Laser prostate ablation and enucleation: Analysis of a national cohort.

OBJECTIVE: To compare characteristics and outcomes of benign prostatic hyperplasia patients undergoing prostate laser ablation with those undergoing laser enucleation using a nationwide cohort. METHODS: Men who underwent prostate laser ablation (n=10054) or laser enucleation (n=1705) between 2011 and 2015 were identified by the common procedural terminology code as recorded in the National Surgical Quality Improvement Program database. Preoperative, intraoperative and postoperative parameters were compared between the groups using univariate and multivariate analysis. RESULTS: Prostate laser ablation patients were older, had more comorbidities and were more likely to have abnormal laboratory values. Enucleations were significantly longer and more likely to result in a hospital stay >1day. Enucleation patients were also more likely to require a blood transfusion postoperatively, but less likely to experience urinary tract infection and sepsis on both univariate and multivariate analysis adjusted for preoperative and intraoperative factors. CONCLUSIONS: Although laser enucleation and prostate laser ablation are both considered minimally invasive techniques, significant differences in patient selection, intraoperative factors and postoperative complications are identified in this national cohort. The present study shows that despite similar outcomes in prospective single-center studies, prostate laser ablation and laser enucleation have distinct practice patterns in a broader national context.

Experiences of Black Women With Pelvic Floor Disorders-A Qualitative Analysis Study.

IMPORTANCE: Disparities research in Black women with pelvic floor disorders (PFDs) has primarily focused on epidemiology or surgical outcomes, but little is known about the patient perspective on seeking PFD care. OBJECTIVE: To provide quality and equitable care to Black women with PFDs, we conducted a qualitative study to hear their perspectives and lived health care experiences. STUDY DESIGN: Black women seeking care for PFDs at a tertiary care institution were invited to participate in qualitative interviews. Open-ended questions explored participants' knowledge, attitudes, and health care experiences. Interviews were transcribed verbatim and coded line-by-line. Inductive content analysis was performed to identify key themes, and consensus was achieved among the research team. RESULTS: Eight Black women aged 21-83 years consented to participate. Patients noted a stigma surrounding PFDs, both among health care professionals and their community. They noted several barriers to care: financial, logistical, and racial bias. They cited difficulties in patient-health care professional communication, including not feeling heard or treated as an individual. They preferred gender and racial concordance with their physicians. These women expressed both a desire for more knowledge and to share this knowledge and advocate for other women. CONCLUSIONS: Black women expressed distinct obstacles in their PFD health care. They reported not feeling heard or treated as a unique individual. The themes derived from this study identify complex patient-centered needs that can serve as the basis for future quality improvement work and/or hypothesis-driven research. By grounding health disparities research in patient perspectives, we can improve the health care experiences of Black women.

Spouses Speak Up: The Impact of Mesh Sling Complications on the Patient's Spouse-A Qualitative Analysis Study.

OBJECTIVE: To examine the perspectives, attitudes, and beliefs of the spouses of women with complications of mesh midurethral sling (MUS) surgery with the goal of increasing our understanding of the multidimensional nature of MUS surgery complications. METHODS: After IRB approval, the spouses of patients who underwent surgery for MUS complications at a single tertiary care institution participated in qualitative interviews. Using an interview guide with standardized prompts, semistructured interviews were conducted. Interviews were transcribed verbatim and reviewed line-by-line by two researchers independently. Inductive content analysis was used to code the transcripts and identify themes, and consensus was achieved by the research team. RESULTS: Seven male spouses participated in qualitative interviews, and several themes and subthemes were identified. First, spouses expressed feelings of regret. They described that their partner's dyspareunia detracted from their intimate relationship. The participants also reported the negative impact on their lives and their households. Due to the personal nature of the issue, couples would avoid involving friends and family, creating a sense of isolation. Finally, they expressed hope of finding a healthcare team experienced with mesh complications and invested in their spouse's improvement. CONCLUSION: Spouses of women who experience MUS complications serve as caregivers and provide support; they are impacted by adverse outcomes. It is important to acknowledge their role in patients' healthcare experiences and learn from their insights. Our study lays the foundation for future work and ultimately for improving the experiences of patients and their spouses with MUS surgery and potential complications.

Women in Leadership in Urology: The Case for Increasing Diversity and Equity.

There is a persistent male gender predominance in urology, especially with respect to female representation in leadership. We review the current status of women in urology leadership, discuss challenges women face in leadership positions, present the case for adopting inclusive practices that increase diversity and gender equity in urology leadership, and review the potential benefits of such an expansion. We discuss practical strategies to grow the role of women in urologic leadership, including increasing mentorship, modifying academic promotion criteria, and addressing implicit bias, while presenting a roadmap toward achieving equity and diversity at the highest ranks of urologic leadership.

Quality of Life before and after Endoscopic Pituitary Surgery as Measured by the Short-Form-36.

Objectives/Hypotheses To assess quality of life (QOL) after transnasal, endoscopic pituitary surgery using the 36-item short form (SF-36) instrument. Design Retrospective review was used for this study. Setting The study was conducted in a tertiary academic medical center. Participants Patients who underwent endoscopic, transnasal, transsphenoidal surgery for pituitary adenomas between January 1, 2007 and July 1, 2016 and completed preoperative and postoperative SF-36 surveys. Main Outcome Measures SF-36 survey data as measured by its eight domains (physical functioning, physical role functioning, emotional role functioning, energy/fatigue, emotional well-being, social functioning, pain, and general health). Results There were 18 preoperative, 13 short-term (2 weeks or less after surgery) postoperative, and 14 longer term (>2 weeks after surgery) postoperative surveys. There was no significant difference between preoperative and long-term postoperative SF-36 scores across domains ( p > 0.05). In comparing short-term postoperative and preoperative scores, tumor size was positively associated with emotional well-being ( p = 0.049) and general health scores ( p = 0.031), while visual changes preoperatively were positively associated with general health scores ( p = 0.046). Compared with standard U.S. general population summary data, these patients scored lower preoperatively in all domains except for emotional role functioning and pain ( p < 0.05). Postoperatively, patients improved to baseline general population data scores with the exception of the physical role functioning domain ( p < 0.0001). Conclusion Patients undergoing endoscopic, transnasal, transsphenoidal surgery for pituitary adenomas had lower QOL in six of eight domains preoperatively, but improved to baseline values on the long run after surgery in seven of eight domains. This suggests that minimally invasive pituitary surgery has a restorative role in general QOL as measured by the SF-36.

Treatment Outcomes of Rathke's Cleft Cysts Managed with Marsupialization.

Objectives Rathke's cleft cysts (RCC) are benign cystic lesions of the sella resulting from incomplete obliteration of Rathke's cleft. Symptomatic lesions often require surgical decompression, which is often amenable to a transnasal, transsphenoidal (TNTS) approach. We report our experience with marsupialization of RCC and describe a novel technique to promote re-epithelization of the cyst cavity. Design Retrospective review. Setting Tertiary academic medical center. Participants Patients who underwent TNTS for RCC between 2007 and 2015. Main Outcome Measures Demographics, lesion characteristics, and reconstruction and treatment outcomes. Results In total, 52 patients were identified. The mean age was 41 ± 18 years. The mean RCC size was 13 ± 5 mm. Intraoperative cerebrospinal fluid (CSF) leak was encountered in 14 (27%) patients; all were repaired. There were six complications (12%) and no deaths. Mean follow-up was 20 ± 18 months, with five (10%) recurrences. RCC size was associated with intraoperative CSF leak (p = 0.04). In 12 patients, the marsupialized cyst cavity was lined with a free mucosal graft (FMG) to promote healing and re-epithelialization. Conclusions The TNTS approach is safe and effective in surgical decompression of RCC. Lining the exposed cyst cavity with an FMG is a simple intervention without added morbidity that may promote formation of an epithelialized tract. Level of Evidence Not applicable.

Four-variable risk model in men and women with heart failure.

BACKGROUND: Risk stratification is an integral component of clinical decision making in heart failure (HF). Women with HF have unique characteristics compared with men, and it is unknown whether common prognostic factors are equally useful in both populations. We aimed to investigate whether sex-specific risk models are more accurate for risk prediction in patients with advanced HF. METHODS AND RESULTS: Patients with advanced HF referred to University of California, Los Angeles (UCLA; n=2255), were stratified by sex into derivation (referred in 2000-2007) and validation (referred in 2008-2011) cohorts. Cox regression analysis was used to ascertain key variables predictive of the primary end point of death/urgent transplantation/ventricular assist device in the derivation cohorts and confirmed in the validation cohorts in men, women, and the total population. Women were younger, with higher ejection fraction and better event-free survival. Despite differences in baseline characteristics, the 4 strongest predictors of outcome in both women and men, as well as in the total cohort, were B-type natriuretic peptide, peak oxygen consumption by cardiopulmonary exercise testing (pkVO2), New York Heart Association (NYHA) classification, and use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. In addition, the UCLA model performed better than the Seattle Heart Failure Model (SHFM) and the Heart Failure Survival Score (HFSS) in our cohort (c-indices of 0.791[UCLA] versus 0.758 [SHFM], 0.607 [noninvasive HFSS], and 0.625 [invasive HFSS]). CONCLUSIONS: A simple risk model assessing 4 clinical variables-B-type natriuretic peptide, pkVO2, NYHA, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use-is well suited to provide prognostic information in both men and women with advanced HF.

Microenvironment influences vascular differentiation of murine cardiovascular progenitor cells.

We examined the effects of the microenvironment on vascular differentiation of murine cardiovascular progenitor cells (CPCs). We isolated CPCs and seeded them in culture exposed to the various extracellular matrix (ECM) proteins in both two-dimensional (2D) and 3D culture systems. To better understand the contribution of the microenvironment to vascular differentiation, we analyzed endothelial and smooth muscle cell differentiation at both day 7 and day 14. We found that laminin and vitronectin enhanced vascular endothelial cell differentiation while fibronectin enhanced vascular smooth muscle cell differentiation. We also observed that the effects of the 3D electrospun scaffolds were delayed and not noticeable until the later time point (day 14), which may be due to the amount of time necessary for the cells to migrate to the interior of the scaffold. The study characterized the contributions of both ECM proteins and the addition of a 3D culture system to continued vascular differentiation. Additionally, we demonstrated the capability bioengineer a CPC-derived vascular graft.

Hyaluronan-Based Three-Dimensional Microenvironment Potently Induces Cardiovascular Progenitor Cell Populations.

The relationship between stem cell niches in vivo and their surrounding microenvironment is still relatively unknown. Recent advances have indicated that extrinsic factors within the cardiovascular progenitor cell niche influence maintenance of a multipotent state as well as drive cell-fate decisions. We have previously shown the direct effects of extracellular matrix (ECM) proteins and have now investigated the effects of dimension on the induction of a cardiovascular progenitor cell (CPC) population. We have shown here that the three-dimensionality of a hyaluronan-based hydrogel greatly induces a CPC population, as marked by Flk-1. We have compared the effects of a 3D microenvironment to those of conventional 2D cell culture practices and have found that the 3D microenvironment potently induces a progenitor cell state.

The obesity paradox in men versus women with systolic heart failure.

Obesity is common in heart failure (HF) and is associated with improved outcomes, a finding often termed the "obesity paradox." Although fat distribution varies by gender, the role of obesity in the outcomes of women compared to men with HF has not been well studied. In a cohort of patients with advanced systolic HF followed at a single university center, 2,718 patients had body mass indexes (BMIs) measured at baseline, and 469 patients with HF had waist circumferences (WCs) measured at baseline. Elevated BMI was defined as ≥25 kg/m(2). High WC was defined as ≥88 cm in women and ≥102 cm in men. The primary outcome was death, urgent heart transplantation, or ventricular assist device placement. The mean age was 53.0 ± 12.4 years, 25% of subjects were women, and the mean left ventricular ejection fraction was 22.9 ± 7.19%. In men, 2-year event-free survival was better for high versus normal BMI (63.2% vs 53.5%, p <0.001) and for high versus normal WC (78.8% vs 63.1%, p = 0.01). In women, 2-year event-free survival was better for elevated versus normal BMI (67.1% vs 56.6%, p = 0.01) but similar in the 2 WC groups. In multivariate analyses, normal BMI and normal WC were associated with higher relative risk for the primary outcome in men (BMI 1.34, WC 2.02) and women (BMI 1.38, WC 2.99). In conclusion, in patients with advanced HF, high BMI and WC were associated with improved outcomes in both genders. Further investigation of the interaction between body composition and gender in HF outcomes is warranted.

Characterization and therapeutic potential of induced pluripotent stem cell-derived cardiovascular progenitor cells.

BACKGROUND: Cardiovascular progenitor cells (CPCs) have been identified within the developing mouse heart and differentiating pluripotent stem cells by intracellular transcription factors Nkx2.5 and Islet 1 (Isl1). Study of endogenous and induced pluripotent stem cell (iPSC)-derived CPCs has been limited due to the lack of specific cell surface markers to isolate them and conditions for their in vitro expansion that maintain their multipotency. METHODOLOGY/PRINCIPAL FINDINGS: We sought to identify specific cell surface markers that label endogenous embryonic CPCs and validated these markers in iPSC-derived Isl1(+)/Nkx2.5(+) CPCs. We developed conditions that allow propagation and characterization of endogenous and iPSC-derived Isl1(+)/Nkx2.5(+) CPCs and protocols for their clonal expansion in vitro and transplantation in vivo. Transcriptome analysis of CPCs from differentiating mouse embryonic stem cells identified a panel of surface markers. Comparison of these markers as well as previously described surface markers revealed the combination of Flt1(+)/Flt4(+) best identified and facilitated enrichment for Isl1(+)/Nkx2.5(+) CPCs from embryonic hearts and differentiating iPSCs. Endogenous mouse and iPSC-derived Flt1(+)/Flt4(+) CPCs differentiated into all three cardiovascular lineages in vitro. Flt1(+)/Flt4(+) CPCs transplanted into left ventricles demonstrated robust engraftment and differentiation into mature cardiomyocytes (CMs). CONCLUSION/SIGNIFICANCE: The cell surface marker combination of Flt1 and Flt4 specifically identify and enrich for an endogenous and iPSC-derived Isl1(+)/Nkx2.5(+) CPC with trilineage cardiovascular potential in vitro and robust ability for engraftment and differentiation into morphologically and electrophysiologically mature adult CMs in vivo post transplantation into adult hearts.