Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes.

BACKGROUND: A subset of patients with Peyronie's disease (PD) treated with collagenase clostridium histolyticum (CCH) experience persistent bother and some require surgery. AIM: We characterize patients experiencing persistent bother after CCH treatment and identify associations and predictors of surgical intervention/outcomes. METHODS: We retrospectively identified patients with PD from October 2014 to October 2019 and identified those presenting with persistent bother after CCH treatment by other urologists. Intracavernosal injection and penile Doppler ultrasonography were performed, and subsequent interventions/outcomes were recorded. Baseline characteristics were compared with Student t-test and chi-square test. Predictors of surgical intervention and complications were assessed using multivariable logistic regression. OUTCOMES: The primary outcome was surgery after CCH treatment. Secondary outcomes included worsened erectile function, sensory deficits, and penile length change. RESULTS: Of 573, 67 (11.7%) patients with PD had undergone prior CCH treatment with median 6 injections (range 2-24). Mean post-CCH PD Questionnaire bother score was 10.1 (SD: 3.1), and total International Index of Erectile Function-5 was 15.3 (SD: 8.7). Mean PD duration was 27.8 (SD: 35.7) months, with a mean composite curvature (MCC) of 69.0° (SD: 33.8) measured after injection. Of 67, 44 (65.7%) patients had MCC >60°. Of 67, 52 (77.6%) patients had indent, narrowing, or hourglass and 26 (38.8%) had hinge effect (buckling of the erect penis with axial pressure) on examination. Calcification was identified in 26 of 67 (38.8%) patients, with grade 3 calcifications comprising 6 of 23 (26.1%) patients. Of 67, 33 (49.3%) patients underwent surgery, with 20 (60.1%) undergoing partial plaque excision and grafting with/without tunica albuginea plication, 6 (18.2%) undergoing tunica albuginea plication alone, and 7 (21.2%) undergoing penile prosthesis with plaque incision and grafting. Surgical patients had greater mean curvature (82.6 vs 55.4, P = .001) and were more likely to have hinge (54.5% vs 20.6%, P = .005). On multivariable analysis, MCC ≥60° predicted patient's decision for surgery (odds ratio: 2.99, P < .01, 95% confidence interval: 1.62-4.35). There were no associations between surgical complications and number of injections or CCH-associated adverse events. CLINICAL IMPLICATIONS: Patients presenting with persistent bother after CCH treatment often have narrowing and calcifications (despite calcifications being a contraindication to CCH treatment), and those who have hinge or severe curvature are more likely to undergo surgery with low rates of complications. STRENGTHS/LIMITATIONS: This study's generalizability is limited by selection bias, but useful data are provided for patient counseling. CONCLUSION: Patients with persistent bother after CCH treatment had high rates of indentation/narrowing, plaque calcifications, and MCC >60° at completion of CCH treatment. Surgical intervention is more common with hinge and is safe and feasible in these patients, with low rates of complications. These findings suggest possible negative prognostic factors for CCH treatment, which merit further investigation. Bajic P, Wiggins AB, Ziegelmann MJ, et al. Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes. J Sex Med 2020;17:1005-1011.

Internal Validation of a Predictive Model for Complications After Total Hip Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is projected to increase in prevalence and associated complications will impose significant cost on the US healthcare system. The purpose of this study is to validate a predictive model for postoperative complications utilizing a novel 11-component hip-specific questionnaire encompassing preoperatively available clinical and radiographic data. METHODS: Consecutive primary THA patients between January 2014 and January 2016 were included. Exclusion criteria included patients without questionnaire scoring variables and less than 1-year follow-up. Patients were stratified into 4 tiers based on their questionnaire score: low risk (>74), mild risk (57-73), moderate risk (41-56), and high risk (<40). A binary logistic regression was performed to determine if the questionnaire predicted complications. Receiver-operator curves were constructed to determine the threshold score below which there was a high likelihood of experiencing a complication. RESULTS: Four hundred fifty patients were included in the final analysis with a mean (range) follow-up of 2.1 years (1.0-5.9), age of 63.1 years (25.7-9.17), and body mass index of 31.7 kg/m2 (17.8-64.5). The complication rate was 13.6%. A hip questionnaire score of 73.8 conferred a 98.5% sensitivity and 98.5% negative predictive value for complications. The questionnaire score was the strongest predictor of a decreased complication likelihood (odds ratio 0.94, 95% confidence interval 0.90-0.97, P < .001). Risk tier was significantly associated with complications (low risk: 0; mild risk: 12; moderate risk: 25; and high risk: 24; P < .001). CONCLUSION: This novel hip questionnaire demonstrated a high sensitivity and negative predictive value to identify patients at risk for postoperative complications. Future studies should attempt to prospectively validate the use of this questionnaire.

The Effect of Preoperative Medications on Length of Stay, Inpatient Pain, and Narcotics Consumption After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: To determine the association between preoperative medications and length of stay, inpatient pain, and narcotics consumption after a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Previous studies have identified risk factors for increased length of hospital stay, inpatient pain, and narcotics consumption. However, little is known regarding the effects of preoperative medications on outcomes after spine surgery. METHODS: A prospectively maintained surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Preoperative medications taken within 30 days before surgery were recorded for each patient and categorized by medication type. Poisson regression with robust error variance was used to determine the association between preoperative medications and length of stay, pain scores, and narcotics consumption. Multivariate analysis was performed using a backwards, stepwise regression to identify independent risk factors. RESULTS: In total, 138 patients were included in this analysis. On bivariate analysis, benzodiazepines were associated with longer hospital stays [relative risk (RR)=2.03; P=0.031]. Benzodiazepines (RR=3.71; P<0.001) and preoperative narcotics (RR=2.60; P=0.012) were risk factors for pain ≥7 on postoperative day 0. On multivariate analysis, benzodiazepines were an independent risk factor for prolonged stay. Benzodiazepines, narcotics, and nonsteroidal anti-inflammatories were identified as independent risk factors for increased postoperative pain. CONCLUSIONS: These results suggest that benzodiazepines are a risk factor for increased length of stay and postoperative pain after MIS TLIF. Preoperative narcotics and nonsteroidal anti-inflammatories were also identified as risk factors for postoperative pain though this did not lead to increases in narcotics consumption. Patients taking these medications should undergo more vigilant perioperative monitoring for adequate pain management. More work must be done to further elucidate the association between preoperative medications and postoperative outcomes after MIS TLIF.

The Patient-Reported Outcomes Measurement Information System in spine surgery: a systematic review.

OBJECTIVEThe Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to provide a standardized measure of clinical outcomes that is valid and reliable across a variety of patient populations. PROMIS has exhibited strong correlations with many legacy patient-reported outcome (PRO) measures. However, it is unclear to what extent PROMIS has been used within the spine literature. In this context, the purpose of this systematic review was to provide a comprehensive overview of the PROMIS literature for spine-specific populations that can be used to inform clinicians and guide future work. Specifically, the authors aimed to 1) evaluate publication trends of PROMIS in the spine literature, 2) assess how studies have used PROMIS, and 3) determine the correlations of PROMIS domains with legacy PROs as reported for spine populations.METHODSStudies reporting PROMIS scores among spine populations were identified from PubMed/MEDLINE and a review of reference lists from obtained studies. Articles were excluded if they did not report original results, or if the study population was not evaluated or treated for spine-related complaints. Characteristics of each study and journal in which it was published were recorded. Correlation of PROMIS to legacy PROs was reported with 0.1 ≤ |r| < 0.3, 0.3 ≤ |r| < 0.5, and |r| ≥ 0.5 indicating weak, moderate, and strong correlations, respectively.RESULTSTwenty-one articles were included in this analysis. Twelve studies assessed the validity of PROMIS whereas 9 used PROMIS as an outcome measure. The first study discussing PROMIS in patients with spine disorders was published in 2012, whereas the majority were published in 2017. The most common PROMIS domain used was Pain Interference. Assessments of PROMIS validity were most frequently performed with the Neck Disability Index. PROMIS domains demonstrated moderate to strong correlations with the legacy PROs that were evaluated. Studies assessing the validity of PROMIS exhibited substantial variability in PROMIS domains and legacy PROs used for comparisons.CONCLUSIONSThere has been a recent increase in the use of PROMIS within the spine literature. However, only a minority of studies have incorporated PROMIS for its intended use as an outcomes measure. Overall, PROMIS has exhibited moderate to strong correlations with a majority of legacy PROs used in the spine literature. These results suggest that PROMIS can be effective in the assessment and tracking of PROs among spine populations.