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1.
BJU Int ; 2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31389161

RESUMO

OBJECTIVE: To compare the healthcare utilisation and repeat surgical treatment rate amongst older men undergoing an electrosurgical-transurethral resection of the prostate (TURP) vs photoselective vaporisation of the prostate (PVP), as the real-world implementation and outcomes of laser-based treatment have not been well studied. PATIENTS AND METHODS: We used administrative data from the province of Ontario, Canada, to identify all men aged >66 years who underwent their first electrosurgical-TURP/PVP between 2003 and 2016. Our primary exposure was type of procedure (PVP or electrosurgical-TURP). Our primary outcome was need for repeat surgical treatment. The primary analysis was an adjusted marginal Cox model approach, which accounted for clustering of patients within surgeons; adjusted hazard ratios (aHRs) or odds ratios (aORs) and 95% confidence intervals (CIs) are reported. RESULTS: We identified 52 748 men: 6838 (13%) underwent PVP, and 45 910 (87%) underwent electrosurgical-TURP. The median age was similar, and PVP became more common with time. Compared to the PVP group, more patients in the electrosurgical-TURP group had prior gross haematuria or urinary retention, and fewer had used anticoagulants, α-blockers, or 5α-reductase inhibitors. The need for repeat surgical treatment was significantly higher amongst men who had PVP (aHR 1.57, 95% CI 1.38-1.78; absolute risk difference +2.3%). PVP was also associated with a slightly higher risk of return to the emergency room within 30 days (aOR 1.11, 95% CI 1.01-1.22) and a significantly lower risk of blood transfusion (aOR 0.24, CI 0.16-0.37); the majority of PVP cases were done with a <24 h stay (73%) vs electrosurgical-TURP (7%). CONCLUSIONS: While some of the expected benefits of PVP (such as reduced transfusion risk and shorter length of stay) were observed, the significantly higher rate of repeat surgical treatment compared to electrosurgical-TURP may represent an important difference in implementation of this technology outside of clinical trials.

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3.
Artigo em Inglês | MEDLINE | ID: mdl-31348899

RESUMO

OBJECTIVE: To validate if better upper extremity (UE) motor function predicts clean intermittent catheterization (CIC) adoption and adherence after spinal cord injury (SCI) using a validated instrument (as opposed to prior research using scales based on expert opinion). DESIGN: We examined data from the Neurogenic Bladder Research Group SCI registry, a multicenter, prospective, observational study assessing persons with neurogenic bladder following SCI. All participants who were unable to volitionally void and were >1 year post injury were included. Participants were dichotomized into those performing CIC vs those using other bladder management methods. In addition to demographic and clinical characteristics, UE motor function was examined using the SCI-Fine Motor Function Index using validated categorization levels: (1) no activities requiring hand function, (2) some activities involving gross hand movement, (3) some activities requiring dexterity or coordinated UE movement, or (4) most activities requiring dexterity and coordinated UE movement. Associations were examined using logistic regression. SETTING: Multicenter study. PARTICIPANTS: Registry participants unable to volitionally void after SCI (N=1236). INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Upper extremity motor function association with CIC. RESULTS: A total of 1326 individuals met inclusion criteria (66% performing CIC, 60% male, and 82% white). On multivariate analysis, better UE motor function was associated with a statistically increased odds of performing CIC (odds ratio, 3.10 [Level 3] and odds ratio, 8.12 [Level 4] vs Levels 1 and 2 [P<.001]). CONCLUSION: In persons with SCI who are unable to volitionally void, UE motor function is highly associated with CIC. These results validate prior findings and continue to suggest that following SCI, the degree of preserved UE motor function is associated with CIC more than any other factor.

4.
Spinal Cord ; 2019 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-31289367

RESUMO

STUDY DESIGN: Descriptive study OBJECTIVES: Urinary tract infections (UTIs) are one of the most frequent types of infections following spinal cord injury (SCI). Here we assess the relationship between frequency of UTIs and activity level/overall quality of life (QOL) measures, determine the frequency of temporally associated conditions associated with UTI and identify factors associated with frequent UTIs. SETTING: Canada METHODS: The Spinal Cord Injury Community Survey was developed to assess major dimensions of community living and health outcomes in persons with chronic SCI in Canada. Participants were stratified by self-reported UTI frequency. The relationship between UTI frequency and QOL, health resource utilization, and temporally associated conditions were assessed. Results were analysed with cross tabulations, χ2 tests, and ordinal logistic regression. RESULTS: Overall 73.5% of participants experienced at least one self-reported UTI since the time of injury (mean 18.5 years). Overall QOL was worse with increasing frequency of these events. Those with frequent self-reported UTIs had twice as many hospitalizations and doctors' visits and were limited in financial, vocational and leisure situations, physical health and ability to manage self-care as compared with those with no UTIs. Self-reported UTIs were associated with higher incidence of temporally associated conditions including bowel incontinence, constipation, spasticity, and autonomic dysreflexia. Individuals who were younger and female were more likely to have frequent UTIs and those with constipation and autonomic dysreflexia had worse QOL. CONCLUSIONS: Higher frequency self-reported UTIs is related to poor QOL of individuals with long-term SCI. These findings will be incorporated into SCI UTI surveillance and management guidelines.

7.
Urology ; 130: 126-131, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31129193

RESUMO

OBJECTIVE: To determine how often prostate- and bladder-specific medications for lower urinary tract symptoms are used following a transurethral prostatectomy (TURP). METHODS: This study utilized several linked, routinely collected datasets from the province of Ontario, Canada to identify men older than 66 years who underwent their first TURP between April 2003 and March 2016. The primary outcome was the probability of using at least 30 days of either prostate-specific alpha blockers (AB), 5-alpha reductase inhibitors (5ARI), or anticholinergics/beta-3 agonists (AC/B3) after their TURP. RESULTS: We identified 58,038 men (median age 75), with a median follow-up of 4.9 years. In the 6 months prior to their TURP, AB, 5ARIs or AC/B3 were used by 62%, 32%, and 6%, respectively. Following a 90-day washout period after TURP, these medications were used by 27%, 20%, and 15% of men, respectively. The cumulative probability of using these medications within the first 10 years after TURP was 38%, 28%, and 20%, respectively. Family physicians prescribed the majority of AB, while urologists prescribed the majority of the AC/B3. Among men on AC/B3 prior to TURP, 46% used them after TURP; in multivariate cox regression analysis age ≥75, diabetes, preoperative use of AC/B3, and no preoperative urinary retention predicted postoperative utilization of AC/B3 medications. CONCLUSION: There is considerable use of AB and 5ARIs despite a lack of evidence for using these medications after a TURP. Given the well-characterized placebo response in BPH patients, this practice should be properly evaluated for clinical efficacy.

8.
Can J Ophthalmol ; 54(2): 212-222, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30975345

RESUMO

OBJECTIVE: To identify factors associated with secondary surgical intervention after glaucoma filtration surgery. DESIGN: Population-based retrospective cohort. METHODS: Patient records with billing claims for a primary glaucoma filtration surgery occurring between April 2003 and March 2015 were identified. Each identified record was examined for instances of secondary glaucoma surgeries within the patient's first postoperative year. Baseline characteristics of patients who required secondary surgical intervention were compared with those who did not. A multivariable Cox proportional hazards model was used to calculate hazard ratios. RESULTS: Within a cohort of 10,097 patients, 349 (3.46%) underwent a secondary surgical intervention within the first postoperative year. Interventions were less frequent after surgeries that included an indwelling drainage device (HR=0.58 95% CI, 0.37-0.89), phacoemulsification (HR=0.33, 0.21-0.52), or both (HR=0.09, 0.03-0.31). Patients with preoperative aminoglycoside and mydriatic exposure had significantly increased risk of secondary surgical intervention (HR=3.19, 1.89-5.36) and (HR=2.32, 1.49-3.61). Patients who underwent surgery on their contralateral eye experienced secondary surgical interventions more frequently: 7.44 per 10,000 person-days (versus 1.18 per 10,000 person-days, p < 0.0001). No significant differences in the rates of secondary surgical intervention were observed for patients taking different classes of glaucoma medications or those exposed to higher amounts of benzalkonium chloride. CONCLUSIONS: In Ontario, the overall rates of secondary surgical interventions in the first postoperative year are low but significantly higher in certain patient populations. Further work is required to address the higher rate of secondary surgical intervention in patients with a history of certain perioperative eye drop medications and those who require sequential-bilateral procedures.


Assuntos
Cirurgia Filtrante/estatística & dados numéricos , Glaucoma/cirurgia , Pressão Intraocular/fisiologia , Vigilância da População/métodos , Complicações Pós-Operatórias/cirurgia , Reoperação/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Glaucoma/fisiopatologia , Humanos , Incidência , Masculino , Ontário/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco
9.
J Urol ; 202(3): 574-584, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30958741

RESUMO

PURPOSE: Neurogenic bladder significantly impacts individuals after spinal cord injury. We hypothesized that there would be differences in bladder related symptoms and quality of life for 4 common bladder management methods. MATERIALS AND METHODS: In this prospective observational study we measured neurogenic bladder related quality of life after spinal cord injury. Study eligibility included age 18 years or greater and acquired spinal cord injury. Bladder management was grouped as 1) clean intermittent catheterization, 2) an indwelling catheter, 3) surgery (bladder augmentation, a catheterizable channel or urinary diversion) and 4) voiding (a condom catheter, involuntary leaking or volitional voiding). The primary outcomes were the NBSS (Neurogenic Bladder Symptom Score) and the SCI-QoL Difficulties (Spinal Cord Injury Quality of Life Measurement System Bladder Management Difficulties). Secondary outcomes were the NBSS subdomains and satisfaction with urinary function. Multivariable regression was done to establish differences between the groups, separated by level. RESULTS: Of the 1,479 participants enrolled in the study 843 (57%) had paraplegia and 894 (60%) were men. Median age was 44.9 years (IQR 34.4-54.1) and median time from injury was 11 years (IQR 5.1-22.4). Bladder management was clean intermittent catheterization in 754 cases (51%), an indwelling catheter in 271 (18%), surgery in 195 (13%) and voiding in 259 (18%). In regard to primary outcomes, in cases of paraplegia and tetraplegia an indwelling catheter and surgery were associated with fewer urinary symptoms on the NBSS compared to clean intermittent catheterization while voiding was associated with more symptoms. In paraplegia and tetraplegia cases surgery was associated with fewer bladder management difficulties according to the SCI-QoL Difficulties. In regard to secondary outcomes, surgery was associated with improved satisfaction in individuals with paraplegia or tetraplegia. CONCLUSIONS: In individuals with spinal cord injury fewer bladder symptoms were associated with an indwelling catheter and surgery, and worse bladder symptoms were noted in voiding individuals compared to those on clean intermittent catheterization. Satisfaction with the urinary system was improved after surgery compared to clean intermittent catheterization.


Assuntos
Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Traumatismos da Medula Espinal/complicações , Bexiga Urinaria Neurogênica/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Resultado do Tratamento , Bexiga Urinária/inervação , Bexiga Urinária/fisiopatologia , Bexiga Urinária/cirurgia , Bexiga Urinaria Neurogênica/etiologia , Bexiga Urinaria Neurogênica/fisiopatologia , Bexiga Urinaria Neurogênica/psicologia , Cateterismo Urinário/métodos , Micção/fisiologia , Procedimentos Cirúrgicos Urológicos/métodos , Adulto Jovem
10.
Urology ; 128: 107-111, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30890419

RESUMO

OBJECTIVE: To examine the utility of the Neurogenic Bladder Symptom Score (NBSS) in adults with cerebral palsy (CP). METHODS: Patients participated in a structured intake which included bladder management. Patients (or caregivers, if patients unable) completed NBSS and SF-Qualiveen twice over a 2-week period. Validity was determined using Cronbach's alpha and correlation testing between NBSS, intake, and SF-Qualiveen. Reliability was determined using test-retest method and intraclass correlation coefficients. RESULTS: Fifty-four patients were included. Thirty-six patients (67%) used a wheelchair; 35 patients (66%) required a caregiver to complete questionnaires. Median NBSS subdomain scores were 12 of 29 for incontinence, 9 of 22 for storage and/or voiding, 2 of 23 for consequences and 1 of 4 for quality of life (QOL). Lower scores reflect fewer symptoms. Reliability was high (intraclass correlation coefficients = 0.90). There was a moderate correlation (R = 0.70) between NBSS QOL and SF-Qualiveen. Bladder management method, as determined by the NBSS, was indwelling catheter in 4, intermittent catheterization in 6, voiding into a toilet in 33, and missing in 11. Importantly, there was no option for voiding into a diaper, which was common in this population. CONCLUSION: For adults with CP, the NBSS has high reliability and statistically, it demonstrated appropriate validity, but it has limitations. Its face validity is questionable given that diapers were not an option. The validity of caregiver completion needs further assessment. The NBSS may have a floor effect for detecting urinary consequences or QOL, reflected by consistently low scores in these subdomains. The development of a specific urinary symptom and/or QOL tool for adults with CP is needed.

11.
Neurourol Urodyn ; 38(5): 1332-1338, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30912199

RESUMO

OBJECTIVE: Clean intermittent catheterization (CIC) is a preferred method of bladder management for many patients with spinal cord injury (SCI), but long-term adherence is low. The aim of this study is to identify factors associated with low urinary quality of life (QoL) in SCI adults performing CIC. METHODS: Over 1.5 years, 1479 adults with SCI were prospectively enrolled through the Neurogenic Bladder Research Group registry, and 753 on CIC with no prior surgeries were included. Injury characteristics, complications, hand function, and Neurogenic Bladder Symptom Score (NBSS) were analyzed. The NBSS QoL question (overall satisfaction with urinary function) was dichotomized to generate comparative groups (dissatisfied vs neutral/satisfied). RESULTS: The cohort was 32.9% female with a median age of 43.2 (18-86) years, time since the injury of 9.8 (0-48.2) years, and 69.0% had an injury at T1 or below. Overall 36.1% were dissatisfied with urinary QoL. On multivariable analysis, female gender (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.15-2.31; P = 0.016), earlier injury (OR, 0.95 per year; 95% CI, 0.93-0.97; P < 0.001), ≥4 urinary tract infections (UTIs) per year (OR, 2.36; 95% CI, 1.47-3.81; P = 0.001), and severe bowel dysfunction (OR, 1.42; 95% CI, 1.02-1.98; P = 0.035) predicted dissatisfaction. Level of injury, fine motor hand function, and caregiver dependence for CIC were not associated with dissatisfaction. CONCLUSIONS: In a mature SCI cohort, physical disability does not predict dissatisfaction with urinary QoL but severe bowel dysfunction and recurrent UTIs have a significant negative impact. With time the rates of dissatisfaction decline but women continue to be highly dissatisfied on CIC and may benefit from early intervention to minimize the burden of CIC on urinary QoL.

12.
Spinal Cord ; 57(8): 700-707, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30872758

RESUMO

STUDY DESIGN: The Neurogenic Bladder Research Group (NBRG) registry is a multicenter prospective observational study. This manuscript is retrospective based on a cross-sectional survey. OBJECTIVES: To assess patient subjective assessment of urinary tract infection (UTI) frequency and severity are associated with the degree of use of catheters or incontinence products. SETTING: Multiple hospitals across the United States. METHODS: Eligibility included: age > 18 years and acquired SCI. Over 1.5 years, 1479 eligible participants were enrolled. We excluded those with surgical reconstruction or diversion of the bladder. In total, 1282 participants were grouped by bladder management: (1) indwelling catheter (IDC), (2) clean intermittent catheterization (CIC), (3) external devices (pads/condom), and (4) volitional voiding (Void). UTI frequency was classified as 0, 1-3, 4-6, or > 6 over the prior year. UTI severity was determined by hospitalization for UTI in the prior year. Multivariate regression compared these factors across groups. RESULTS: UTIs were least frequent in Void followed by pads/condom, CIC, and IDC (all p ≤ 0.001). UTI severity followed a similar pattern. Controlling for covariates, the adjusted odds of UTI frequency (Void = reference) were 2.28 (1.38-3.76) for pads/condom, 3.42 (2.25-5.18) for CIC, and 4.3 (2.59-6.70) for IDC (all p ≤ 0.001). CONCLUSIONS: Patient subjective assessment of UTI frequency is highest with IDC, followed by CIC, pads/condom, and lowest with spontaneous voiding. The odds of hospitalization for UTI were three times higher for IDC than spontaneous voiding. UTI risk should be considered when counseling patients about bladder management options. These associations do not imply causation but warrant further investigation in a prospective manner. SPONSORSHIP: Patient-Centered Outcomes Research Institute (PCORI) Award (CER14092138).

14.
Reg Anesth Pain Med ; 2019 Jan 23.
Artigo em Inglês | MEDLINE | ID: mdl-30679335

RESUMO

BACKGROUND AND OBJECTIVES: Radiofrequency ablation (RFA) is a common treatment modality for chronic axial spine pain. Controversy exists over its effectiveness, and outcomes in a real-world setting have not been evaluated despite increasing use of RFA. This study examined changes in healthcare utilization and opioid use after RFA in Ontario, Canada. METHODS: This retrospective cohort study was conducted in Ontario using administrative data. Ontario residents receiving their initial RFA between 1 January 2009 and 31 March 2015 were included. Physician visits, spinal injections, and opioid dosing/prescriptions in the 12-month periods before and after RFA were compared. RESULTS: The study included 4653 patients. The number of RFA procedures significantly increased from 2009 to 2014 (22.5 cases/1 000 000 person-years to 82.5 cases/1 000 000 person-years). 4465 patients had at least one physician visit pre-RFA; there was a significant 23.89% reduction in physician visits post-RFA (pre-RFA: 29 616 visits; post-RFA: 22 542 visits). All reviewed specialties demonstrated a decrease in physician visits post-RF except neurosurgery. 3445 (85.70%) fewer spinal interventions for axial pain (medial/lateral branch blocks, facet/sacroiliac injections) were performed post-RFA. Significantly fewer epidurals were also performed post-RFA. 198 of 1007 patients (19.66%) on the Ontario Drug Benefit who received opioids pre-RFA did not require a postprocedure opioid prescription. Mean opioid dosing was unchanged post-RFA. CONCLUSIONS: Healthcare utilization was significantly reduced in the 12 months following RFA, and some patients eliminated opioid use. Selection criteria for RFA are not standardized in Ontario, and appropriate use guidelines for spine interventions may improve outcomes and reduce unnecessary procedures.

15.
J Obstet Gynaecol Can ; 41(8): 1168-1176, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30686606

RESUMO

OBJECTIVE: As quality-based procedures (QBPs) are being established across the province of Ontario, it is important to identify reliable quality indicators (QIs) to ensure that compensation coincides with quality. Hysterectomy is the most commonly performed gynaecologic procedure and as such is a care process for which a QBP is being developed. The aim of this study was to evaluate the technicity index (TI) as a QI for hysterectomy by defining it in the context of specific surgical outcomes and complications. METHODS: This population-based, retrospective cohort study included all women who underwent hysterectomy from April 2003 to October 2014 in the province of Ontario. Unadjusted and adjusted generalized linear models were created to assess the effect of a minimally invasive hysterectomy (MIH) approach on the primary outcome measure: all hysterectomy-associated complications (Canadian Task Force Classification II-2). RESULTS: Of the procedures meeting the study's inclusion criteria, 56.8% were performed using an abdominal hysterectomy approach, whereas 43.2% were performed using an MIH approach. Over the study period, TI improved significantly from 33.23% in 2003 to 58.47% in 2014. During this time span, the overall incidence of all hysterectomy-associated complications was 13.1%. CONCLUSION: The composite risk of all hysterectomy-associated complications was reduced by 46% with an MIH approach. The uptake of MIH improved significantly in Ontario from 2003 to 2014 and is adequately assessed by the TI. The TI is an appropriate QI for hysterectomy that can be used to track patients' outcomes and direct hysterectomy funding.

17.
Neurourol Urodyn ; 2018 Nov 29.
Artigo em Inglês | MEDLINE | ID: mdl-30499226

RESUMO

AIM: To systematically review the qualitative literature on neurogenic bladder management to better understand the relevant psychosocial issues. METHODS: We used two reviewers to systematically review EMBASE, CINAHL, and PsycINFO for qualitative studies that included a neurogenic bladder patient population and were relevant to bladder management. We used a meta-ethnography technique to summarize and synthesize the data. RESULTS: We found 13 studies that were relevant. When choosing a bladder management technique (three studies), there were two major themes (bladder management decision makers, and characteristics and risks) that impacted the process. For studies evaluating life with a urinary catheter (five about intermittent catheters, and five about indwelling catheters), relevant themes could be arranged into three consecutive periods: First, a changed life (the initial stage of selecting and using a catheter: coping, teaching and technical challenges, and control and independence). Second, learning to live with a catheter (the practical skill and knowledge that goes into using a catheter: knowledge, adjustments, and normalization). Third, a new life (the acceptance and integration of a catheter into a person's life: problems and benefits, unpredictability, travel and social activities, intimacy and relationships, and dealing with negative emotions). Themes were generally consistent across studies. Conclusions Several important themes were identified from the existing qualitative literature; these can provide insight into how neurogenic bladder patients select a bladder management method, and how physicians can optimize their counseling and the long-term management of these patients.

18.
Urology ; 121: 145-146, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30526902
19.
Can Urol Assoc J ; 2018 12 03.
Artigo em Inglês | MEDLINE | ID: mdl-30526805

RESUMO

INTRODUCTION: Baseline urodynamic characterization in patients with neurogenic lower urinary tract dysfunction (NLUTD) allows detection of unsafe storage and voiding pressures and optimization of these parameters through medical or surgical intervention. Surveillance urodynamics (sUDS) studies are performed in the ambulatory setting after baseline characterization, with the goal of monitoring bladder function. How often this study should be performed and the circumstances that should prompt repeated studies are unknown. The primary objective of this review is to evaluate the evidence supporting sUDS in the setting of NLUTD as assessed by whether the study leads to 1) change in patient management; 2) determination of new findings not suggested by imaging or symptoms; 3) demonstration of superior outcomes compared to observation. The secondary objective is to review sUDS practice patterns among urologists in their assessment of NLUTD. METHODS: PubMed, EMBASE, and Cochrane Library databases were reviewed for English-language literature published between January 1975 and March 2018. RESULTS: Twenty-eight independent articles (1368 patients, 9486 patient-years of followup) were included. Given heterogeneous data, 49% of 263 subjects were asymptomatic, yet demonstrated sUDS abnormality prompting treatment. Eight cross-sectional studies (four spinal cord injury [SCI], two NLUTD, two spina bifida) surveyed urologists regarding current sUDS patterns; 53% of 498 respondents perform sUDS between one and three years. CONCLUSIONS: Evidence supporting optimal surveillance for NLUTD is lacking. Level 2b-4 evidence suggests that sUDS is likely to modify patient treatment and often demonstrates findings that modify treatment in the absence of symptoms or imaging changes.

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