average of 24 users per day seeking more information on birth control methods. The responses gathered from the program will likely allow for both a better understanding of the characteristics of women who desire birth control and refinement of the program, with the aim of better serving those who are seeking contraceptive advice.