Devin N. Patel

Surgery for pelvic organ prolapse.

Purpose of review Surgical repair of pelvic organ prolapse remains one of the most commonly performed inpatient procedures. New evidence has helped establish risk factors for recurrence and helped define the outcomes of native tissue repairs. The role of transvaginal mesh and minimally invasive techniques continues to evolve. Recent findings Recent emphasis on mesh complications and litigation has led to new research showing native tissue vaginal repairs to have higher success rates than previously reported. Mesh placement transvaginally also has acceptably low complication rates when performed with proper technique. Mesh augmentation for prolapse has low complication rates when placed abdominally. Minimally invasive techniques have reduced the morbidity of these abdominal procedures. Summary Native tissue vaginal repairs have high success rates, as long as prolapse of the vaginal apex is identified and addressed when present. The number of procedures performed with mesh augmentation has declined, and surgeons who continue to perform them will likely be high volume technicians with good outcomes.

Impact of prior local therapy on overall survival in men with metastatic castration-resistant prostate cancer: Results from Shared Equal Access Regional Cancer Hospital

To evaluate the impact of previous local treatment on survival in men with newly diagnosed metastatic castration‐resistant prostate cancer.

New Prostate Cancer Biomarkers: The Search Continues

Although prostate-specific antigen (PSA) was originally introduced as a tumor marker for detection of prostate cancer recurrence or progression, its wider adoption in the late 1980s and early 1990s changed prostate cancer screening forever. PSA has been very useful for prostate cancer screening; however, owing to limitations of poor specificity and predictive values of total PSA assays, the search for better biomarkers is an area of active research. Towards this end, this issue of European Urology highlights the work by Klein et al [1] in developing the IsoPSA assay. The authors, recognizing the benefits afforded by the specificity of PSA to prostate tissue, explored the diagnostic potential of its structural variants for detection of prostate cancer. PSA exists in the blood in multiple forms known as isoforms. Some of these forms are more cancer-specific, while others are less related to cancer. IsoPSA takes advantage of these differences to detect isoform structures that are more cancer-specific. While in concept this is similar to free PSA and -2[Pro]PSA, the IsoPSA test analyzes all PSA isoforms, both known and unknown, to categorize the PSA isoform mixture into cancer and benign phenotypes. Using this novel technology, Klein et al examined the diagnostic accuracy of IsoPSA among 261 men scheduled for prostate biopsy in a multicenter setting. For detection of any cancer on biopsy, the IsoPSA assay had significantly better receiver operating characteristics (area under the curve [AUC] 0.79) compared to total PSA (AUC 0.61; p < 0.001). Similarly, for detecting high-grade prostate cancer (Gleason 7), the IsoPSA assay (AUC 0.81) outperformed total PSA (AUC 0.69; p < 0.005). Moreover, relative to the Prostate Cancer Prevention Trial Risk Calculator (PCPTRC) 2.0 risk calculator, the IsoPSA assay had significant improvements in decision curve analysis, showing that it offers net clinical

PSA predicts development of incident lower urinary tract symptoms: results from the REDUCE study

BackgroundThe relationship between baseline prostate-specific antigen (PSA) and development of lower urinary tract symptoms (LUTS) in asymptomatic and mildly symptomatic men is unclear. We sought to determine if PSA predicts incident LUTS in these men.MethodsA post-hoc analysis of the 4-year REDUCE study was performed to assess for incident LUTS in 1534 men with mild to no LUTS at baseline. The primary aim was to determine whether PSA independently predicted incident LUTS after adjusting for the key clinical variables of age, prostate size, and baseline International prostate symptom score (IPSS). Incident LUTS was defined as the first report of medical treatment, surgery, or sustained clinically significant symptoms (two IPSS >14). Cox proportional hazards, cumulative incidence curves, and the log-rank test were used to test our hypothesis.ResultsA total of 1534 men with baseline IPSS <8 were included in the study cohort. At baseline, there were 335 men with PSA 2.5–4 ng/mL, 589 with PSA 4.1–6 ng/mL, and 610 with PSA 6–10 ng/mL. During the 4-year study, 196 men progressed to incident LUTS (50.5% medical treatment, 9% surgery, and 40.5% new symptoms). As a continuous variable, higher PSA was associated with increased incident LUTS on univariable (HR 1.09, p = 0.019) and multivariable (HR 1.08, p = 0.040) analysis. Likewise, baseline PSA 6–10 ng/mL was associated with increased incident LUTS vs. PSA 2.5–4 ng/mL in adjusted models (HR 1.68, p = 0.016). This association was also observed in men with PSA 4.1–6 ng/mL vs. PSA 2.5–4 ng/mL (HR 1.60, p = 0.032).ConclusionsMen with mild to no LUTS but increased baseline PSA are at increased risk of developing incident LUTS presumed due to benign prostatic hyperplasia.

What is the ideal antibiotic prophylaxis for intravesically administered Botox injection? A comparison of two different regimens

IntroductionOnabotulinum toxin A (Botox®) administered intravescially is an effective treatment for idiopathic detrusor overactivity, of which urinary tract infections (UTIs) are a common complication. The purpose of this study was to compare two prophylactic antibiotic regimens with the goal of decreasing UTI rates following intravesically administered Botox® injection.Materials and methodsA retrospective review of two groups of patients undergoing intravesically administered Botox® injections was performed—one with idiopathic and one with neurogenic detrusor overactivity. One group received a dose of ceftriaxone intramuscularly (IM) at the time of Botox® injection, and a second group received a 3-day course of a fluoroquinolone orally starting the day before the procedure. The rate of postprocedure UTI was examined using a χ2 test. A secondary analysis was performed using logistic regression modeling to test the association between clinical characteristics and antibiotic regimen and risk of postprocedure UTIs.ResultsBotox® injections were performed on 284 patients: 236 received a single dose of ceftriaxone IM and 48 received 3 days of a fluoroquinolone orally. The UTI rate was significantly lower in the fluoroquinolone group (20.8%) vs. the cephalosporin group (36%), p = 0.04. Predictors of postprocedure UTIs included single dose of antibiotics IM [odds ratio (OR 2.80, p = 0.02] and a positive preprocedure urine culture (OR 1.31, p = 0.03).ConclusionsWe found a significantly lower rate of UTIs when patients received a 3-day course of a fluoroquinolone orally as opposed to a single dose of a third-generation cephalosporin IM. Patients with a positive preprocedure culture might benefit from an even longer duration of antibiotics at the time of Botox® injection.

Ustekinumab Is Effective for the Treatment of Crohn’s Disease of the Pouch in a Multicenter Cohort

BACKGROUND Crohns disease (CD) of the pouch and chronic pouchitis occur in approximately 10% of patients after ileal pouch-anal anastomosis (IPAA) for refractory ulcerative colitis (UC) or UC-related dysplasia. The efficacy of anti-tumor necrosis factor (anti-TNF) agents and vedolizumab have been reported for the treatment of CD of the pouch and chronic pouchitis, but little is known regarding the use of ustekinumab in these settings. Our primary aim was to evaluate the efficacy of ustekinumab for these conditions. METHODS This is a retrospective, multicenter cohort study evaluating the efficacy of ustekinumab in patients with CD of the pouch and chronic pouchitis. Clinical response or remission was judged by the treating physicians assessment at 6 months. RESULTS Fifty-six patients (47 with CD of the pouch and 9 with chronic pouchitis) were included the study. Of these, 73% had previously been treated with either anti-TNF therapy, vedolizumab, or both after IPAA. Among patients with CD of the pouch and chronic pouchitis, 83% demonstrated clinical response 6 months after induction with ustekinumab. Responders demonstrated significantly less pouch inflammation on endoscopy when compared with nonresponders (29% vs 100%; P = 0.023). Higher mean body mass index at induction (26.3 vs 23.7; P = 0.033) and male sex (83% vs 30%; P = 0.014) were significant predictors of nonresponse to ustekinumab in those with CD of the pouch. CONCLUSION In this refractory patient population, ustekinumab appears to be a safe and effective treatment for chronic pouchitis and CD of the pouch in biologic-naïve patients and those with prior anti-TNF or vedolizumab therapy failure. 10.1093/ibd/izx005_video1 izy302.video1 5844889626001.

Prevalence and Cost of Catheters to Manage Neurogenic Bladder

Purpose of ReviewIn this review, we examine the current literature to address the epidemiology of catheters for managing neurogenic bladder. We will address the epidemiology of conditions associated with neurogenic bladder, including multiple sclerosis, spinal cord injury, Parkinson’s disease, stroke, and spina bifida. Rates of utilization of various catheter strategies, including indwelling urethral catheter, suprapubic catheter, and intermittent catheterization rates will be reviewed. Lastly, we examine the cost considerations between and within each type of strategy.Recent FindingsManagement strategies for neurogenic bladder have evolved overtime. Costs between catheter strategies are largely driven by complications. The highest cost variation within each strategy is related to the technique and type of intermittent catheter. Recently, there has been an increase in costlier single-use intermittent catheter strategies. However, the short- and long-term benefits of these strategies remained understudied.SummaryWithout comparative studies highlighting improvements in complication rates and compliance, the benefits of single-use catheters for intermittent catheterization are largely theoretical. Until such studies are performed, providers should strongly consider managing neurogenic bladder patients with reusable intermittent catheters in order to provide the most cost-conscious care.

Use of cylindrical coordinates to localize prostate cancers on MRI and prostatectomy pathology

PURPOSE To describe and test a quantitative system for designating prostate tumor location on magnetic resonance imaging (MRI) and prostatectomy. A system for describing tumor location will facilitate research correlating MRI and pathology. MATERIALS AND METHODS The prostate cylindrical coordinate (PCC) system was developed for locating prostate tumors using 3 coordinate values. The 3 coordinate values include the angular location centered on the urethra, the radial distance to the periphery and the long axis from apex to base. To evaluate this system, 26 tumors were identified where the prostate cancer was noted by both the radiologist and the pathologist. PCC values were assigned independently to MRI lesions and corresponding tumors. Intraclass correlation coefficient (ICC) was calculated to assess agreement between PCC assigned using MRI and pathology. The coordinates were used to calculate the average distance between the centers of the same lesion measured by MRI and pathology. RESULTS Each of the cylindrical coordinates assigned by MRI and pathology were compared and there was no significant difference. The agreement was excellent, and the ICC was 0.70 (P<0.001) for the angular coordinate, 0.81 (P<0.001) for the radial distance, and 0.94 (P<0.001) for the long axis. Compared to pathology, lesions on MRI were significantly larger (1.17 vs. 0.86cm2, P<0.001) but there was strong agreement between the measurements on MRI and pathology (ICC = 0.89, P<0.001). The distance between the centers of the lesions measured on MRI and pathology was small (10.13mm, s.d. = 8.70). CONCLUSIONS The PCC system quantitatively characterizes lesions seen on MRI and prostatectomy pathology with good agreement.

MP32-17 THE IMPACT OF SOCIAL MEDIA PRESENCE ON ONLINE CONSUMER RATINGS AND SURGICAL VOLUME AMONG CALIFORNIA UROLOGISTS

were compared in terms of real in-hospital charges per surgical episode with a separate pre-ERAS cohort. Mean costs per patient were compared with Wilcoxon-rank sum test and t-test, with p-value < 0.05 considered statistically significant. RESULTS: A total of 257 consecutive patients were evaluated of which 112 were ERAS patients. The median age was 70 years with no difference between the groups (p 1⁄4 0.13). Median length of stay was 6 days (p 1⁄4 0.748). Table 1 lists itemized in-hospital charges. The mean total charges per patient were

PD54-08 WHAT IS THE IDEAL ANTIBIOTIC PROPHYLAXIS FOR INTRAVESICAL BOTOX INJECTION? A COMPARISON OF TWO DIFFERENT REGIMENS

63,364 vs. 65,151 in the ERAS vs. preERAS groups, respectively (p 1⁄4 0.412). The variances between the two groups were statistically significantly different (p < 0.001). ERAS patients incurred higher medication costs (