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Nonclinical Barriers to Care for Neurogenic Patients Undergoing Complex Urologic Reconstruction.
Sosland R, Kowalik CA, Cohn JA, Milam DF, Kaufman MR, Dmochowski RR, Reynolds WS
(2019) Urology 124: 271-275
MeSH Terms: Adult, Female, Female Urogenital Diseases, Health Services Accessibility, Humans, Male, Male Urogenital Diseases, Postoperative Complications, Retrospective Studies, Socioeconomic Factors, Urinary Bladder, Neurogenic, Urologic Surgical Procedures
Show Abstract · Added September 16, 2019
OBJECTIVE - To identify nonclinical factors affecting postoperative complication rates in patients with neurogenic bladder undergoing benign genitourinary (GU) reconstruction.
METHODS - Adult patients with neurogenic bladder undergoing benign GU reconstruction between October 2010 and November 2015 were included. Patients were excluded if a diversion was performed for malignancy, if patients had a history of radiation or if a new bowel segment was not utilized at the time of the operation. Clinical and nonclinical factors were abstracted from the patients' electronic medical records. Health literacy was assessed via the Brief Health Literacy Screen (BHLS), a validated 3-question assessment. Education, marital status, and distance from the medical center were also queried.
RESULTS - Forty-nine patients with a neurogenic bladder undergoing complex GU reconstruction met inclusion and exclusion criteria. On average, patients lived 111 miles (standard deviation 89) from the hospital. Overall, mean BHLS score was 10.4 (standard deviation 4.6) with 35% of patients scoring a BHLS of ≤9. Mean years of educational attainment was 9.7, and only 31% of patients completed high school education. In the first month after surgery, 37 patients (76%) experienced a complication, and 22% were readmitted; however, analysis of complication data did not identify an association between any nonclinical variables and complication rates.
CONCLUSION - Nonclinical factors including unmarried status, poor health literacy, and marked distance from quaternary care are prevalent in patients with neurogenic bladder undergoing complex GU reconstruction. To mitigate these potential risk factors, the authors recommend acknowledgment of these factors and multidisciplinary support perioperatively to counteract them.
Copyright © 2018. Published by Elsevier Inc.
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Postoperative Opiate Use in Urological Patients: A Quality Improvement Study Aimed at Improving Opiate Disposal Practices.
Cabo J, Hsi RS, Scarpato KR
(2019) J Urol 201: 371-376
MeSH Terms: Analgesics, Opioid, Humans, Pain Management, Pain, Postoperative, Patient Education as Topic, Postoperative Period, Prescription Drug Misuse, Quality Improvement, Retrospective Studies, Tennessee, Urologic Surgical Procedures
Show Abstract · Added February 26, 2019
PURPOSE - We aimed to determine trends in postoperative opiate management among urological patients, identify associations with opiate keeping and foster appropriate opiate disposal after surgery via introduction of an educational handout.
MATERIALS AND METHODS - We retrospectively analyzed opiate practices in 68 patients who had undergone urological surgery. In a separate consecutive cohort of 59 patients we distributed a handout detailing FDA (Food and Drug Administration) approved disposal methods. Patient opiate obtainment, use and disposal were assessed via telephone interviews with prescription filling data verified using the Tennessee CSMD (Controlled Substances Monitoring Database). Opiate keeping was defined as possessing any opiates more than 3 weeks after surgery or more than 4 times the duration of the postoperative prescription, whichever was longer.
RESULTS - Opiate keeping was observed in 41 patients (72%) in our initial cohort. Of these patients 68% left the medication unsecured at home. Major barriers to opiate disposal included concern for return of disease specific pain in 44% of patients and unrelated pain in 29%. As assessed on a short test, opiate keepers were less knowledgeable about safe disposal practices compared to nonkeepers (72% vs 85%, p = 0.005). Among opiate keepers there was an improvement in knowledge scores after the intervention (66% to 77%, p = 0.03). When comparing pre-education to post-education, there was no detectable improvement in the rate of opiate keeping (72% vs 68%, p = 0.66) or proper disposal (9% vs 8%, p = 1.0).
CONCLUSIONS - Opiate keeping is common following urological surgery and a major barrier to disposal is concern for the return of disease specific pain. Future interventions aimed at limiting opiate keeping should combine evidence-based prescription practices and targeted patient education.
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Cost-effective management of pelvic fracture urethral injuries.
Johnsen NV, Penson DF, Reynolds WS, Milam DF, Dmochowski RR, Kaufman MR
(2017) World J Urol 35: 1617-1623
MeSH Terms: Adult, Cost-Benefit Analysis, Fractures, Bone, Humans, Lower Urinary Tract Symptoms, Male, Models, Economic, Patient Care Management, Pelvic Bones, Reconstructive Surgical Procedures, United States, Urethra, Urethral Stricture, Urologic Surgical Procedures, Wounds, Nonpenetrating
Show Abstract · Added September 16, 2019
PURPOSE - To compare the cost-effectiveness of various treatment strategies in the management of pelvic fracture urethral injuries using decision analysis.
METHODS - Five strategies were modeled from the time of injury to resolution of obstructed voiding or progression to urethroplasty. Management consisted of immediate suprapubic tube (SPT) placement and delayed urethroplasty; primary endoscopic realignment (PER) followed by urethroplasty in failed patients; or PER followed by 1-3 direct vision internal urethrotomies (DVIU), followed by urethroplasty. Success rates were obtained from the literature. Total medical costs were estimated and incremental cost-effectiveness ratios (ICERs) were generated over a 2-year follow-up period.
RESULTS - PER was preferred over SPT placement in all iterations of the model. PER followed by a single DVIU and urethroplasty in cases of failure was least costly and used as the referent approach with an average cost-effectiveness of $17,493 per unobstructed voider. The ICER of a second DVIU prior to urethroplasty was $86,280 per unobstructed voider, while the ICER of a third DVIU was $172,205. The model was sensitive to changes in the success rate of the first DVIU, where when the probability of DVIU success is expected to be less than 32% immediate urethroplasty after failed PER is favored.
CONCLUSIONS - Management of pelvic fracture urethral injuries with PER is the preferred management strategy according to the current model. For those who fail PER, a single DVIU may be attempted if the presumed success rate is >32%. In all other cases, urethroplasty following PER is the preferred approach.
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Incontinence rates after midurethral sling revision for vaginal exposure or pain.
Jambusaria LH, Heft J, Reynolds WS, Dmochowski R, Biller DH
(2016) Am J Obstet Gynecol 215: 764.e1-764.e5
MeSH Terms: Adult, Aged, Cohort Studies, Device Removal, Dyspareunia, Equipment Failure, Female, Humans, Middle Aged, Pain, Postoperative, Postoperative Complications, Reoperation, Retrospective Studies, Suburethral Slings, Surgical Mesh, Urinary Incontinence, Stress, Urinary Incontinence, Urge, Urologic Surgical Procedures
Show Abstract · Added September 16, 2019
BACKGROUND - Midurethral slings have become the preferred surgical treatment for stress urinary incontinence. Midline transection of midurethral sling for dysfunctional voiding is an effective treatment and also has a low rate of recurrent stress incontinence. Recurrent stress incontinence after sling revision for pain and mesh exposure has not been well defined. It is therefore difficult to counsel patients on risk of recurrent stress incontinence when sling revision is performed for pain or mesh exposure.
OBJECTIVE - We examined the rate of postoperative stress incontinence after midurethral sling revision for the indication of mesh exposure or pain, as well as postoperative pain and urinary urgency.
STUDY DESIGN - This is a retrospective cohort of 245 patients undergoing a vaginal midurethral sling revision in a 10-year period for the indication of mesh exposure or pain. Preoperative indication for revision, baseline characteristics, and preoperative reports of stress incontinence, pain, and urgency were collected. The type of sling revision was then categorized into partial or complete removal. A partial removal of the sling was defined as removing only the portion of sling exposed or causing pain. A complete removal of the sling was defined as vaginal removal of sling laterally out to the pubic rami. Subjective reports of stress incontinence, pain, and urgency at short-term (16 weeks) and long-term (>16 weeks) follow-up visits were gathered. The primary outcome of the study was recurrent stress incontinence.
RESULTS - In our cohort of 245 women who underwent midurethral sling revision, 94 patients had removal for mesh exposure (36 partial and 58 complete) and 151 had removal for pain (25 partial and 126 complete). All patients had a short-term follow-up with a mean time of 5.9 ± 2.8 weeks and 69% patients had long-term follow-up with a mean time of 29.1 ± 17.7 weeks. No differences were seen in preoperative reports of stress incontinence, urgency, or pain in either group. In the patients with revision for mesh exposure with no preoperative stress incontinence, there was greater postoperative stress incontinence with complete vs partial removal of sling at short-term (14% vs 42%, P = .03) and long-term (7% vs 59%, P = .003) follow-up. In the patients with revision for pain with no preoperative stress incontinence, there was no statistically significant difference in recurrent stress incontinence with complete sling removal at long-term follow-up (22% vs 56%, P = .07). In the patients with midurethral sling revision for pain, 72% of partial and 76% of complete sling removal had resolution of pain postoperatively (P = .66). No difference was seen in postoperative reports of urgency or pain improvement in either group between partial or complete sling removal.
CONCLUSION - In women undergoing midurethral sling revision for mesh exposure, complete sling removal resulted in higher recurrent stress incontinence compared to partial sling removal. For the indication of pain, both partial and complete sling removal improved pain in the majority of patients, but there was no statistically significant difference in recurrent stress incontinence.
Copyright © 2016 Elsevier Inc. All rights reserved.
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National Trends in Secondary Procedures Following Pediatric Pyeloplasty.
Dy GW, Hsi RS, Holt SK, Lendvay TS, Gore JL, Harper JD
(2016) J Urol 195: 1209-14
MeSH Terms: Adolescent, Child, Child, Preschool, Female, Humans, Infant, Kidney Pelvis, Male, Reoperation, Treatment Failure, United States, Ureteral Obstruction, Urologic Surgical Procedures
Show Abstract · Added January 16, 2018
PURPOSE - Although reported success rates after pediatric pyeloplasty to correct ureteropelvic junction are high, failure may require intervention. We sought to characterize the incidence and timing of secondary procedures after pediatric pyeloplasty using a national employer based insurance database.
MATERIALS AND METHODS - Using the MarketScan® database we identified patients 0 to 18 years old who underwent pyeloplasty from 2007 to 2013 with greater than 3 months of postoperative enrollment. Secondary procedures following the index pyeloplasty were identified by CPT codes and classified as stent/drain, endoscopic, pyeloplasty, nephrectomy or transplant. The risk of undergoing a secondary procedure was ascertained using Cox proportional hazards models adjusting for demographic and clinical characteristics.
RESULTS - We identified 1,976 patients with a mean ± SD followup of 23.9 ± 19.8 months. Overall 226 children (11.4%) had undergone at least 1 post-pyeloplasty procedure. The first procedure was done within 1 year in 87.2% of patients with a mean postoperative interval of 5.9 ± 11.1 months. Stents/drains, endoscopic procedures and pyeloplasties were noted in 116 (5.9%), 34 (1.7%) and 71 patients (3.1%), respectively. Length of stay was associated with undergoing a secondary procedure. Compared with 2 days or less the HR of 3 to 5 and 6 days or greater was 1.65 and 3.94 (p = 0.001 and <0.001, respectively).
CONCLUSIONS - Following pediatric pyeloplasty 1 of 9 patients undergoes at least 1 secondary procedure with the majority performed within the first year. One of 11 patients undergoes intervention more extensive than placement of a single stent or drain, requiring management strategies that generally signify recurrent or persistent obstruction. Estimates of pyeloplasty success in this national data set are lower than in other published series.
Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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National Trends in Followup Imaging after Pyeloplasty in Children in the United States.
Hsi RS, Holt SK, Gore JL, Lendvay TS, Harper JD
(2015) J Urol 194: 777-82
MeSH Terms: Adolescent, Child, Child, Preschool, Diagnostic Imaging, Diagnostic Techniques, Urological, Female, Follow-Up Studies, Humans, Hydronephrosis, Infant, Kidney Pelvis, Male, Multicystic Dysplastic Kidney, Postoperative Care, United States, Ureteral Obstruction, Urologic Surgical Procedures
Show Abstract · Added January 16, 2018
PURPOSE - Radiographic followup after pyeloplasty for the correction of ureteropelvic junction obstruction is not well defined in children. We characterize trends in frequency and modality of postoperative imaging after open and minimally invasive pediatric pyeloplasty.
MATERIALS AND METHODS - Using the MarketScan® database, we identified patients 0 to 18 years old undergoing pyeloplasty between 2007 and 2013. Followup imaging was classified as functional (diuretic renography, excretory urography) or nonfunctional (ultrasound, computerized tomography, magnetic resonance imaging). We excluded patients with less than 24 months of postoperative enrollment in MarketScan. Multivariate logistic regression was performed to determine associations between demographic variables and imaging use patterns.
RESULTS - We identified 926 patients with a mean ± SD followup of 3.6 ± 1.3 years, of whom 30% underwent minimally invasive pyeloplasty. Overall 5.9% of patients had no postoperative imaging available. Within the first 6 months postoperatively 853 patients (91%) underwent at least 1 imaging study and 192 (24%) underwent renography. Within the first 12 months postoperatively 91% of patients underwent at least 1 imaging study, most commonly ultrasound. After 12 months almost a third of the patients were not followed with imaging. Of the 71% undergoing imaging most underwent ultrasound. Younger age and female gender were independently associated with frequent imaging (at least yearly) on multivariate logistic regression.
CONCLUSIONS - Following pediatric pyeloplasty there is variation in modality and frequency of imaging followup. The majority of patients are followed with renal ultrasound, with less frequent use of functional imaging. Almost a third of patients do not undergo followup imaging after 1 year.
Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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Biochemical recurrence-free survival after robotic-assisted laparoscopic vs open radical prostatectomy for intermediate- and high-risk prostate cancer.
Ritch CR, You C, May AT, Herrell SD, Clark PE, Penson DF, Chang SS, Cookson MS, Smith JA, Barocas DA
(2014) Urology 83: 1309-15
MeSH Terms: Cohort Studies, Disease-Free Survival, Follow-Up Studies, Humans, Kaplan-Meier Estimate, Laparoscopy, Male, Middle Aged, Multivariate Analysis, Neoplasm Invasiveness, Neoplasm Staging, Postoperative Complications, Predictive Value of Tests, Proportional Hazards Models, Prostatectomy, Prostatic Neoplasms, Retrospective Studies, Risk Assessment, Robotics, Time Factors, Treatment Outcome, Urologic Surgical Procedures, Male
Show Abstract · Added May 27, 2014
OBJECTIVE - To compare biochemical recurrence (BCR)-free survival and predictors of BCR in intermediate-risk (IR) and high-risk (HR) patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) vs open radical prostatectomy (ORP).
MATERIALS AND METHODS - We conducted a retrospective study on 1336 men with D'Amico IR or HR prostate cancer who underwent RALP or ORP between 2003 and 2009. Exclusion criteria were use of neoadjuvant therapy, <6 months of follow-up, and insufficient clinicopathologic data. We compared demographic, clinical, and pathologic variables between groups. Kaplan-Meier analysis was performed to compare the 5-year BCR-free survival between groups. Multivariate models were developed to determine whether surgical approach influences BCR.
RESULTS - A total of 979 IR and HR patients (237 ORP and 742 RALP patients) met inclusion criteria. Median follow-up was shorter for RALP (43 vs 63 months; P<.001). ORP patients had a higher median prostate-specific antigen level (7.9 vs 6.7 ng/mL; P<.002), significantly more Gleason sum 8-10 tumors, and more adverse pathologic features overall. There was no difference in positive surgical margins between groups. Pathologic features including extraprostatic extension, seminal vesicle involvement, lymph node involvement, pathologic Gleason sum, and positive surgical margin were significant independent predictors of BCR in multivariate analysis. Surgical approach (RALP vs ORP) did not predict BCR when controlling for other known predictors of BCR.
CONCLUSION - Among IR and HR prostate cancer patients, the oncologic outcomes are similar between RALP and ORP. Not surprisingly, adverse pathologic features are harbingers of BCR.
Copyright © 2014 Elsevier Inc. All rights reserved.
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Long-term follow-up of children who underwent severe hypospadias repair using an online survey with validated questionnaires.
Fraumann SA, Stephany HA, Clayton DB, Thomas JC, Pope JC, Adams MC, Brock JW, Tanaka ST
(2014) J Pediatr Urol 10: 446-50
MeSH Terms: Adolescent, Adult, Child, Child, Preschool, Follow-Up Studies, Humans, Hypospadias, Infant, Male, Patient Satisfaction, Penile Erection, Prognosis, Retrospective Studies, Severity of Illness Index, Sexual Behavior, Surveys and Questionnaires, Urologic Surgical Procedures, Male, Young Adult
Show Abstract · Added February 19, 2015
OBJECTIVE - Few studies of hypospadias repair in childhood have used validated questionnaires to investigate outcomes of cosmesis, urinary function, and sexual function in adulthood. We sought to investigate long-term outcomes in adult patients who had undergone severe hypospadias repair as children using an existing web-based application available to multiple institutions in order to develop an online patient survey of previously validated questionnaires.
MATERIALS AND METHODS - Patients aged 18 years or older who underwent severe hypospadias repair between 1992 and 1997 at our institution were contacted to complete an online survey. Through medical chart reviews, we analyzed the location of meatus, type of repair, and complications. The online survey included questions about penile appearance, and validated questionnaires to assess urinary and sexual function.
RESULTS - Of 58 patients who met the inclusion criteria, we contacted 19, and 13 completed the survey. Fifty-nine percent had complications, with an average of 2.2 procedures per patient. Most (85.0%) were satisfied with penile appearance, although 38.0% had residual penile curvature. Hypospadias patients had mean lower orgasmic function than normal controls. Mean scores for urinary function and other domains of sexual function were similar to normal controls.
CONCLUSIONS - Although the majority of adult patients were satisfied with the outcomes of penile appearance, urinary function, and sexual function, our online survey suggests decreased lower orgasmic function as measured by validated questionnaire. An online survey accessible to multiple institutions with validated questionnaires may facilitate assessment of long-term hypospadias results.
Copyright © 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
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Trends in followup imaging after adult pyeloplasty.
Hsi RS, Holt SK, Gore JL, Harper JD
(2014) J Urol 191: 1357-62
MeSH Terms: Adolescent, Adult, Diagnostic Imaging, Female, Follow-Up Studies, Humans, Kidney Pelvis, Male, Middle Aged, Ureteral Obstruction, Urologic Surgical Procedures, Young Adult
Show Abstract · Added January 16, 2018
PURPOSE - Although success rates are reported to be high, radiographic followup after pyeloplasty to correct ureteropelvic junction obstruction varies in intensity and modality. We characterized postoperative care after pyeloplasty to identify imaging trends.
MATERIALS AND METHODS - Using the MarketScan® database we identified patients 17 to 65 years old treated with pyeloplasty from 2007 to 2010. Followup imaging was classified as functional (diuretic renogram or excretory urogram) and nonfunctional (ultrasound, computerized tomography or magnetic resonance imaging). The postoperative period was divided into intervals of less than 6, 6 to 12, 12 to 24, 24 to 36 and greater than 36 months. We excluded from study patients with less than 24 months of postoperative enrollment in MarketScan. Multivariate logistic regression was used to determine associations between demographic variables and imaging utilization patterns.
RESULTS - We identified 742 patients with a mean ± SD followup of 36.8 ± 3.7 months, of whom 65% underwent minimally invasive pyeloplasty. Of the patients 12% underwent no postoperative imaging. Within the first 6 months 554 patients (75%) underwent at least 1 imaging study and within the first 12 months 82% underwent at least 1 imaging study, which was most commonly functional. After 12 months 54% of patients underwent any imaging, which was most commonly nonfunctional. At least annual imaging was significantly associated with older age, female gender and longer hospital stay. Secondary procedures were required in 62 patients (8%).
CONCLUSIONS - After pyeloplasty in adulthood most patients undergo a functional imaging study within 6 months. However, after 1 year only half of patients undergo followup imaging. Variability and insufficient radiological followup may bias the belief of pyeloplasty success.
Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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Racial variation in the quality of surgical care for bladder cancer.
Barocas DA, Alvarez J, Koyama T, Anderson CB, Gray DT, Fowke JH, You C, Chang SS, Cookson MS, Smith JA, Penson DF
(2014) Cancer 120: 1018-25
MeSH Terms: African Continental Ancestry Group, Aged, Cohort Studies, European Continental Ancestry Group, Female, Florida, Healthcare Disparities, Humans, Male, Maryland, Middle Aged, New York, Quality of Health Care, Regression Analysis, Treatment Outcome, Urinary Bladder Neoplasms, Urologic Surgical Procedures
Show Abstract · Added March 10, 2014
BACKGROUND - Differences in quality of care may contribute to racial variation in outcomes of bladder cancer (BCa). Quality indicators in patients undergoing surgery for BCa include the use of high-volume surgeons and high-volume hospitals, and, when clinically indicated, receipt of pelvic lymphadenectomy, receipt of continent urinary diversion, and undergoing radical cystectomy instead of partial cystectomy. The authors compared these quality indicators as well as adverse perioperative outcomes in black patients and white patients with BCa.
METHODS - The Healthcare Cost and Utilization Project State Inpatient Databases for New York, Florida, and Maryland (1996-2009) were used, because they consistently included race, surgeon, and hospital identifiers. Quality indicators were compared across racial groups using regression models adjusting for age, sex, Elixhauser comorbidity sum, insurance, state, and year of surgery, accounting for clustering within hospital.
RESULTS - Black patients were treated more often by lower volume surgeons and hospitals, they had significantly lower receipt of pelvic lymphadenectomy and continent diversion, and they experienced higher rates of adverse outcomes compared with white patients. These associations remained significant for black patients who received treatment from surgeons and at hospitals in the top volume decile.
CONCLUSIONS - Black patients with BCa had lower use of experienced providers and institutions for BCa surgery. In addition, the quality of care for black patients was lower than that for whites even if they received treatment in a high-volume setting. This gap in quality of care requires further investigation.
© 2013 American Cancer Society.
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