Significant Management Variability of Urethral stricture Disease in United States: Data from the AUA Quality (AQUA) Registry

International Expert Consensus on Development of a State of the Art Male Perineal Anatomy Simulation Model for Urethroplasty and Artificial Urinary Sphincter Insertion

OBJECTIVE

To create a high-fidelity, non-biohazardous, simulation model to train for urethroplasty or placement of artificial urinary sphincters (AUS) in the bulbar urethra. Narrow, deep and dark: the male perineum is a technically difficult area for learners to gain surgical skills and confidence.

METHODS

Nineteen high volume reconstructive urologists were recruited to complete a Delphi process to reach an expert consensus on parameters and design specifications for simulation. Consensus (>80%) was reached regarding procedural realism, anatomical realism, and educational effectiveness. Using validated 3D printing and hydrogel molding techniques, we fabricated a model incorporating expert determined aspects. Prototypes were sent to 11 (58%) of the experts who performed skin-to-skin AUS and urethroplasty simulations. Autopsy and questionnaires evaluated the model to determine if the consensus-defined deliverables were met, and confirm the realism of anatomy during the procedures.

RESULTS

Overall, experts agreed the model could function as a training tool for urethral surgery. 91%, 82%, and 100% agreed the model procedurally replicates the steps necessary to complete urethral exposure, tissue textures/behaviors, and overall anatomical relationships, respectively. Experts agreed on the fidelity of perineal incision/exposure (91%), urethral dissection/exposure (100%), placement of AUS pump (89%) urethral cuff measurement (100%) urethral spatulation (91%), and urethral mucosal suture placement (91%).

CONCLUSION

We successfully designed a high-fidelity, non-biohazardous, simulation model for urethral procedures in the perineum utilizing expert consensus. The model displayed high procedural and anatomical realism, and has potential as an effective educational platform. This as a groundbreaking tool to enhance training in complex urethral surgeries, bridging the gap between theory and practice.

Retrospective analysis of urethral anastomosis with ancillary maneuvers and intraoperative biaxial defect measurements to achieve a tension free guidance system for redo PFUDD treatment

OBJECTIVES

Redo surgery for pelvic fracture urethral distraction defects (PFUDDs) is still a challenge. the long urethral defect makes it difficult while the high tension increase the recurrence rate. Although certain ancillary maneuvers can relieve tension, there is no consensus or guidelines for the prediction/planning of the selection. In this study, we present our experience with developing an intraoperative guidance system to achieve tension-free urethral anastomosis.

PATIENTS AND METHODS

A total of 91 recurrent PFUDD patients managed at our center between 2020 and 2022 were retrospectively analyzed. The patients underwent scar removing and urethral anastomosis. For the long defect and high-tension cases, 6 kinds of tension-relieving maneuvers were used respectively during the process of urethral anastomosis. Preoperative assessment of the urethrogram was done before surgery, while biaxial (vertical and horizontal) defect measurements were performed intraoperatively. The patients were followed-up for 12 months (8.9 ± 4.2), furthermore, recurrence and complications were analyzed.

RESULTS

The overall success rate was 86.81%. The mean defect in urethrogram was 2.9 ± 1.1 cm. 27 simple anastomosis was performed when the vertical plus horizontal defect was less than 2 cm with 11.11% recurrence. 24 cavernous septum splittings were performed when the horizontal defect was greater than 2 cm with 8.33% recurrence. 21 inferior pubectomies were performed when the horizontal defect was greater than 3 cm with 19.05% recurrence. 15 ancillary distal urethra manipulations (fully distal urethral mobilization, urethral suspension and corpus cavernosa folding) were performed when the vertical defect was 3 to 4 cm with 13.33 recurrence. 4 reroutings were performed when the vertical defect was greater than 4 cm with 25.00% recurrence.

CONCLUSIONS

Ancillary maneuvers are effective for reducing tension in redo urethral anastomosis. Measurement of divergent vertical and horizontal urethral defects could guide the selection of ancillary maneuvers. Combined tension-relieving maneuvers is recommended according to the defect direction and length to achieve a tension-free anastomosis.

Insights from the AQUA Registry: a retrospective study of anticholinergic polypharmacy in the United States

Background

Anticholinergic (ACH) burden is a risk factor for negative health outcomes among older adults. Several medications contribute to ACH burden, including antimuscarinics used to manage overactive bladder (OAB).

Objectives

This study aimed to understand the extent of ACH burden in an OAB population in the United States.

Design

Non-interventional retrospective analysis.

Methods

Adults with OAB whose care providers participated in the American Urological Association Quality (AQUA) Registry between 2014 and 2020 were included in this study. An adapted version of the Pharmacy Quality Alliance (PQA) measure of anticholinergic polypharmacy (poly-ACH) was used to assess ACH burden. The primary outcome was the annual prevalence of poly-ACH, and a secondary outcome was the percentage of patients taking 0, 1, 2, 3, 4, or ⩾ 5 ACH medications by calendar year. Analyses were stratified by age category at diagnosis and sex.

Results

The sample comprised 552,840 patients with OAB. The mean age at initial OAB diagnosis was 65.7 years (58.2% male; 57.4% white). Prevalence of poly-ACH was highest in 2015 (3.7%) and lowest in 2020 (1.9%). Patients prescribed no ACH medications made up the largest proportion of each cohort, while those prescribed five or more comprised the smallest. The trend of decreasing proportions of patients taking increasing numbers of ACH medications was consistent. The proportion of patients prescribed no ACH medications increased from 63.3% in 2014 to 74.6% in 2020. The percentage of those prescribed three or more ACHs remained largely unchanged. Poly-ACH was highest among younger individuals (< 65 years of age) and females; temporal trends were similar overall and within each age and sex stratum.

Conclusion

In this study, poly-ACH in patients with OAB was relatively infrequent and decreased over the study period. Further evaluation of poly-ACH is needed to assess whether the study findings reflect increased awareness of the negative effects of poly-ACH.

Evaluating Quality Improvement and Patient Safety Amongst Practicing Urologists: Analysis of the 2018 American Urological Association Census

OBJECTIVE

To describe factors associated with Quality improvement and patient safety (QIPS) participation using 2018 American Urological Association Census data. QIPS have become increasingly important in medicine. However, studies about QIPS in urology suggest low levels of participation, with little known about factors predicting non-participation.

METHODS

Results from 2339 census respondents were weighted to estimate 12,660 practicing urologists in the United States. Our primary outcome was participation in QIPS. Predictor variables included demographics, practice setting, rurality, fellowship training, QIPS domains in practice, years in practice, and non-clinical/clinical workload.

RESULTS

QIPS participants and non-participants significantly differed in distributions of age (P = .0299), gender (P = .0013), practice setting (P <.0001), employment (employee vs partner vs owner vs combination; P <.0001), and fellowship training (P <.0001). QIPS participants reported fewer years in practice (21.3 vs 25.9, P = .018) and higher clinical (45.2 vs 39.2, P = .022) and non-clinical (8.76 vs 5.28, P = .002) work hours per week. Non-participation was associated with male gender (OR = 2.68, 95% CI 1.03-6.95) and Asian race (OR = 2.59, 95% CI 1.27-5.29) for quality programs and private practice settings (ORs = 8.72-27.8) for patient safety initiatives.

CONCLUSION

QIPS was associated with academic settings. Interventions to increase rates of quality and safety participation should target individual and system-level factors, respectively. Future work should discern barriers to QIPS engagement and its clinical benefits.

A 25-year perspective on advances in the study of the epidemiology, disparities, and outcomes of urologic cancers

In this narrative review, key developments in epidemiologic and clinical outcomes-based research from eminent historical data sources over the past quarter century are summarized. We then describe the rise of secondary and administrative datasets (AD), summarizing the predominant types of available secondary datasets for contemporary research and describe the benefits and inherent limitations in working with secondary data. We review the methodological advances that permit researchers to capitalize on the full capability of secondary data while also addressing the limitations inherent in utilizing these data for the purposes of epidemiologic and outcomes research. Finally, we present candidate strategies to perpetuate this momentum towards optimizing the development of clinical research infrastructure that harnesses the full potential of the ADs to further clinical and epidemiological research, advancing data analysis, and address the many unanswered questions that remain.