Outcomes and Complication Rates of Cuff Downsizing in the Treatment of Worsening or Persistent Incontinence After Artificial Urinary Sphincter Implantation

Purpose This study investigated the functional outcomes and complication rates of cuff downsizing for the treatment of recurrent or persistent stress urinary incontinence (SUI) in men after the implantation of an artificial urinary sphincter (AUS). Methods Data from our institutional AUS database spanning the period from 2009 to 2020 were retrospectively analyzed. The number of pads per day was determined, a standardized quality of life (QoL) questionnaire and the International Consultation on Incontinence Questionnaire (ICIQ) were administered, and postoperative complications according to the Clavien-Dindo classification were analyzed. Results Out of 477 patients who received AUS implantation during the study period, 25 (5.2%) underwent cuff downsizing (median age, 77 years; interquartile range [IQR], 74–81 years; median follow-up, 4.4 years; IQR, 3–6.9 years). Before downsizing, SUI was very severe (ICIQ score 19–21) or severe (ICQ score 13–18) in 80% of patients, moderate (ICIQ score 6–12) in 12%, and slight (ICIQ score 1–5) in 8%. After downsizing, 52% showed an improvement of >5 out of 21 points. However, 28% still had very severe or severe SUI, 48% had moderate SUI, and 20% had slight SUI. One patient no longer had SUI. In 52% of patients, the use of pads per day was reduced by ≥50%. QoL improved by >2 out of 6 points in 56% of patients. Complications (infections/urethral erosions) requiring device explantation occurred in 36% of patients, with a median time to event of 14.5 months. Conclusions Although cuff downsizing carries a risk of AUS explantation, it can be a valuable treatment option for selected patients with persistent or recurrent SUI after AUS implantation. Over half of patients experienced improvements in symptoms, satisfaction, ICIQ scores, and pad use. It is important to inform patients about the potential risks and benefits of AUS to manage their expectations and assess individual risks

Online tools for patient counseling in bladder and kidney cancer—ready for prime time?

Gauging prognosis is a key element when facing treatment decisions in cancer care. Several prognostic tools, such as risk tables and nomograms are at hand to aid this process. In the context of patient-centered care, prognostic tools are of great interest to caregivers and -providers alike, as they can convey sizeable amounts of information and provide tailored, accurate estimates of prognosis. Given the rising number of prognostic tools in cancer care over the last two decades, and similarly, ever increasing presence of the Internet, we aimed to assess how this would translate into the availability of online tools for patient counseling. We used a modified systematic review to evaluate the web-based availability, format, and content of prognostic tools for bladder and kidney cancer care. Our search identified a total of twenty-three tools, offered by eight providers, which assessed a total of six (bladder cancer) and five (kidney cancer) different outcomes. Despite the restricted availability of online tools, we observed that the majority showed limited user-friendliness (including, for example, a statement/explanation of intended use, visualization of data, availability as application software for handheld devices). Only one tool included modifiable risk factors such as smoking behavior and body weight. Lastly, none of the tools incorporated genomic or molecular markers or treatment associated quality of life. Taken together, online tools for patient counseling in bladder and kidney cancer care are only beginning to align with the growing need in clinical reality. Further and future avenues include incorporation of health-related quality of life as well as genomic and biomarkers into prediction tools

Adult iatrogenic ureteral injury and stricture–incidence and treatment strategies

Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment. Left untreated they are associated with severe short- and long-term complications such as urinoma, septic state, renal failure, and loss of a renal unit. Treatment depends on timing of diagnosis, as well as extent of injury, and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts. While recent advances in ureteral tissue engineering are promising the topic is still underreported. Historically a domain of open surgery, laparoscopic and robotic-assisted approaches have proven their feasibility in small case series, and are increasingly being utilized as means of reconstructive surgery. This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances

Regression Discontinuity Analysis of Salvage Radiotherapy in Prostate Cancer.

There is a lack of randomized evidence comparing early (eSRT) to late (lSRT) salvage radiotherapy (SRT) after radical prostatectomy (RP) for prostate cancer (PCa). Moreover, the existing evidence is often affected by lead-time bias. We sought to address this gap in a cohort of 1458 PCa patients undergoing SRT for biochemical recurrence (BCR) after RP in two tertiary care centers between 1992 and 2013. Using a quasi-randomized study design known as regression discontinuity (RD) and adjusting for lead-time bias, we compared metastasis-free survival (MFS) at 5 and 10years after surgery between eSRT (prostate-specific antigen [PSA] \u3c0.5ng/ml) and lSRT (PSA\u3e/=0.5ng/ml). Overall, 1049 patients (71.9%) underwent eSRT and 409 (28.1%) lSRT at a mean follow-up of 84 mo (interquartile range (IQR) 52-120.4). The MFS rate decreased nonsignificantly at the proposed cutoff by 0.04 (95% confidence interval [CI]: -0.06 to 0.19) at 5years and by 0.07 (95% CI:-0.12 to 0.32) at 10years. Cox regression analysis revealed a hazard ratio for the cutoff examined of 1.3 (95% CI: 0.8-2.4; p=0.2). In conclusion, in a quasirandomized study design accounting for lead-time bias, eSRT (PSA\u3c0.5ng/ml) did not improve MFS. Our results underline the need for level-one evidence to compare eSRT and lSRT. PATIENT SUMMARY: We compared early versus late salvage radiotherapy (SRT) for biochemical recurrence after radical prostatectomy by simulating a randomized trial. We found that early SRT (initiated at prostate-specific antigen \u3c0.5ng/ml) compared to late SRT did not improve metastasis-free survival

Rate and Extent of Pelvic Lymph Node Dissection in the US Prostate Cancer Patients Treated With Radical Prostatectomy.

PURPOSE: To evaluate the utilization of pelvic lymph node dissection (PLND) and its extent in contemporary US patients, and to correlate it to the detection of pN1 disease. PATIENTS AND METHODS: A total of 328,710 individuals who received radical prostatectomy between the years 2004 and 2013 were identified within the National Cancer Data Base. The Cochran-Armitage test was used to assess the statistical significance of temporal trends. Logistic regression analysis tested the relationship between the number of lymph nodes removed (LNR) and pN1 rate. RESULTS: Most patients had T2 disease (76.7%) and a Gleason score of 7 (55.9%). Overall, 63.5% of the patients received PLND; this ranged between 58.9% and 72.1% over the study period (P = .8). In patients receiving PLND, mean LNR increased from 6.1 nodes in 2004 to 7.2 nodes in 2013 (P \u3c .001). When stratified by tumor risk, utilization and extent of PLND increased in intermediate- and high-risk tumors, while it decreased in low-risk tumors. Overall pN1 rate was 3.73%, and it increased from 2.9% to 5.3% between 2004 and 2013 (P \u3c .001). In multivariable analysis, LNR was an independent predictor of pN1 (P \u3c .001). CONCLUSION: The utilization patterns of PLND in the United States have improved, with an increased focus on patients with intermediate- and high-risk disease. Likewise, the extent of PLND has improved to include more lymph nodes. This seems to translate into more accurate tumor, node, metastasis classification system staging, as more patients are being appropriately diagnosed with pN1 disease

Exploring the intersection of functional recurrence, patient-reported sexual function, and treatment satisfaction after anterior buccal mucosal graft urethroplasty

Purpose!#!To evaluate the interplay of stricture recurrence, sexual function, and treatment satisfaction after substitution urethroplasty.!##!Methods!#!Observational study of men undergoing 1-stage buccal mucosal graft urethroplasty for anterior urethral stricture between 2009 and 2016. Patients were dichotomized by self-reported treatment satisfaction. Sexual function was assessed by validated and non-validated patient-reported outcome measures. Functional recurrence was defined as symptomatic need of re-intervention. Bivariate analyses, Kaplan-Meier estimates, qualitative and quantitative analyses by uni- and multivariable regression were employed to evaluate the interplay of sexual function, functional recurrence, and treatment satisfaction.!##!Results!#!Of 534 men with bulbar (82%), penobulbar (11%), and penile strictures (7.3%), 451 (84%) were satisfied with the surgery. There were no differences in stricture location, previous treatment, graft length, or surgical technique between satisfied and unsatisfied patients (all p  ≥  0.2). Recurrence-free survival was 85% at a median follow-up of 33 mo and decreased significantly with each Likert item towards increasing dissatisfaction (p  <  0.001). Dissatisfied patients more often reported postoperative loss of rigidity, tumescence, reduced ejaculatory volume, ejaculatory pain, and reduced penile length (all p  ≤  0.042). In 83 dissatisfied men, functional recurrence (28%) and oral morbidity (20%) were the main drivers of dissatisfaction in qualitative analysis. Multivariable analyses revealed functional recurrence and impaired postoperative ejaculatory function as independent predictors of treatment dissatisfaction (all p  ≤  0.029) after adjusting for confounders.!##!Conclusion!#!We found an association of both functional success and sexual function with patient-reported treatment satisfaction after substitution urethroplasty. Such findings validate the clinical significance of defining the symptomatic need for re-intervention as an endpoint and underline the importance of further research evaluating sexual function before and after open urethral reconstruction

Multilevel analysis of readmissions after radical cystectomy for bladder cancer in the USA: Does the hospital make a difference?

Background: Hospitals are increasingly being held responsible for their readmissions rates. The contribution of hospital versus patient factors (eg, case mix) to hospital readmissions is unknown.Objective: To estimate the relative contribution of hospital and patient factors to readmissions after radical cystectomy (RC) for bladder cancer.Design, setting, and participants: We identified individuals who underwent RC in 2014 in the Nationwide Readmissions Database (NRD). The NRD is a nationally representative (USA), all-payer database that includes readmissions at index and nonindex hospitals. Survey weights were used to generate national estimates.Outcome measurements and statistical analysis: The main outcome was readmission within 30 d after RC. Using a multilevel mixed-effects model, we estimated the statistical association between patient and hospital characteristics and readmission. A hospital-level random-effects term was used to estimate hospital-level readmission rates while holding patient characteristics constant.Results and limitations: We identified a weighted sample of 7095 individuals who underwent RC at 341 hospitals in the USA. The 30-d readmission rate was 29.5% (95% confidence interval [CI] 27.8-31.2%), ranging from 1.4% (95% CI 0.6-2.2%) in the bottom quartile to 73.6% (95% CI 68.4-78.7) in the top. In our multilevel model, female sex and comorbidity score were associated with a higher likelihood of readmission. The hospital random-effects term, encompassing both measured and unmeasured hospital characteristics, contributed minimally to the model for readmission when patient characteristics were held constant at population mean values (pseudo-R2\u3c0.01% for hospital effects). Surgical volume, bed size, hospital ownership, and academic status were not significantly associated with readmission rates when these terms were added to the model.Conclusions: After adjusting for patient characteristics, hospital-level effects explained little of the large between-hospital variability in readmission rates. These findings underscore the limitations of using 30-d post-discharge readmissions as a hospital quality metric.Patient summary: The chance of being readmitted after radical cystectomy varies substantially between hospitals. Little of this variability can be explained by hospital-level characteristics, while far more can be explained by patient characteristics and random variability

Racial disparity in quality of care and overall survival among black vs. white patients with muscle-invasive bladder cancer treated with radical cystectomy: A national cancer database analysis.

OBJECTIVES: To examine the impact of race on quality of care and overall survival (OS) among patients with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) in the U.S. MATERIALS & METHODS: Our cohort consisted of 12,652 patients receiving RC for MIBC within the National Cancer Database from 2004 to 2012. Patients were stratified by race (Black non-Hispanic vs. White non-Hispanic) and imbalances in patient characteristics mitigated using propensity score weighting. Logistic and Cox regressions examined the impact of race on quality of care metrics (receipt of pelvic lymph node dissection (PLND), lymph node count, hospital volume, length of stay, delay of treatment) and on OS. The difference in OS was expressed as Delta, and stratified by facility-type, hospital volume, and region. RESULTS: Blacks were less likely to receive PLND (odds ratio [OR] 0.70, 95% confidence interval [CI]: 0.55-0.91), or to have a greater number of lymph nodes removed (OR 0.76, 95%CI: 0.64-0.90). They exhibited greater length of stay (OR 1.34, 95%CI: 1.13-1.59), and delay of RC among recipients of neoadjuvant chemotherapy (OR 2.59, 95%CI: 1.77-3.85) (all P ≤ 0.001). Notably, utilization of neoadjuvant chemotherapy in advanced disease stages was more common in blacks (OR 2.82, 95%CI: 1.93-4.13, P \u3c 0.001). Additionally, Black race was associated with inferior OS (Hazard ratio 0.87, 95%CI: 0.79-0.97, P \u3c 0.014). Disparities in OS varied based on facility type and geographical region, but not hospital volume. Specifically, Blacks had worse OS when treated in a community cancer program (Delta 0.42, 95%CI: 0.28-0.57,P \u3c 0.001), or within New England/Middle Atlantic region (Delta 0.16, 95% CI: 0.07-0.24,P \u3c 0.001). CONCLUSION: Black race is an independent predictor of inferior quality of care and OS in patients undergoing RC for MIBC. Survival disparities vary based on geographical region and facility type. Notably, the OS disparity appears to have narrowed in comparison to previous studies