Urodynamics less likely to change diagnosis and management in uncomplicated overactive bladder.

INTRODUCTION: Given the invasive nature of urodynamics and its unclear impact on altering patient management, we aimed to determine whether performing a urodynamic study (UDS) resulted in a change in either patient diagnosis or treatment offered in women with uncomplicated urinary incontinence. MATERIALS AND METHODS: A retrospective review was performed of all female patients who underwent UDS for urinary incontinence at our practice between January 2014 and 2017. Patients with neurogenic lower urinary tract dysfunction, incomplete emptying, urinary retention, or prior anti-incontinence surgery were excluded. We compared the ICD-10 diagnosis and primary treatment offered in the absence of UDS to their post-UDS diagnosis and recommended therapy. Descriptive statistics, chi-squared, and multivariable analyses were performed. RESULTS: A total of 141 patient charts were analyzed. The indications for UDS were mixed urinary incontinence (MUI) (45.3%), stress urinary incontinence (SUI) (29.1%), and overactive bladder (OAB) (25.5%). A change in diagnosis following UDS was seen in 40.4% of the entire cohort including 53.1% of patients with MUI and 48.8% of those with SUI compared to 8.3% of those with OAB. A change in treatment was seen in 32.6% of patients including 54.9% with MUI, 41.7% with SUI, and 10% with OAB. When compared to patients with SUI on adjusted multivariate logistic regression, those with OAB were less likely to have a change in either diagnosis (OR 0.06 (0.01-0.31)) or management (OR 0.15 (0.04-0.62)). CONCLUSIONS: Diagnosis and management are unlikely to change after UDS in patients presenting with uncomplicated OAB. Conversely, UDS provided important diagnostic information that often changed management in those presenting with MUI and SUI. Our results suggest that UDS may be omitted in patients with uncomplicated refractory OAB in favor of earlier initiation of third line therapies.

Optimal Irrigation and Debridement of Infected Total Joint Implants with Chlorhexidine Gluconate.

Previous study at our institution demonstrated that scrubbing a methicillin-resistant Staphylococcus aureus (MRSA)-coated titanium disk with chlorhexidine gluconate (CG) solution achieved superior biofilm eradication compared to alternative solutions. The current study aimed to identify the minimum CG concentration for effective bacteria eradication of an in vitro periprosthetic joint infection (PJI) model. MRSA colony-forming units (CFUs) were counted following simulated irrigation and debridement with varying CG solutions before and after a 24-hour reincubation period. Significant decrease was noted on all disks before reincubation. Postreincubation, significant decrease in CFUs was found in the 4% and 2% groups. This study demonstrated that I+D of an infected PJI model with 4% CG solution was effective at treating MRSA biofilm at concentrations as low as 2%.

OUTCOMES OF INTRAVESICAL BACILLUS CALMETTE-GUERIN IN A MULTIRACIAL COHORT WITH NON-MUSCLE-INVASIVE BLADDER CANCER.

INTRODUCTION: We sought to determine if outcomes of Bacillus Calmette-Guerin (BCG) therapy in patients with non-muscle-invasive bladder cancer (NMIBC) vary by race. METHODS: A retrospective chart review was conducted on 149 patients treated with BCG for intermediate- and high-risk NMIBC between 2001 and 2018, and who were followed up for cancer recurrence through March 2019.The primary outcomes were disease-free survival (DFS), low-grade disease-free survival (LGDFS), high-grade disease-free survival (HGDFS), and progression-free survival (PFS) at five years. Kaplan-Meier survival curves stratified by race (African American vs non-African American) were analyzed for all the above outcomes and multivariate Cox regression analyses were also performed to compare recurrence differences by race, after adjusting for age, sex, initial stage and grade. RESULTS: Of the 149 patients, 37.6% were Caucasian, 24.8% were African American, 26.8% were Hispanic, and 10.7% were of other/unknown race. Disease stage at initial presentation was 65.1% Ta, 34.9% T1, and 18.1% CIS. African American patients (N=37) did not have evidence for worse outcomes compared to non-African American patients when considering DFS (54.1% vs. 65.7%, p = 0.202), HGDFS (58.8% vs. 71.7%, p = 0.158), and PFS (83.8% vs. 92.6%, p = 0.117) at five years. Multivariate analysis did not reveal statistically significant racial differences in recurrence or progression. CONCLUSIONS: African Americans with NMIBC did not have worse disease recurrence and progression after receiving intravesical BCG treatment. Although there did appear to be a trend towards worse oncologic outcomes in African Americans, larger studies are needed to validate this finding.

Outcomes and Management Considerations in Patients on Dialysis Undergoing Laparoscopic Radical Nephrectomy for Renal-Cell Carcinoma.

PURPOSE: To analyze the perioperative outcomes and management considerations in patients with dialysis-dependent end-stage renal disease (ESRD) undergoing laparoscopic radical nephrectomy for renal-cell carcinoma (RCC). METHODS: There were 224 consecutive laparoscopic radical nephrectomies reviewed. Of those, 37 patients with ESRD were identified and compared with 187 patients with sporadic RCC. Evaluable parameters included age, sex, race, side of surgery, medical comorbidities, body mass index, American Society of Anesthesiologist (ASA) scoring, and age adjusted Charlson Comorbidity Index. All complications occurring intraoperatively and within the first 30 days were classified as per the Clavien classification system. Presurgical workup and transplant considerations were evaluated. Demographic and clinical characteristics were compared using Student t tests and chi-square tests for categoric variables. RESULTS: Compared with non-ESRD patients, those with ESRD were younger and had smaller tumors. ASA was significantly higher in the ESRD group (P<0.001). Mean blood loss was similar between ESRD patients and non-ESRD patients. Overall complication rates were higher in patients with ESRD. Pathologic characteristics of ESRD renal masses included a higher proportion of papillary RCC. CONCLUSION: Patients with RCC associated with ESRD tend to have a higher ASA class and lower grade tumors. In addition, this population is at increased risk of surgical complications and more likely to need transfusions. Careful preoperative preparation and intraoperative anesthetic management are crucial to minimize patient morbidity and improve outcomes.

The relationship between visceral obesity and the clinicopathologic features of patients with small renal masses.

INTRODUCTION AND OBJECTIVES: It is well known that adipose tissue plays a key role in the metabolic syndrome. We investigated whether visceral fat (VFA) and or subcutaneous fat (SQF) levels are associated with the tumor phenotype of small renal masses. Additionally, we sought to investigate the relationship between VFA and baseline renal function as measured by glomerular filtration rate. MATERIALS AND METHODS: From 2002 through 2011, 144 patients undergoing minimally invasive partial nephrectomy were retrospectively reviewed by a radiologist for VFA and SQF fat measurements, using standard software. A third parameter, visceral adipose tissue percent (VAT%), was also calculated using the formula: (VAT%=[VFA/VFA+SQF]×100%). We used tertiles of VFA and SQF content to compare demographic and clinical characteristics. We also looked at VFA as a continuous variable. Associations between covariables were analyzed using multivariate logistic regression analysis and odds ratios with 95% confidence intervals. RESULTS: Eighty-one patients had renal-cell carcinoma (RCC) and 30 patients had non-RCC pathology. On multivariate analysis, increasing BMI (p=0.023), VFA (p=0.048), VAT% (p=0.028), and Charlson comorbidity score (p=0.047) were significantly associated with worse preoperative Modification of Diet in Renal Disease (MDRD). In a subset multivariate analysis of the 81 patients with RCC, increasing VFA was statistically associated with worsening Fuhrman grade (p=0.017). CONCLUSIONS: VFA may be linked to the pathophysiology of renal function in patients evaluated for renal masses. Additionally, VFA may be associated with worsening tumor grades in patients with small-volume RCC. Interestingly, SQF did not play such a role. This small study proposes an interesting physiologic link between VFA and the biology of both kidney function and tumor histology. Larger studies are needed to corroborate our findings.