Kai Dallas

Where do Women go for Revision Surgeries? Geographic Migration Patterns after Urethral Sling Placement in California

Introduction: Although long‐term rates of sling revision after urethral sling placement have been well studied, details of these revisions have not been addressed. In this study we explore the timing, location and migration of patients from one facility to another for revision procedures. Methods: Using data from the Office of Statewide Health Planning and Development (OSHPD) for the state of California (2005 to 2011), all females who underwent index outpatient urethral sling procedures at nonfederal facilities were identified (CPT 57288). Cases requiring eventual sling revision or urethrolysis were subsequently identified. Location, distance traveled and factors associated with seeking a new facility for revision were explored. Results: Of the 44,605 patients undergoing urethral sling surgery 842 (1.9%) underwent sling revision, with 178 (22.5%) at a new facility. Facilities in the top 10% of surgical volume placed 41% of the slings and performed more than 50% of revisions. Patient proximity to multiple facilities and increased time between procedures were associated with an increased odds of changing facilities for revision (OR 2.11, p <0.0001 and OR 1.05 per month, p <0.0001, respectively). Placement at a high volume center was associated with decreased odds of changing facilities for revision (OR 0.32, p <0.0001). Patients migrated toward larger centers in urban areas for revision. Conclusions: Overall 78% of sling revisions are performed at the facility where the initial placement was performed. This suggests that the majority of facilities where urethral slings are placed also have the capability of sling revision surgery.

What Impacts the All Cause Risk of Reoperation after Pelvic Organ Prolapse Repair? A Comparison of Mesh and Native Tissue Approaches in 110,329 Women

Purpose: Several factors are hypothesized to impact the risks of mesh augmented pelvic organ prolapse repair, including 1) the characteristics of the material, 2) surgical experience and 3) patient selection. We present a large, population based approach to explore the impact of these factors on outcomes and describe an ideal mesh use strategy. Materials and Methods: Data from the Office of Statewide Health Planning and Development were accessed to identify all women who underwent pelvic organ prolapse repair in California from 2005 to 2011. Multivariate mixed effects logistic regression models were constructed to explore which patient, surgical and facility factors were associated with repeat surgery for a complication due to mesh or recurrent pelvic organ prolapse. Results: A total of 110,329 women underwent pelvic organ prolapse repair during the study period and mesh was used in 16.2% of the repairs. The overall repeat surgery rate was higher in women who underwent mesh repair (5.4% vs 4.3%, p <0.001). However, multivariate modeling revealed that mesh itself was not independently associated with repeat surgery. Rather, repair at a facility where there was a greater propensity to use mesh was independently associated with repeat surgery (highest vs lowest mesh use quartile OR 1.55, p <0.01). Further modeling revealed that the lowest risk occurred when mesh was used in 5% of anterior and 10% of anterior apical repairs. Conclusions: Our findings demonstrate that mesh is not independently associated with an increase in the rate of complications of pelvic organ prolapse repair on a large scale. We present a model that supports judicious use of the product on the population level which balances the risk of complications against that of recurrent pelvic organ prolapse.

The association between varicocoeles and vascular disease: an analysis of U.S. claims data

S‪tudies have suggested an association between varicocele, hypogonadism, and elevated oxidative stress markers, but no other health risks have been associated with varicoceles. ‬‬‬‬We sought to determine the association between varicocele and incident medical comorbidities. ‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬Using the Truven Health MarketScan® claims database from 2001 to 2009, we identified 4459 men with varicoceles, and 100,066 controls based on ICD‐9 and CPT codes, with an average follow‐up of 3.1 person years. Men with varicoceles were classified as symptomatic or asymptomatic based on co‐existing diagnoses. Men with medical comorbidities present before or within 1 year of index diagnosis were excluded. Metabolic and cardiovascular outcome variables were identified via ICD‐9 codes. A Cox regression analysis was used to assess incident risk of metabolic and cardiovascular disease amongst the different groups. Men with varicoceles had a higher incidence of heart disease compared to men who underwent infertility testing (HR 1.22, 95% CI: 1.03–1.45), and men who underwent vasectomy (HR 1.32, 95% CI 1.13–1.54). The varicoceles group also had a higher risk of diabetes (HR 1.73, 95% CI: 1.37–2.18) and hyperlipidemia (HR 1.15, 95% CI: 1.03–1.28) compared to the vasectomy group. Furthermore, men with symptomatic varicoceles (n = 3442) had a higher risk of heart disease, diabetes, and hyperlipidemia following diagnosis, while men with asymptomatic varicoceles (n = 1017) did not. Given the prevalence of varicoceles, further research is needed to understand the implications of a varicocele to a mans overall health.

Intermittent Projectile Urethraggia: An Unusual Sequela of a Skateboarding Accident in an Adolescent Male

Our patient suffered a perineal straddle injury, resulting in right cavernosal artery pseudoaneurysm in combination with a cavernosal-urethral fistula. The urethra failed to heal after several weeks, and the patient presented with severe intermittent urethral bleeding. The pseudoaneurysm was successfully treated by coil embolization, with resolution of the bleeding. The patient recovered completely, with normal erectile and voiding function. This type of injury is very rare in the literature: traumatic cavernosal arterial pseudoaneurysm is known to cause high flow priapism, but in this case additional cavernosal-urethral fistula resulted in a severe urethraggia. This is the only case, to our knowledge, of delayed urethral bleeding from cavernosal artery pseudoaneursym in combination with a cavernosal-urethral fistula.

Unplanned Hospital Visits in the First 30 Days After Urethral Sling Procedures

OBJECTIVE To evaluate unplanned hospital visits within 30 days of urethral sling placement in the form of emergency department visits, inpatient admissions, or repeat surgery. METHODS We accessed nonpublic data from the Office of Statewide Health Planning and Development in the state of California for the years 2005-2011. All female patients who underwent an ambulatory urethral sling procedure (Current Procedural Terminology 57288) without concomitant surgery (other than cystoscopy) were included. Any subsequent emergency department visit, inpatient admission, or sling revision operation within 30 days of the original surgery were then examined. RESULTS A total of 28,635 women were identified who underwent outpatient urethral sling placement as a sole procedure. Within 30 days, 1630 women (5.7%) had at least 1 unplanned hospital visit. This included 1327 emergency department visits (4.7%), 295 inpatient admissions (1.0%), and 79 sling revisions (0.28%). Urinary retention and Foley catheter problems were the most common emergency department visit diagnoses (18.7% of visits), followed by urinary tract infection (9.3% of visits). CONCLUSION One in 18 women will have an unplanned hospital visit within 30 days of urethral sling placement, the majority of which are emergency department visits (~81%). Our findings can be used to improve patient counseling and suggest areas that one might target to decrease unnecessary emergency department visits in the early postoperative period.

Rates and Risk Factors for Future Stress Urinary Incontinence Surgery After Pelvic Organ Prolapse Repair in a Large Population Based Cohort in California

OBJECTIVES To determine the rate and risk factors for future stress urinary incontinence (SUI) surgery in a large population-based cohort of previously continent women following pelvic organ prolapse (POP) repair without concomitant SUI treatment. METHODS Data from the Office of Statewide Health Planning and Development were used to identify all women who underwent anterior, apical, or combined anteroapical POP repair without concomitant SUI procedures in the state of California between 2005 and 2011 with at least 1-year follow-up. Patient and surgical characteristics were explored for associations with subsequent SUI procedures. RESULTS Of 41,689 women undergoing anterior or apical POP surgery, 1,504 (3.6%) underwent subsequent SUI surgery with a mean follow-up time of 4.1 years. Age (odds ratio [OR] 1.01), obesity (OR 1.98), use of mesh at the time of POP repair (OR 2.04), diabetes mellitus (OR 1.19), white race, and combined anteroapical repair (OR 1.30) were associated with increased odds of future SUI surgery. CONCLUSION The rate of subsequent surgery for de novo SUI following POP repair on a population level is low. Patient and surgical characteristics may alter a womans individual risk and should be considered in surgical planning.

Care Seeking Patterns for Women Requiring a Repeat Pelvic Organ Prolapse Surgery due to Native Tissue Repair Failure Compared to a Mesh Complication

OBJECTIVE To explore patient migration patterns in patients requiring repeat surgery after Pelvic Organ Prolapse (POP) repair as there is a limited understanding of care seeking patterns for repeat surgery after POP repair. We hypothesized that undergoing repeat surgery for a prolapse mesh complication would be associated with an increased incidence of migration to a new facility for care compared to those undergoing repeat surgery for recurrent POP. METHODS In this retrospective population based study, all females who underwent an index POP repair procedure (with or without mesh) at nonfederal facilities who subsequently underwent a repeat surgery (recurrent prolapse repair or mesh complication) were identified from the Office of Statewide Health Planning and Development for the state of California (2005-2011). The location of index repair and repeat surgery were identified and factors associated with migration were explored. RESULTS Of the 3,930 women who underwent repeat surgery for either POP recurrence or a mesh complication, 1,331 (33.9%) had surgery at a new facility. Multivariate analysis revealed that mesh complications (odds ratio [OR] 1.28, P = 0.004) or native tissue same compartment recurrence (OR 1.19, P = 0.02) were both associated with increased odds of undergoing surgery at a new facility. Having surgery in a county with multiple centers increased the odds of migration to a new facility for care (OR = 1.33, P < 0.001), unless the initial repair was at a high volume institution (OR = 0.32, P < 0.001). Overall across indications, women changing locations for their second surgery tended to migrate toward select centers in urban areas. CONCLUSION Women who undergo repeat surgery after POP repair have similar patterns of migration to a new facility irrespective of the indication for surgery.

Volitional Voiding of the Bladder after Spinal Cord Injury: Validation of Bilateral Lower Extremity Motor Function as a Key Predictor

Purpose: In many individuals with spinal cord injury a return of volitional bladder voiding is considered more important than regaining motor function. Recently a predictive model using only composite bilateral lower extremity motor scores for levels L2‐S1 (range 0 to 50) was proposed by the EMSCI (European Multicenter Study about Spinal Cord Injury) group. The model showed exceptional predictive power with an AUC of 0.912. We sought to further validate the EMSCI model in a national spinal cord injury cohort. Materials and Methods: We created models of volitional voiding using the United States NSCID (National Spinal Cord Injury Database) for 2007 to 2016. In addition to testing lower extremity motor scores, we evaluated other patient variables that we hypothesized might affect volitional voiding. Results: Volitional voiding was present in 1,333 of the cohort of 4,327 individuals (30.8%) at 1‐year followup. While younger age, female gender, increased sacral sparing, improved AIS (American Spinal Injury Association Impairment Scale) classification and a more caudal sensory level predicted volitional voiding, lower extremity motor scores were most predictive (AUC 0.919). Adding the other patient characteristics did little to improve model performance (full model AUC 0.932). Further analysis of the predictive power of lower extremity motor scores suggested that while the AUC appeared to decrease in persons who were most likely to void volitionally, the performance of the predictive model remained outstanding with a combined AIS C and D AUC of 0.792. Conclusions: Our study verifies the validity of the EMSCI predictive model of volitional voiding after spinal cord injury. The differing performance of lower extremity motor scores in various AIS classifications should be noted.

MP79-18 TRENDS IN THE MANAGEMENT OF OVERACTIVE BLADDER IN THE UNITED STATES FROM 2003-2015

A rise in Mirabegron use in 2012 coincides with a decline in anticholinergic use for management of OAB, suggesting that providers are increasingly utilizing Mirabegron. Chemodenervation increased over time since 2010 while PTNS and SNS use remained low. Further research is needed to determine whether newer oral therapies are more efficacious or whether third line therapies are not being fully utilized. Raveen Syan MD, Chiyuan A. Zhang, MS, Kai Dallas MD, Ekene Enemchukwu MD, MPH Stanford University, School of Medicine, Department of Urology

Payer Type, Race/Ethnicity, and the Timing of Surgical Management of Urinary Stone Disease

PURPOSE Surgery for upper tract urinary stone disease is often reserved for symptomatic patients and those whose stone does not spontaneously pass after a trial of passage. Our objective was to determine whether payer type or race/ethnicity is associated with the timeliness of kidney stone surgery. MATERIALS AND METHODS A population-based cohort study was conducted using the California Office of Statewide Health Planning and Development dataset from 2010 to 2012. We identified patients who were discharged from an emergency department (ED) with a stone diagnosis and who subsequently underwent a stone surgery. Primary outcome was time from ED discharge to urinary stone surgery in days. Secondary outcomes included potential harms resulting from delayed stone surgery. RESULTS Over the study period, 15,193 patients met the inclusion criteria. Median time from ED discharge to stone surgery was 28 days. On multivariable analysis patients with Medicaid, Medicare, and self-pay coverage experienced adjusted mean increases of 46%, 42%, and 60% in time to surgery, respectively, when compared with those with private insurance. In addition, patients of Black and Hispanic race/ethnicity, respectively, experienced adjusted mean increases of 36% and 20% in time to surgery relative to their White counterparts. Before a stone surgery, underinsured patients were more likely to revisit an ED three or more times, undergo two or more CT imaging studies, and receive upper urinary tract decompression. CONCLUSIONS Underinsured and minority patients are more likely to experience a longer time to stone surgery after presenting to an ED and experience potential harm from this delay.