Omar Ayyash

Clinical and Radiological Risk Factors Predicting Open Surgical Repair in Pediatric Patients With Dilating Vesicoureteral Reflux

OBJECTIVE To study the individual patient-related risk factors in those undergoing open corrective vesicoureteral reflux (VUR) surgery in a contemporary series. The management of VUR remains controversial, and the indications for open surgery has evolved from that of surgeon and patient preference to criteria involving breakthrough urinary tract infections and grade of VUR. MATERIALS AND METHODS A retrospective study was performed, and patients undergoing open surgical repair for dilating VUR (grade III-V) from 2005 to 2014 were included. Characteristics of patients were determined to identify predictors of operative intervention. Statistical analysis including Fishers exact test and multivariable logistic regression of patient demographics and independent predictors of surgery was performed using the Stata (College Station, TX) version 13 software package. RESULTS Of the 469 patients, 351 (74.8%) underwent open intravesical ureteroneocystostomy and 118 (25.2%) were managed conservatively. Based on the multivariable analysis, age, female sex, number of febrile urinary tract infections, maximum grade of reflux, prenatal hydronephrosis, ureteral dilatation, and persistence of VUR on voiding phase of voiding cystourethrogram were strong predictors of eventual surgery. Female sex (odds ratio [OR]: 19.8), ureteral dilatation (OR: 6.2), and persistence of VUR on voiding phase (OR: 5.03) were among the strongest predictors of surgical intervention. CONCLUSION Female sex and higher grades of VUR were the strongest predictors of eventual surgical intervention. VCUG characteristics of ureteral dilatation >7 mm and persistence of VUR on the voiding phase were also very strong predictors of eventual surgical intervention.

Control of the vertebral artery from a posterior approach: a technical report.

BACKGROUND CONTEXT Vertebral artery (VA) injury is a rare but potentially devastating complication of cervical spinal fusion. The Magerl and Harms techniques are associated with a rate between 0% to 8% and 0% to 5%, respectively. Most of reported VA injuries are related to surgical exposure or screw placement, which in turn is likely due to variability in VA anatomy. PURPOSE The purpose of this report was to present the case of a 77-year-old woman, with a history of right VA occlusion, who sustained an intraoperative left VA injury during posterior cervical spine fusion and the subsequent intraoperative and postoperative management strategies. STUDY DESIGN This is a single-patient case report. METHODS The patient was placed prone and into Mayfield tongs. A midline incision was made, and dissection was carried down to the lamina and facet joints from occiput to T2. During dissection, she sustained a left-sided VA injury, which was subsequently controlled. RESULTS The patient was doing well at her 1-year postoperative visit without any residual neurologic deficits. Her severe neck pain had resolved. CONCLUSION A detailed understanding of VA anatomy of each individual patient is paramount. There are four types of anomalies: intraforaminal; extraforaminal; arterial; and anomalies of the surrounding bony and soft-tissue architecture. In the event of a posterior intraoperative VA injury, we outlined an algorithm to deal with this complication: control bleeding temporarily to gain visualization of the arterial injury; remove lateral masses and tissue to adequately visualize the arterial injury; once visualized, control the bleeding and see if there are any neuromonitoring changes as a result of the VA occlusion; and proceed with definitive control of the artery by either repair or ligation.

Cystatin C-calculated Glomerular Filtration Rate—A Marker of Early Renal Dysfunction in Patients With Neuropathic Bladder

OBJECTIVE To asses if cystatin c-calculated glomerular filtration rate (GFR) can reveal chronic kidney disease (CKD) not detected by creatinine-based calculations in a larger prospective cohort of children with myelomeningocele (MMC). Wheelchair-bound MMC patients frequently have low muscle mass, and assessing renal deterioration based on creatinine-based GFR is imprecise. MMC patients are also at risk for end-stage renal disease. METHODS Prospectively enrolled patients with MMC underwent annual serum creatinine and cystatin c testing. Anthropometric measurements were obtained from clinic visit. The modified (bedside) Schwartz formula for creatinine-based GFR and the Zappitelli cystatin C formula were utilized for calculation. The exclusion criteria were patients with reduced GFR (CKD stage 2) or chronic CKD (CKD stage 3 and greater); these patients were excluded from analysis on the premise that they had already been identified for closer renal monitoring. RESULTS A total of 131 patients were included in the analysis. The median creatinine-based estimated GFR was 126.5 mL/min/1.73 m2 (range: 22-310). The median cystatin C-based estimated rate was 98.5 mL/min/1.73 m2 (range: 16-171), yielding an absolute median rate reduction of 30.2%. Using cystatin c-calculated GFR, CKD stage was upgraded from stage 1 to ≥2 in 34 patients (26%). CONCLUSION In MMC patients with poor muscle mass, cystatin C-based GFR is more sensitive than creatinine-based GFR in detecting early CKD. In this high-risk population, serial cystatin C estimation is a valuable tool in identifying children who may benefit from early nephrology referral and intervention.

Bipolar Transurethral Incision of Bladder Neck Stenoses with Mitomycin C Injection.

Introduction. To determine the efficacy of bipolar transurethral incision with mitomycin C (MMC) injection for the treatment of refractory bladder neck stenosis (BNS). Materials and Methods. Patients who underwent bipolar transurethral incision of BNS (TUIBNS) with MMC injection at our institution from 2013 to 2014 were retrospectively reviewed. A total of 2 mg of 40% mitomycin C solution was injected in four quadrants of the treated BNS. Treatment failure was defined as the need for subsequent intervention. Results. Thirteen patients underwent 17 bipolar TUIBNS with MMC injection. Twelve (92%) patients had failed a mean of 2.2 ± 1.1 prior endoscopic procedures. Median follow-up was 16.5 months (IQR: 14–18.4 months). Initial success was 62%; five (38%) patients had a recurrence with a median time to recurrence of 7.3 months. Four patients underwent a repeat procedure, 2 (50%) of which failed. Overall success was achieved in 77% (10/13) of patients after a mean of 1.3 ± 0.5 procedures. BNS recurrence was not significantly associated with history of pelvic radiation (33% versus 43%, p = 0.9). There were no serious adverse events. Conclusions. Bipolar TUIBNS with MMC injection was comparable in efficacy to previously reported techniques and did not result in any serious adverse events.

Marketing and Testosterone Treatment in the USA: A Systematic Review

CONTEXT Testosterone replacement therapy (TRT) is currently approved by the Food and Drug Administration only for classic hypogonadism, although off-label indications have resulted in a dramatic expansion in prescriptions in the USA. Marketing may significantly affect prescriber behavior. OBJECTIVE To systematically review all available evidence on marketing and TRT in the USA. EVIDENCE ACQUISITION PubMed, Embase, and Scopus were searched up to July 2017 for all relevant publications reporting on assessments of the TRT market size, economic costs associated with hypogonadism, trends in TRT prescriptions, drug discontinuation rates, and advertising and sales efforts in the USA. EVIDENCE SYNTHESIS Twenty retrospective studies were included in the final analysis. The market size for hypogonadism constitutes 5.6-76.8% of men in the USA, with the lower end of the range representing the strictest criteria for diagnosis. Men with a diagnosis of hypogonadism consume

Outcomes of Ureteroscopic Management of Pediatric Urolithiasis: A Comparative Analysis of Prepubertal and Adolescent Patients

14 118 in direct and indirect costs to the payer. Over the last 2 decades, TRT prescriptions have increased between 1.8- and 4-fold. After 1 yr, 80-85% of men discontinue TRT. There is an association between direct-to-consumer advertising and testosterone testing, TRT prescriptions, and TRT without testosterone testing. There is a high prevalence of misinformation on Internet advertising. CONCLUSIONS Off-label indications have driven the dramatic expansion of TRT prescriptions over the last 2 decades. Direct-to-consumer advertising poses a unique challenge in the USA. Overtreatment can be avoided by applying strict diagnostic criteria for hypogonadism, which limits the addressable market for TRT. PATIENT SUMMARY In this report, we reviewed the relationship between marketing and testosterone therapy in the USA. We found that many patients are prescribed testosterone without an appropriate diagnosis of hypogonadism, which may be related to the marketing efforts for off-label prescribing.

Defining the Rate of Primary Ureteroscopic Failure in Unstented Patients: A Multi-Institutional Study

OBJECTIVE To compare the outcomes of ureteroscopic intervention in terms of both the stone-free rate and complications in both prepubertal and adolescent patients. Although safety of pediatric ureteroscopic intervention is well established, a comparative outcome of prepubertal and adolescent patients is lacking. MATERIALS AND METHODS Pediatric patients who underwent ureteroscopic treatment of a renal or ureteral stone at our institution from July 2005 to August 2014 were retrospectively identified. Patients were classified by age either as prepubertal (≤11 years) or adolescent (>11 years) for purposes of comparison. Demographic and intraoperative variables as well as 30-day postoperative complication rates were compared between groups. Data were analyzed using χ(2) and Fishers exact tests as appropriate. RESULTS A total of 104 patients were identified, of whom 64 (62%) were prepubertal and 40 (38%) were adolescent. Ureteroscopic failure occurred in a minority of patients (5% vs 4.7%, P > .9). Complication rates including ureteral perforation (0% vs 1.6%, P > .9), postoperative urinary tract infection (2.5% vs 4.7%, P > .9), hematuria with clot passage (0% vs 7.8%, P = .15), and persistent flank pain (15% vs 17%, P = .85) were not significantly different between adolescent and prepubertal patients, respectively. CONCLUSION In spite of small size and small body habitus, the ureteroscopic management of pediatric urolithiasis can be performed successfully in both the prepubertal and adolescent patients with acceptable and equivalent morbidity as well as successful clearance of stone.

Extreme Price Variation for Generic Benign Prostatic Hyperplasia Medications

PURPOSE Primary ureteroscopic intervention for kidney or ureteral stones occasionally encounters difficulty with passage of the ureteroscope in the initial procedure. These patients require a second procedure after stenting. We aim to define the contemporary failure rate of primary ureteroscopy (URS) and identify predictive factors that necessitate prestenting. This will assist in preoperative patient counseling, informed consent, and clinical decision-making. MATERIALS AND METHODS We conducted a multi-institutional retrospective review of 535 unstented patients undergoing primary URS from August 2011 to August 2013. The primary outcome was gaining access to the unstented ureter. RESULTS The failure rate for accessing the unstented ureter was 7.7% (41/535). The median age of females with primary ureteroscopic failure was significantly lower than in females who had successful ureteroscopic access (34 vs 52 years; p = 0.0041). There was no difference in the median age of males with access vs failure (58 vs 57 years; p = 0.3683). Proximal ureteral stones had the highest failure rate for ureteral access at 18.28% (p = 0.006). On multivariable logistic regression, proximal ureteral stone location remained a significant predictor of failure when compared to renal stones (odds ratio [OR] 3.14, p = 0.006). When including only ureteral stones in the multivariable analysis, stone location in the proximal ureter compared to the distal ureter remained the only significant predictor of access failure (OR 0.24, p = 0.015). CONCLUSIONS A low overall rate of ureteral access failure in unstented patients is shown. Young female patients and proximal ureteral stones were less likely to be accessed primarily. This study provides information that will help urologists counsel their patients preoperatively regarding their likelihood of failing primary URS necessitating a second procedure. This will also help the patient to make an informed decision during the consent process and may guide urologists on selective prestenting in higher risk patients.

MP90-12 DOES THE TIMING OF MAGNESIUM SUPPLEMENTATION AFFECT URINARY OXALATE LEVELS IN PATIENTS WITH NEPHROLITHIASIS?

OBJECTIVE To characterize geographic variability of generic benign prostatic hyperplasia (BPH) medications in order to improve drug price transparency and improve patient access to affordable medication sources. This is of interest because BPH is one of the most common chronic diseases in men and contributes to individual healthcare cost. Medical therapy is the main treatment modality for BPH, burdening patients with lifelong medication expenses which may impact adherence and subsequent outcomes. With an aging population, this is compounded by many older individuals requiring multiple daily medications. METHODS All pharmacies within a 25-mile radius of our institution were identified and classified as chain, wholesale or independent. The out-of-pocket price for a 30-day supply of tamsulosin (0.4 mg), finasteride (5 mg), oxybutynin (5 mg TID), and oxybutynin 10 mg XL were obtained using a scripted telephone survey. Multivariable linear regression assessed the association between census-tract level demographic and socioeconomic factors and disparate generic out-of-pocket drug-pricing. RESULTS The response rate was 93% with 255 pharmacies across 173 census tracts providing data. By pharmacy type, there was up to 5.5-fold variation in median out-of-pocket drug prices for the most common BPH medications. Demographic and socioeconomic factors were not significantly associated with generic BPH drug price variation. CONCLUSION The out-of-pocket price of generic medications for BPH varies significantly between pharmacies in a geographically-confined area. This study highlights the need for quality improvement initiatives that empower patients to price-compare and improve drug price transparency.

MP76-03 SMALL EFFECT OF PHARMACEUTICAL INDUSTRY PAYMENTS TO PHYSICIANS ON MEDICARE PRESCRIPTION HABITS: USING ABIRATERONE AND ENZALUTAMIDE

INTRODUCTION AND OBJECTIVES: Urinary magnesium has been shown previously to inhibit kidney stone formation in chemical models however, when applied to in vivo human models the results have been conflicting. The purpose of this study is to investigate the timing of magnesium supplementation on the inhibitory effect on nephrolithiasis. We hypothesize that if magnesium is taken with meals, more will be absorbed in the small intestine and excreted in the kidney to allow for better inhibitory effect, specifically by reducing oxalate excretion. METHODS: We prospectively enrolled known calcium oxalate stone formers with isolated hyperoxaluria identified on 24 hour stone risk testing. Patients were then randomized to take magnesium supplementation either fasting or with food. An initial 24 hour urine collection was obtained on enrollment and then repeated after 7 days of magnesium supplementation to determine the effect on urinary excretion of oxalate. Participants were given a controlled diet during the 7 days of intervention which included adequate fluid intake, low oxalate, low salt, moderate animal protein, and normal calcium intake e the standard dietary treatment for hyperoxaluric kidney stone patients. RESULTS: Seven patients were enrolled with 3 patients randomized to each arm of magnesium supplementation. Those taking it with food experienced 41.2mg/d increase in urinary magnesium and a 25.2mg/d decrease in their urinary oxalate over the course of 7 days as compared to a 14.3mg/d increase in magnesium and 13.7mg/d decrease in citrate for those taking magnesium while fasting. There were only modest decreases in calcium oxalate supersaturation and calcium but profound increases in stone protective factors like citrate (Table). Secondary endpoints including sodium (decrease 53mg/d with food vs 84mg/d fasting) also showed improvement with little difference between groups. CONCLUSIONS: Those taking magnesium supplementation with food experienced a more than 3 fold increase in urinary magnesium and twice the reduction in urinary oxalate as those who took it while fasting. Additionally, secondary endpoints like citrate and sodium showed improvement with modest differences between groups. Our pilot study supports the need for further investigation with a larger sample to establish the significance of these trends.