Kristy M. Borawski

Urinary Tract Infection and Neurogenic Bladder

Urinary tract infections (UTIs) are frequent, recurrent, and lifelong for patients with neurogenic bladder and present challenges in diagnosis and treatment. Patients often present without classic symptoms of UTI but with abdominal or back pain, increased spasticity, and urinary incontinence. Failure to recognize and treat infections can quickly lead to life-threatening autonomic dysreflexia or sepsis, whereas overtreatment contributes to antibiotic resistance, thus limiting future treatment options. Multiple prevention methods are used but evidence-based practices are few. Prevention and treatment of symptomatic UTI requires a multimodal approach that focuses on bladder management as well as accurate diagnosis and appropriate antibiotic treatment.

Levels of evidence ratings in the urological literature: an assessment of interobserver agreement

To determine to what extent urologists with no specific training agree upon level of evidence (LoE) ratings of studies published in the urological literature, as LoE are commonly referenced as a measure of evidence quality.

Stone Forming Risk Factors in Patients With Type Ia Glycogen Storage Disease

PURPOSE Patients with type Ia glycogen storage disease have an increased recurrent nephrolithiasis rate. We identified stone forming risk factors in patients with type Ia glycogen storage disease vs those in stone formers without the disease. MATERIALS AND METHODS Patients with type Ia glycogen storage disease were prospectively enrolled from our metabolic clinic. Patient 24-hour urine parameters were compared to those in age and gender matched stone forming controls. RESULTS We collected 24-hour urine samples from 13 patients with type Ia glycogen storage disease. Average +/- SD age was 27.0 +/- 13.0 years and 6 patients (46%) were male. Compared to age and gender matched hypocitraturic, stone forming controls patients had profound hypocitraturia (urinary citrate 70 vs 344 mg daily, p = 0.009). When comparing creatinine adjusted urinary values, patients had profound hypocitraturia (0.119 vs 0.291 mg/mg creatinine, p = 0.005) and higher oxalate (0.026 vs 0.021 mg/mg creatinine, p = 0.038) vs other stone formers. CONCLUSIONS Patients with type Ia glycogen storage disease have profound hypocitraturia, as evidenced by 24-hour urine collections, even compared to other stone formers. This may be related to a recurrent nephrolithiasis rate greater than in the overall population. These findings may be used to support different treatment modalities, timing and/or doses to prevent urinary lithiasis in patients with type Ia glycogen storage disease.

Urinary diversion in patients with spinal cord injury in the United States

OBJECTIVE To describe the patterns in the use of bladder augmentation and urinary diversion to manage urologic sequelae among patients with spinal cord injury in the United States. MATERIALS AND METHODS Discharge estimates were derived from the Nationwide Inpatient Sample. All patients underwent bladder augmentation or ileal conduit diversion from 1998 to 2005 and had a diagnosis of spinal cord injury. RESULTS Ileal loop diversion was performed in an estimated 1919 patients and bladder augmentation in 1132 patients with spinal cord injury from 1998 to 2005. Patients undergoing urinary diversion tended to be older (mean age 46 vs 34 years; P <.001) and to have Medicare as the primary payer (55.0% vs 30.8%; P <.001). Patients who underwent urinary diversion appeared to use more healthcare resources, with a longer length of stay (15 vs 9 days), higher hospital charges (

Levels of Evidence and Clinical Guidelines—Considerations for the Practicing Urologist

58,626 vs

MP86-05 IMPLEMENTATION OF MEDICAL SCRIBES IN AN ACADEMIC UROLOGY PRACTICE: AN ANALYSIS OF PRODUCTIVITY, REVENUE, AND SATISFACTION

37,222), and a greater use of home healthcare services after discharge (all P <.001). Patients at teaching institutions were more likely to undergo bladder augmentation (42%) than those at nonteaching institutions (23%; P <.001). CONCLUSION Bladder augmentation is used in approximately one-third of cases to manage the urologic complications of spinal cord injury. These patients likely constitute a clinically distinct population that uses fewer healthcare resources. The lower augmentation rates at nonteaching institutions may indicate an opportunity for quality improvement.

Trends and Patterns of Urodynamic Studies in U.S. Males, 2000-2012.

INTRODUCTION It is important for urologists to remain up-to-date regarding research and clinical guidelines within their specialty. This has become increasingly difficult as the volume of research increases while the quality of evidence has not followed suit. It is, therefore, important for urologists to understand the methodology of critical appraisal of evidence, for both the assessment of individual journal articles as well as the construction of organizational clinical guidelines. METHODS The methodology for clinical guideline creation used by the American Urological Association (AUA) is reviewed along with that of the U.S. Preventive Services Task Force (USPSTF). Two popular grading schemas are then reviewed to provide an overview of existing methods for the critical analysis of research. We conclude with a description of the Grading of Recommendations Assessment Development and Evaluation (GRADE)-a classification system that attempts to unify various grading systems and is rapidly gaining popularity among well-reputed national organizations. RESULTS The AUA uses a systematic and evidence-based approach to creating clinical guidelines. The USPSTF is similar to the AUA in its approach to reviewing the literature and creating guidelines. The Centre for Evidence Based Medicine offers a novel approach to evidence-based literature review, providing a metric for the analysis of the literature to answer specific clinical questions. GRADE is working toward the development of a more transparent and standardized approach to the creation and reporting of clinical guidelines. CONCLUSIONS A number of organizations have attempted to standardize and clarify the literature review process to provide physicians with tools to critically evaluate higher quality evidence and apply guidelines to clinical practice. As urologists, we must understand how national organizations review the literature and develop clinical guidelines. Additionally, we must develop our own process for reviewing the literature in order to answer questions that have not yet been addressed by these organizations. Kirby EW, Borawski KM, and Smith AB. Levels of evidence and clinical guidelines-Considerations for the practicing urologist. Sex Med Rev 2013;1:17-23.

The Oncologic Outcomes of Robotic-Assisted Laparoscopic Prostatectomy

Purpose Pressure on physicians to increase productivity is rising in parallel with administrative tasks, regulations, and the use of electronic health records (EHRs). Physician extenders and clinical pathways are already in use to increase productivity and reduce costs and burnout, but other strategies are required. We evaluated whether implementation of medical scribes in an academic urology clinic would affect productivity, revenue, and patient/provider satisfaction.

Predicting implantation with a neuromodulator using two different test stimulation techniques: A prospective randomized study in urge incontinent women†

Objective To evaluate trends in urodynamic procedures in the U.S. males from 2000–2012 and determine if a 2010 decline in reimbursement was associated with decreased utilization. Subjects and methods We analyzed 2000–2012 administrative healthcare claims from Truven Health’s Marketscan Database and evaluated males ≥18 years of age. We identified cystometrograms and any concurrent procedures using procedure billing codes. Covariates included age, year of cystometrogram, region and associated diagnosis codes. We estimated standardized cystometrogram utilization rates per 10,000 person-years (PY). We used age, region, and calendar year adjusted Poisson regression models to estimate the independent effect of calendar year and region. Results During 127,558,186 PY of observation, we identified 153,168 cystometrograms for an overall utilization rate of 12.0 per 10,000 PY (95% CI 11.9–12.1). Cystometrogram utilization increased with age, peaking at age 85 with a rate of 77.7 per 10,000 PY (95% CI 74.7–80.7). Adjusted cystometrogram utilization rate ratios show that compared to a referent of 2000–2004, utilization was significantly higher in each year 2005 to 2011 among all patients and in 2012 among patients ≥ 65. Standardized utilization rates peaked in 2008 at 12.4 per 10,000 PY (95% CI 12.2–12.6), remained elevated until 2010, then decreased slightly in 2011 and substantially in 2012 to 8.5 per 10,000 PY (95% CI 8.4–8.7). Conclusions Utilization of urodynamic procedures increased until 2010 and decreased thereafter. Utilization was greatest among men older than 65.

Long-term lemonade based dietary manipulation in patients with hypocitraturic nephrolithiasis.

Whenever a new procedure is introduced, it is imperative that it offers the same or improved outcomes compared to the gold standard. This is especially true when one is dealing with oncologic outcomes. Proponents of robotic surgery are in favor of its three-dimensional (3D) visualization, wristed instruments, finger-controlled movements, seven degrees of freedom (six degrees and freedom of grip) as well as tremor elimination.1–6 With these advantages there a is a possibility of increased precision and improved oncologic outcomes. One disadvantage, however, is the lack of tactile feedback.