Managing Urology Consultations During COVID-19 Pandemic: Application of a Structured Care Pathway

OBJECTIVE: To describe and evaluate a risk-stratified triage pathway for inpatient urology consultations during the SARS-CoV-2 (COVID-19) pandemic. This pathway seeks to outline a urology patient care strategy that reduces the transmission risk to both healthcare providers and patients, reduces the healthcare burden, and maintains appropriate patient care. MATERIALS AND METHODS: Consultations to the urology service during a 3-week period (March 16 to April 2, 2020) were triaged and managed via one of 3 pathways: Standard, Telemedicine, or High-Risk. Standard consults were in-person consults with non COVID-19 patients, High-Risk consults were in-person consults with COVID-19 positive/suspected patients, and Telemedicine consults were telephonic consults for low-acuity urologic issues in either group of patients. Patient demographics, consultation parameters and consultation outcomes were compared to consultations from the month of March 2019. Categorical variables were compared using Chi-square test and continuous variables using Mann-Whitney U test. A P value \u3c.05 was considered significant. RESULTS: Between March 16 and April 2, 2020, 53 inpatient consultations were performed. By following our triage pathway, a total of 19/53 consultations (35.8%) were performed via Telemedicine with no in-person exposure, 10/53 consultations (18.9%) were High-Risk, in which we strictly controlled the urology team member in-person contact, and the remainder, 24/53 consultations (45.2%), were performed as Standard in-person encounters. COVID-19 associated consultations represented 18/53 (34.0%) of all consultations during this period, and of these, 8/18 (44.4%) were managed successfully via Telemedicine alone. No team member developed COVID-19 infection. CONCLUSION: During the COVID-19 pandemic, most urology consultations can be managed in a patient and physician safety-conscious manner, by implementing a novel triage pathway

Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study

AIMS: Evidence is sparse on the long-term outcomes of continent cutaneous ileocecocystoplasty (CCIC). We hypothesized that obesity, laparoscopic/robotic approach, and concomitant surgeries would affect morbidity after CCIC and aimed to evaluate the outcomes of CCIC in adults in a multicenter contemporary study. METHODS: We retrospectively reviewed the charts of adult patients from sites in the Neurogenic Bladder Research Group undergoing CCIC (2007-2017) who had at least 6 months of follow-up. We evaluated patient demographics, surgical details, 90-day complications, and follow-up surgeries. the Mann-Whitney U test was used to compare continuous variables and χ² and Fisher\u27s Exact tests were used to compare categorical variables. RESULTS: We included 114 patients with a median age of 41 years. The median postoperative length of stay was 8 days. At 3 months postoperatively, major complications occurred in 18 (15.8%), and 24 patients (21.1%) were readmitted. During a median follow-up of 40 months, 48 patients (42.1%) underwent 80 additional related surgeries. Twenty-three patients (20.2%) underwent at least one channel revision, most often due to obstruction (15, 13.2%) or incontinence (4, 3.5%). Of the channel revisions, 10 (8.8%) were major and 14 (12.3%) were minor. Eleven patients (9.6%) abandoned the catheterizable channel during the follow-up period. Obesity and laparoscopic/robotic surgical approach did not affect outcomes, though concomitant surgery was associated with a higher rate of follow-up surgeries. CONCLUSIONS: In this contemporary multicenter series evaluating CCIC, we found that the short-term major complication rate was low, but many patients require follow-up surgeries, mostly related to the catheterizable channel

Understanding the Economic Impact of Neurogenic Lower Urinary Tract Dysfunction.

Neurogenic bladder is a chronic and disabling condition associated with multiple comorbidities and a widespread economic impact. Literature on cost of care and resource utilization is sparse and heterogeneous. Nonstandardized approaches, impact perspectives, and types of costs are used to describe the economic implications of neurogenic bladder. The financial toll is difficult to ascertain due to indirect and intangible costs exacerbated by the underlying disability. Health resource utilization based on clinical manifestations of neurogenic bladder may serve as an alternative measure. Understanding the multifold economic implications and health resource utilization patterns of neurogenic bladder may guide improvement of treatment strategies

Polydimethylsiloxane Erosion as a Cause for Recurrent Urinary Tract Infections

Background: Urethral bulking agents are commonly used for the management of stress urinary incontinence (SUI). Little long-term data exist for these agents, with few reports of migration or urethral erosion. Case Presentation: We describe a unique case of a woman who received a midurethral sling 3 years after receiving an injection of the urethral bulking agent, polydimethylsiloxane, because of persistent SUI. Her subsequent recurrent urinary tract infections led to the identification of a bladder neck erosion of the urethral bulking agent with a concomitant calcification. Conclusion: When irritative voiding symptoms are experienced in patients who have received urethral bulking agents, erosion must be considered. Furthermore, little is known regarding the definitive management of SUI in patients that have previously received an injection of a urethral bulking agent

Outcomes of Native Tissue Sacrospinous Ligament Fixation with Unilateral Deschamp Needle Suture Ligature

Introduction: The prevalence of pelvic organ prolapse (POP) is 3-6% based on symptoms and up to 50% when based on examination. Risk factors for POP include vaginal birth, obesity, smoking and fetal macrosomia. Randall and Nichols described sacrospinous ligament fixation (SSLF) in 1971 which was found to have a 63% success rate at 2-years by the OPTIMAL trial. This study describes our institutional outcomes of SSLF using the Deschamps needle passer. Methods: IRB approval was obtained for a retrospective chart review of patients who underwent unilateral SSLF using the Deschamp needle passer. Primary and secondary outcomes measured change in pelvic organ quantification stage and urinary symptom scores (AUASS, ISI, PFDI-20), respectively. Failure defined as occurrence of prolapse related reoperation. Our cohort consisted of patients who underwent SSLF using Deschamps, performed by a single surgeon from 2012-2017; excluding patients who underwent SSLF with another device. Paired t-test and Wilcoxin rank-sum test were used for normal distribution and non-normal distribution, respectively. P-value \u3c 0.05 was considered statistically significant. Results: Thirty-four patients met the inclusion criteria. Mean age of the population was 65.11 years (+/-8.8 years). Of the sample size, 62% White, 32% Black, 3% American Indian, 3% declined. The mean parity was 2.97 (+/-1.34). The median follow-up time was 10 months (-/+ 9 months). The median preoperative POP-Q stage was 3 (+/-0.52) and median postoperative POP-Q stage was 0 (+/-1.09) [p\u3c0.001]. Median preoperative AUASS score was 15 and median postoperative AUASS score was 10 [p\u3c0.001]. No patient required prolapse related reoperation. Analysis of the PFDI-20 revealed statistical improvement in the POPDI-6 [p = 0.006] with no difference in the CRAD-8 or the UDI-6 scores. Conclusion: Within short-term follow up, the Deschamps needle passer for SSLF was associated with a high success rate, improved prolapse related symptom scores and POP-Q stages. Although SSLF technique was not specifically described in the OPTIMAL trial, the Deschamps needle passer appears to have a high success rate. The Extended OPTIMAL trial concluded a surgical failure rate of 61.5% and 70.3% with USLF and SSLF at 5-years with no statistically significant improvement between symptom scores. Long term follow-up of this cohort will determine if similar outcomes are noted

Utilization of third line therapy in the urologic management of patients with multiple sclerosis

Introduction: Multiple sclerosis (MS) is a demyelinating neurologic condition affecting approximately 2 million people worldwide. Lower urinary tract symptoms (LUTS) affect up to 50%‐90% of MS patients. Urodynamic (UD) evaluation for these patients often shows evidence of Neurogenic Detrusor Overactivity (NDO). Treatment strategies include behavioral and physical therapy, oral medications, and third line therapies (intravesical botox, Interstim, PTNS). We sought to characterize MS patients with NDO, measure changes in urinary quality of life with treatment, and evaluate for any factors predictive of progression to third line therapies. Methods: Using a prospectively collected, routinely updated database of MS patients within a single neuro‐urologist practice between 2013‐2019, patient demographics, UD data, treatment variables, and pre‐ and posttreatment patient‐reported questionnaire responses were recorded. We present descriptive characteristics of the patients with NDO within this cohort. We grouped these patients into two groups: those who progress to third line therapy and those who remain on medical therapy. We evaluate for any differences in UD characteristics between these groups and compare the degree of change in symptom and quality of life scores. Urodynamic and quality of life data were compared using chi‐square and Wilcoxon rank sum statistics, respectively. Results: Our cohort of 182 patients with MS, averages 55 years of age, is 84% female and 45% Caucasian. Nearly 50% of these patients are diagnosed with relapsing remitting MS. Eighty percent of our patients underwent UD, with findings showing detrusor sphincter dyssynergia (DSD) in 24% and NDO in 45% (66 patients). Nearly 40% of patients with NDO progress to third line therapy with intravesical botox being the most common in our cohort (89%). As seen in the Table, there were no demographic or UD factors predictive of progressing to third line therapy. However, patients who undergo third line therapy show larger improvements in symptom score than those who do not. Conclusion: NDO is a common cause for LUTS in patients with MS. 40% of our MS patients with NDO progress to third line therapy with no UD factors predictive of progression. Symptom improvements are greater those patients who undergo third line therapies compared to those who remain on medical therapy

Best Approaches to Evaluation and Feedback in Post-Graduate Medical Education

PURPOSE OF REVIEW: The objectives of this literature review are to appraise current approaches and assess new technologies that have been utilized for evaluation and feedback of residents, with focus on surgical trainees. RECENT FINDINGS: In 1999, the Accreditation Council for Graduate Medical Education introduced the Milestone system as a tool for summative evaluation. The organization allows individual program autonomy on how evaluation and feedback are performed. In the past, questionnaire evaluations and informal verbal feedback were employed. However, with the advent of technology, they have taken a different shape in the form of crowdsourcing, mobile platforms, and simulation. Limited data is available on new methods but studies show promise citing low cost and positive impact on resident education. No one best approach exists for evaluation and feedback. However, it is apparent that a multimodal approach that is based on the ACGME Milestones can be effective and aid in guiding programs