Fragility of overactive bladder medication clinical trials: A systematic review

PURPOSE

Overactive bladder (OAB) syndrome significantly impairs quality of life, often necessitating pharmacological interventions with associated risks. The fragility of OAB trial outcomes, as measured by the fragility index (FI: smallest number of event changes to reverse statistical significance) and quotient (FQ: FI divided by total sample size expressed as a percentage), is critical yet unstudied.

MATERIALS AND METHODS

We conducted a systematic search for randomized controlled trials on OAB medications published between January 2000 and August 2023. Inclusion criteria were trials with two parallel arms reporting binary outcomes related to OAB medications. We extracted trial details, outcomes, and statistical tests employed. We calculated FI and FQ, analyzing associations with trial characteristics through linear regression.

RESULTS

We included 57 trials with a median sample size of 211 participants and a 12% median lost to follow-up. Most studies investigated anticholinergics (37/57, 65%). The median FI/FQ was 5/3.5%. Larger trials were less fragile (median FI 8; FQ 1.0%) compared to medium (FI: 4; FQ 2.5%) and small trials (FI: 4; FQ 8.3%). Double-blinded studies exhibited higher FQs (median 2.9%) than unblinded trials (6.7%). Primary and secondary outcomes had higher FIs (median 5 and 6, respectively) than adverse events (FI: 4). Each increase in 10 participants was associated with a +0.19 increase in FI (p < 0.001).

CONCLUSIONS

A change in outcome for a median of five participants, or 3.5% of the total sample size, could reverse the direction of statistical significance in OAB trials. Studies with larger sample sizes and efficacy outcomes from blinded trials were less fragile.

Conservative Management of Penile and Urethral Lichen Sclerosus: A Systematic Review

PURPOSE

We evaluate the efficacy and safety profiles of currently available conservative management options for penile and urethral lichen sclerosus.

MATERIALS AND METHODS

A systematic review of existing literature on lichen sclerosus was conducted utilizing the PubMed, Embase, and Web of Science databases. References were assessed for relevance to nonsurgical management of male genital lichen sclerosus by title and abstract by 3 independent reviewers, then reviewed in full and in duplicate by 5 independent reviewers.

RESULTS

Seventeen studies describing conservative management of histologically confirmed penile and urethral lichen sclerosus in male patients were included in the final review. We present available evidence supporting the use of 4 major treatment modalities represented in the existing literature: topical corticosteroids, tacrolimus, platelet-rich plasma, and CO2 laser. We also briefly discuss the limited studies on the use of oral acitretin and polydeoxyribonucleotide injections. Outcomes assessed include symptoms, clinical appearance, quality of life, sexual satisfaction, adverse effects, and long-term efficacy of treatment.

CONCLUSIONS

Topical corticosteroids remain the mainstay of conservative management of penile and urethral lichen sclerosus, with current literature supporting the use of other therapies such as tacrolimus and platelet-rich plasma as alternatives or adjuvant treatments when escalation of treatment is necessary. Future research should further explore the efficacy and safety of newer therapies through additional controlled clinical trials in the targeted population.

Reimagining Ambulatory Care in Urology: Conversion of the Urology Clinic into a Procedure Center Improves Patient's Experience

Introduction: The coronavirus disease 2019 (COVID-19) pandemic made it necessary to practice social distancing and limited in-person encounters in health care. These restrictions created alternative opportunities to enhance patient access to care in the ambulatory setting. We hypothesized that by transforming clinics into centers that prioritize procedures and transitioning ambulatory appointments to telehealth, we could establish a secure, streamlined, and productive method for providing patient care. Methods: Clinic templates were restructured to allow the use of the physical space to perform procedure-based clinics exclusively, while switching to virtual telemedicine for all nonprocedural encounters. Staff members were given specific roles to support one of the patient care modalities for a given day (Procedures vs. Telehealth). Performance and patient satisfaction metrics were collected between two periods of time defined as P1 (February-June 2019) and P2 Post-COVID (February-June 2020) and compared. These served as proxies of periods when the clinic workflow and templates were structured in the traditional versus the emerging way. Statistical analysis was performed using bivariate analyses. Results: The percentage of procedures performed among all in-person visits were higher in P2 compared to P1 (45% vs. 29%, p < 0.001). Although total charges and relative value units were lower in P2, the overall revenue generated was higher compared to P1 ($4,597,846 vs. $4,517,427$, respectively). This increase in revenue was mainly driven by the higher relative income generated by procedures. Patient experience, reflected through patient-reported outcomes, was more favorable in P2 where patients seemed more likely to "Recommend this provider office" (90% vs. 85.7%, p = 0.01), report improved "Access overall" (56% vs. 49%, p = 0.02), and felt they were "Moving through your visit overall" (59% vs. 51%, p = 0.007). Conclusions: Our data suggest that reorganizing urology clinics into a space that is centered around outpatient procedures can represent a model that improves the patient's access to care and clinical experience, while simultaneously improving operational financial strength. This efficient care model could be considered for many practice settings and drive high-value outpatient care.

Electric Bicycle Injuries and Hospitalizations

This cross-sectional study investigates injury trends associated with electric bicycles in the US from 2017 to 2022.

Real-World Complications of the SpaceOAR Hydrogel Spacer: A Review of the Manufacturer and User Facility Device Experience Database

OBJECTIVE

To characterize adverse events related to use of the perirectal spacing agent SpaceOAR, we examined the Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

The MAUDE database was queried for "SpaceOAR" and "Augmenix" from June 2015 (when SpaceOAR was approved by the Food and Drug Administration) to October 2022. Reports were reviewed for adverse events (AEs), operative procedures performed because of the AE, and changes to the radiation plan. AEs were categorized using Common Terminology Criteria for Adverse Events (CTCAE), version 5.0.

RESULTS

Six hundred fifty-four reports were reviewed. Eighty-four were excluded and 4 reports reviewed 2 separate cases of SpaceOAR administration. Five hundred seventy-four cases were ultimately included. Three deaths were reported (0.5% of all AEs). One point six percent of cases represented CTCAE grade 4 injuries (life-threatening consequences; urgent intervention indicated), 15.9% grade 3 (severe but not immediately life-threatening; hospitalization), 24.2% grade 2 (moderate; local/noninvasive intervention), and 57% of events were CTCAE grade 1 (mild; asymptomatic or mild symptoms). Bowel diversion occurred in 29 cases (9%).

CONCLUSION

Both asymptomatic (n = 311) and debilitating (n = 12) complications of SpaceOAR hydrogel use were identified. Death, gel embolization, anaphylaxis, rectal ulcerations, and infections requiring bowel or urinary diversions were among the complications reviewed. Providers should consider these potential complications before perirectal spacer administration and during patient counseling.

Oral phosphodiesterase type 5 inhibitors and priapism: A VigiBase analysis

PURPOSE

To explore the differences of priapism events among a diverse cohort taking erectogenic medicines (i.e., phosphodiesterase type 5 inhibitors [PDE5i] and intracavernousal drugs).

METHODS

We queried the World Health Organization global database of individual case safety reports (VigiBase) for records of the adverse drug reactions (ADR) with sildenafil, tadalafil, avanafil, vardenafil, papaverine, and alprostadil. Disproportionality analyses (case/non-case approach) were performed to assess the reporting odds ratio (ROR) of priapism reporting in PDE5i consumers compared to intracavernousal drug recipients.

RESULTS

From a total of 133 819 ADR events for erectogenic medications, 632 were priapism (PDE5is: n = 550, 0.41%; intracavernousal drugs: n = 82, 9.92%). Priapism disproportionality signals from intracavernousal drugs were 25 times stronger than PDE5is (ROR = 34.7; confidence interval [CI] 95%: 27.12-43.94 vs. ROR = 1.38; 95% CI: 1.24-1.54). For all PDE5i agents, the 12-17 years age group had the highest ROR (9.49, 95% CI: 3.76-19.93) followed by 2-11 years (4.31, 95% CI: 1.57-9.4). Disproportionality signals for consumers under 18 for both all PDE5is as a whole (ROR = 4.57, 95% CI: 2.48-7.73) and sildenafil (ROR = 4.89, 95% CI: 2.51-8.62) were stronger than individuals 18 or older (ROR = 1.06, 95% CI: 0.93-1.21 and ROR = 1.08, 95% CI: 0.91-1.26, respectively).

CONCLUSIONS

PDE5i use shows disproportionate priapism signals which are higher in young patients.

Haemorrhagic cystitis: a review of management strategies and emerging treatments

Haemorrhagic cystitis (HC) is characterised by persistent haematuria and lower urinary tract symptoms following radiotherapy or chemotherapy. Its pathogenesis is poorly understood but thought to be related to acrolein toxicity following chemotherapy or fibrosis/vascular remodelling after radiotherapy. There is no standard of care for patients with HC, although existing strategies including fulguration, hyperbaric oxygen therapy, botulinum toxin A, and other intravesical therapies have demonstrated short-term efficacy in cohort studies. Novel agents including liposomal tacrolimus are promising targets for further research. This review summarises the incidence and pathogenesis of HC as well as current evidence supporting its different management strategies.

Adverse reactions of PDE5 inhibitors: An analysis of the World Health Organization pharmacovigilance database

BACKGROUND

Despite their efficacy and general safety, rare but devastating adverse drug reactions have been associated with phosphodiesterase type 5 inhibitors.

OBJECTIVES

To determine the safety profile of oral phosphodiesterase type 5 inhibitors with a particular focus on priapism and malignant melanoma.

MATERIALS AND METHODS

In this case-non-case study, we queried the individual case safety reports for phosphodiesterase type 5 inhibitors within the World Health Organization global database of individual case safety reports (VigiBase) between 1983 and 2021. We included all individual case safety reports for sildenafil, tadalafil, vardenafil, and avanafil in men. For comparison, we also extracted the safety data from the Food and Drug Administration trials for these drugs. We assessed the safety profile of phosphodiesterase type 5 inhibitors by disproportionality analysis by measuring reporting odds ratio for their most commonly reported adverse drug reactions, once for all phosphodiesterase type 5 inhibitor reports and once for reports of oral phosphodiesterase type 5 inhibitor use in adult men (≥18 years old) with sexual dysfunction.

RESULTS

A total of 94,713 individual case safety reports for phosphodiesterase type 5 inhibitors were extracted. A total of 31,827 individual case safety reports were identified relating to adult men taking oral sildenafil, tadalafil, vardenafil, or avanafil for sexual dysfunction. The most common adverse drug reactions included poor drug efficacy (42.5%), headache (10.4% vs. 8.5%-27.6% [Food and Drug Administration]), abnormal vision (8.4% vs. ≤4.6% [Food and Drug Administration]), flushing (5.2% vs. 5.1%-16.5% [Food and Drug Administration]), and dyspepsia (4.2% vs. 3.4%-11.1% [Food and Drug Administration]). Priapism showed significant signals for sildenafil (reporting odds ratio = 13.81, 95% confidence interval: 11.75-16.24), tadalafil (reporting odds ratio = 14.54, 95% confidence interval: 11.56-18.06), and vardenafil (reporting odds ratio = 14.12, 95% confidence interval: 8.36-22.35). Comparing with other medications in VigiBase, sildenafil (reporting odds ratio = 8.73, 95% confidence interval: 7.63-9.99) and tadalafil (reporting odds ratio = 4.25, 95% confidence interval: 3.19-5.55) had significantly higher reporting odds ratios for malignant melanoma.

CONCLUSION

Phosphodiesterase type 5 inhibitors show significant signals correlating with priapism among a large international cohort. Further clinical study is needed to elucidate whether this is from proper or inappropriate use or other confounding conditions, as analysis of pharmacovigilance data does not allow for quantifying the clinical risk. Also, there appears to be a relationship between phosphodiesterase type 5 inhibitor use and malignant melanoma, which warrants additional study to better understand causation.

Urethral Slings for Irradiated Patients With Male Stress Urinary Incontinence: A Meta-analysis

OBJECTIVE

To systematically compare success, cure and complication rates of urethral sling surgeries in stress urinary incontinence patients with and without a history of pelvic radiotherapy (RT).

MATERIALS AND METHODS

We searched PUBMED, EMBASE, and Web of Science to identify relevant articles. The primary outcomes were the success and cure rates. The secondary outcomes included the rates of infection, urethral erosion, total complications, explantation, and satisfaction. Outcomes were analyzed using a random-effects model to calculate the unadjusted odds ratio (OR) in patients with a history of RT compared with those without prior RT.

RESULTS

On pooled analysis, we found significantly lower odds of success (OR 0.68; 95% confidence interval [CI] 0.53-0.87, P < .001) and cure (OR 0.67; 95% CI 0.55-0.82, P < .001) in radiated patients than in nonirradiated patients. Subgroup analysis by type of sling showed significantly lower odds of success in Advance subgroup (OR 0.66; 95% CI 0.45-0.95, P < .001) and significantly lower odds of cure in Advance (OR 0.59; 95% CI 0.36-0.95, P < .001) and Atoms subgroups (OR 0.70; 95% CI 0.54-0.93, P < .001). We also found significantly greater odds of sling explantation (OR 2.93; 95% CI 1.62-5.29, P < .001) and infection (OR 3.06, 95% CI 1.03-9.07, P < .001) in radiated patients than in nonradiated patients.

CONCLUSION

Patients with a history of pelvic RT have lower odds of success and cure and higher odds of infection and sling explantation than those without a history of pelvic RT.

The Effect of Bike Seat Models on Perineal Pressure During Cycling: Implications for Patients After Lower Genitourinary Reconstructive Surgery

OBJECTIVE

To understand the effect of bicycle saddle shape and size on the pressure transmitted to the perineum, as prolonged perineal pressure and microtrauma amongst avid cyclists may increase the risk for complications following lower genitourinary surgery.

METHODS

We tested five seats (Bontrager, Waterloo, WI) with varying levels of padding and morphology (comfort, fitness, fitness gel, race, and performance) for two different riders. The seats were installed on a Peloton stationary exercise bike (New York City, NY). Force measurements were performed using a 9833E-50 Large F-Socket Sensor (Tekscan, South Boston, MA). We measured total and perineal forces in three conditions at the same resistance: (a) at rest (not pedaling); (b) at 8mph; (c) at 15mph.

RESULTS

Significant differences across the bicycle seats were observed with fitness gel seats providing the lowest perineal pressure. In all measurements, perineal forces were significantly lower at 15mph compared to 8mph (P < .001). When a rider used an oversized seat, less force was exerted compared to the appropriate size at both 8mph (P < .001) and 15mph (P < .001) speeds. Conversely, an undersized seat significantly increased perineal pressures at both 8mph (P = .018) and 15mph (P = .007).

CONCLUSION

Larger seats constructed of more impressionable materials absorb a greater total force and act to distribute the subject's weight thereby delivering less force to the perineum. More perineal pressure is delivered at lower speeds and at rest likely due to the cyclist lifting off the seat during times of strenuous activity.

Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study

PURPOSE

To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management.

METHODS

We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery).

RESULTS

Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found.

CONCLUSION

Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

Radiation-induced Fistulas in Patients With Prior Pelvic Radiotherapy for Prostate Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically aggregate and summarize existing data on fistula prevalence among patients with a history of pelvic radiotherapy for prostate cancer.

MATERIALS AND METHODS

We queried PubMed, Embase, and Web of Science on October 7, 2020 for peer-reviewed publications pertaining to radiation-induced fistulas in the pelvis. For meta-analysis, we used the random-effects model. We used the I2 statistic to quantify heterogeneity and the Newcastle-Ottawa Scale to assess risk of bias.

RESULTS

Our final meta-analysis included 6 cohort studies with a total of 7665 patients exposed to pelvic radiotherapy between 1967 and 2013. Median follow-up time was 35.5 months (IQR 33.5-57.5). Pooled prevalence of radiation-induced fistula across all 6 cohort studies was 0.2% (95% CI: 0.1-0.4, I2 = 0.000%, P < .608). In subgroup analysis, we did not detect significant heterogeneity in fistula prevalence in patients who were re-irradiated (0.3%, 95% CI: 0.1-0.4; P = .762) or patients on concurrent chemotherapy (0.4%, 95% CI: -0.3 -1.2; P = .664) compared to those receiving their first course of radiotherapy alone. No randomized controlled trials met inclusion criteria due to ambiguous and inconsistent reporting language for fistula occurrence.

CONCLUSION

There is limited published literature reporting fistula as an adverse event of prostate cancer radiotherapy, especially in the medium and long-term period. Patients undergoing pelvic radiotherapy for prostate cancer appear at low short-term risk for developing fistulas. Adverse event reporting in randomized controlled trials merits greater granularity where fistulas should be reported with specificity rather than aggregating into broad categories of genitourinary or gastrointestinal adverse events.

Clinical and postoperative characteristics of stentless ureteroscopy patients: a prospective analysis from ReSKU

INTRODUCTION

To evaluate the clinical characteristics as well as the postoperative course of urolithiasis patients undergoing a ureteroscopy (URS) without stent placement.

MATERIALS AND METHODS

This was a prospective case cohort study utilizing data collected in the Registry for Stones of the Kidney and Ureter (ReSKU) from a single institution between October 2015 and December 2020. We identified all consecutive patients undergoing URS for stone disease and analyzed data encompassing demographics, medical history, intra and postoperative characteristics, including complications and postoperative symptoms. Univariate and multivariate logistic regression analyses were performed based on the presence or absence of an indwelling ureteral stent.

RESULTS

A total of 470 patients were included for analysis, 92 patients in the stentless group (19.5%). Factors associated with stentless ureteroscopy were a lower stone burden (p < 0.001), the pre-existence of a ureteral stent (37.4% vs. 27.9% p = 0.011), absence of an access sheath (14.6% vs. 69.5% p < 0.001), and a shorter operative time (31 vs. 58 min p < 0.001). Postoperative gross hematuria and lower urinary tract symptoms (LUTS) were reported less frequently in stentless patients (p = 0.02, p = 0.01, respectively). There was no difference in postoperative complications between both groups (15.2% vs. 12.0%, p = 0.385). On multivariate analysis, the risk of postoperative complications was associated with obesity, stone burden ≥ 1 cm, and positive preoperative urine culture. There was no patient who required emergent stent placement in the stentless group.

CONCLUSION

Our data show that, in well selected patients, omitting ureteral stent placement after URS can decrease postoperative gross hematuria and LUTS without increasing postoperative complications.

Ultrasound-Only Percutaneous Nephrolithotomy Is Safe and Effective Compared to Fluoroscopy-Directed Percutaneous Nephrolithotomy

Introduction: Outcomes after ultrasound-only percutaneous nephrolithotomy (PCNL), in which no fluoroscopy is used, are not well known. The goal of this study was to compare outcomes of ultrasound-only and fluoroscopy-directed PCNL. Materials and Methods: Prospectively collected data from the Registry for Stones of the Kidney and Ureter database were reviewed for all patients who underwent PCNL at one academic center from 2015 to 2021. Primary outcomes were complications and stone-free rates (no residual fragments ≥3 mm). Results: Of the 141 patients who underwent ultrasound-only PCNL and 147 who underwent fluoroscopy-directed PCNL, there was no difference in complication rates (15% vs 16%, p = 0.87) or stone-free status (71% vs 65%, p = 0.72), respectively. After adjusting for body mass index, American Society of Anesthesiologists (ASA), stone size, and stone complexity by Guy score, ultrasound-only PCNL was not associated with any increased odds of complications (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.3-1.6, p = 0.41) or residual stone fragments ≥3 mm (OR 1.0, 95% CI 0.5-1.9, p = 0.972) compared with fluoroscopy-directed PCNL. Ultrasound-only PCNL was associated with shorter operative time (median 99.5 vs 126 minutes, p < 0.001), and the use of ultrasound remained a significant predictor of short operative time (<100 minutes) after controlling for supine positioning, stone size, and stone complexity by Guy score (OR 2.31, 95% CI 1.01-5.29, p = 0.048). Patients in the ultrasound-only group were spared a mean radiation exposure dose of 10 mGy per procedure. Conclusions: Ultrasound-only PCNL is safe and achieves similar stone-free rates compared with fluoroscopy-directed PCNL with the added benefit of avoidance of radiation.

Comparative analysis of partial versus radical nephrectomy for renal cell carcinoma: Is oncologic safety compromised during nephron sparing in higher stage disease?

Objectives

Over the past 20 years, the utility of partial nephrectomy (PN), compared to radical nephrectomy (RN), for the management of localized renal cell carcinoma (RCC) has progressively increased, particularly for larger and more complex masses. We sought to compare the recurrence-free survival (RFS) outcomes of PN versus RN in a single-institution cohort.

Methods

Between 2002 and 2017, 228 patients underwent RN or PN for lcT1a-T2b, N0M0 RCC at a single tertiary referral center, performed by five surgeons. The clinical end point result was (local or distant) RFS. Univariate and multivariate (cox regression) models were used to evaluate the association between type of surgery (PN vs. RN) and RFS, in the overall cohort and in a subgroup of patients with cT1b.

Results

The median age was 59 (interquartile range [IQR] 48-66), and the median tumor size was 4.5 cm (IQR 3-7). There were 128 PN and 100 RN. Over a median follow-up of 4.2 years (IQR 2.2-6.9), the Kaplan-Meier analysis showed no significant RFS difference between PN and RN (logrank P = 0.53). On multivariate analysis, pathologic stage ≥T2a, Fuhrman Grade ≥3, and chromophobe histology were associated with a worse RFS. PN was not significantly associated with diminished RFS (Hazard ratio [HR] 1.78, 95% confidence interval [CI] 0.74-4.3, P = 0.199) in the overall cohort compared to RN. However, in the cT1b subgroup, PN was associated with a significant increase in recurrence compared to RN (HR = 12.4, 95% CI 1.45-133.4, P = 0.038).

Conclusions

Our institutional data highlight the possibility of compromise in RFS for clinically localized RCC treated with PN compared to RN, particularly for larger and more complex masses. These data raise concern, especially in light of the nonproven association of survival benefit of PN over RN, warranting future randomized prospective studies for further evaluation.

Role for Conservative Management in Grade V Renal Trauma

PURPOSE

We assessed the use of conservative management for American Association for the Surgery of Trauma grade V renal trauma in the National Trauma Databank.

MATERIALS AND METHODS

We used data of grade V renal trauma patients in the 2017-2019 National Trauma Databank. Conservative management was defined by the absence of surgical or procedural intervention except for ureteral stent or percutaneous drain placement. We initially analyzed patients who survived to final hospital discharge and reported the percent utilization of conservative management. We then repeated our analysis in the overall grade V population and in all those who did not die in the emergency department.

RESULTS

Of 1,474 who survived to discharge, 557 (37.8%) patients were managed conservatively. In the adjusted analysis, penetrating trauma mechanism (OR 0.13, 95% CI 0.09-0.19, P < .001) and receiving transfusion (OR 0.22, 95% CI 0.17-0.29, P < .001) were associated with decreased odds of receiving conservative management. Overall, there were 1,919 patients with grade V injury, of whom 731 (38.1%) were managed conservatively. Mortality rate was 22.8% in those managed conservatively vs 23.8% in those who had intervention. After excluding 110 patients who died in the emergency department, there were 1,809 patients, of whom 625 (34.6%) were managed conservatively. Mortality rate was 22.6% in the operatively managed group and 10.9% in the conservatively managed group.

CONCLUSIONS

A substantial portion of grade V renal trauma cases were managed successfully without intervention in the National Trauma Databank. Further research is needed to identify radiological phenotypes suitable for nonoperative management and to overcome possible renal trauma grade misclassification.

Cushioning the blow: role of perirenal fat in renal trauma injury severity

OBJECTIVES

To explore the association between perirenal fat thickness (PFT) and renal trauma grade. We hypothesise this association is related to a shock-absorbing effect of adiposity around the kidney.

PATIENTS AND METHODS

We identified all patients with renal trauma who arrived at the emergency department of a single trauma centre between 2014 and 2020. Radiology images were reviewed to measure the PFT around the uninjured kidney due to disrupted PFT around the traumatised kidney. Patients with no available images or penetrating trauma mechanism were excluded. Logistic regression was used to assess the relation between PFT and high-grade renal trauma (HGRT; defined as American Association for the Surgery of Trauma Renal Grade IV-V), adjusting for age, sex, and Injury Severity Scale (ISS).

RESULTS

A total of 150 patients with renal trauma were included. The median (interquartile range) age was 38.5 (26-52) years and 106 (70.7%) were males. The PFT ranged between 2.1 and 50.1 mm, and 31 (20.7%) had HGRT. Interestingly, PFT only mildly correlated with body mass index (BMI; Pearson correlation coefficient 0.42, P < 0.001). Those with HGRT had significantly lower PFT compared to those without HGRT (median 9.5 vs 11.9 mm, P = 0.047). In the multivariable analysis adjusting for age, sex, and ISS, increasing PFT was associated with decreased odds (odds ratio 0.91, 95% confidence interval 0.84-0.98; P = 0.015) of HGRT.

CONCLUSION

Increasing PFT is associated with lower risk of HGRT following blunt injury. These results support a protective cushion role of adiposity in renal trauma. Notably, PFT was not strongly correlated with BMI, underscoring limitations of BMI in measuring adiposity.

Posterior urethral stenosis: a comparative review of the guidelines

PURPOSE

We aimed to provide a thorough comparative review of the available guidelines on the diagnosis, management, and follow-up for patients with posterior urethral stenosis by the American Urologic Association (2016), Société Internationale d'Urologie (2010), and European Urologic Association (2022).

METHODS

The AUA, SIU, and EAU guidelines were evaluated for recommendations on the diagnosis, evaluation, and treatment of posterior urethral stenosis. We also included the EAU and AUA urologic trauma guidelines for the trauma-related stenosis. The level or strength of recommendations is included in case of disparity between the guidelines.

RESULTS

The three guidelines align considerably in recommendations provided for the diagnosis, management, and follow-up of patients with posterior urethral stenosis. SIU and EAU emphasize the role of repeat endoscopic treatment in guidelines compared to AUA.

CONCLUSION

The preferred method to repair bulbo-membranous stricture/stenosis following radiation therapy remains an area of active interest, focusing on continence preservation. Additionally, there may be a role for advanced endoscopic treatments with or without adjunct therapies to manage even obliterated stenoses.

Incidence of circumcision among insured adults in the United States

Purpose

Although circumcision is the most commonly performed surgery in males, less is known about the incidence and indications of adult circumcision. In this study, we aim to present the incidence of adult circumcision across the United States.

Methods

Using IBM MarketScan^® Commercial Database from 2015 to 2018, we obtained claims for circumcision in men between 18 and 64 years of age. We calculated the incidence of adult circumcision over the study period and across the United States. We also collected data on indications for surgery using International Classification of Diseases codes.

Results

We identified a total of 12,298 claims for adult circumcisions. The mean age was 39 (±12.9) years. The average incidence rates remained relatively constant from 98.1 per 100,000 person-years in 2015 to 98.2 per 100,000 person-years in 2018 (Δ+0.1%). The age-standardized incidence rates varied significantly across the United States (from 0 to 194.8 per 100,000 person-years) with South Dakota having the highest rate. The most common indications for adult circumcision were phimosis (52.5%), routine/ritual circumcision (28.7%), phimosis + balanitis/balanoposthitis (6.8%), balanitis (3.8%) and balanoposthitis (2.6%), and significantly varied by age groups.

Conclusion

This study suggested a wide geographic variation in rates of adult circumcision between states with highest incidences in the Northeast United States. Future studies can identify the underlying causes for the observed variations.

COVID-19 Misinformation and Social Network Crowdfunding: Cross-sectional Study of Alternative Treatments and Antivaccine Mandates

BACKGROUND

Crowdfunding is increasingly used to offset the financial burdens of illness and health care. In the era of the COVID-19 pandemic and associated infodemic, the role of crowdfunding to support controversial COVID-19 stances is unknown.

OBJECTIVE

We sought to examine COVID-19-related crowdfunding focusing on the funding of alternative treatments not endorsed by major medical entities, including campaigns with an explicit antivaccine, antimask, or antihealth care stances.

METHODS

We performed a cross-sectional analysis of GoFundMe campaigns for individuals requesting donations for COVID-19 relief. Campaigns were identified by key word and manual review to categorize campaigns into "Traditional treatments," "Alternative treatments," "Business-related," "Mandate," "First Response," and "General." For each campaign, we extracted basic narrative, engagement, and financial variables. Among those that were manually reviewed, the additional variables of "mandate type," "mandate stance," and presence of COVID-19 misinformation within the campaign narrative were also included. COVID-19 misinformation was defined as "false or misleading statements," where cited evidence could be provided to refute the claim. Descriptive statistics were used to characterize the study cohort.

RESULTS

A total of 30,368 campaigns met the criteria for final analysis. After manual review, we identified 53 campaigns (0.17%) seeking funding for alternative medical treatment for COVID-19, including popularized treatments such as ivermectin (n=14, 26%), hydroxychloroquine (n=6, 11%), and vitamin D (n=4, 7.5%). Moreover, 23 (43%) of the 53 campaigns seeking support for alternative treatments contained COVID-19 misinformation. There were 80 campaigns that opposed mandating masks or vaccination, 48 (60%) of which contained COVID-19 misinformation. Alternative treatment campaigns had a lower median amount raised (US $1135) compared to traditional (US $2828) treatments (P<.001) and a lower median percentile of target achieved (11.9% vs 31.1%; P=.003). Campaigns for alternative treatments raised substantially lower amounts (US $115,000 vs US $52,715,000, respectively) and lower proportions of fundraising goals (2.1% vs 12.5%) for alternative versus conventional campaigns. The median goal for campaigns was significantly higher (US $25,000 vs US $10,000) for campaigns opposing mask or vaccine mandates relative to those in support of upholding mandates (P=.04). Campaigns seeking funding to lift mandates on health care workers reached US $622 (0.15%) out of a US $410,000 goal.

CONCLUSIONS

A small minority of web-based crowdfunding campaigns for COVID-19 were directed at unproven COVID-19 treatments and support for campaigns aimed against masking or vaccine mandates. Approximately half (71/133, 53%) of these campaigns contained verifiably false or misleading information and had limited fundraising success.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1001/jamainternmed.2019.3330.

Impact of the COVID-19 pandemic on emergency department visits for genitourinary trauma

Introduction

The mean number of emergency department visits for all-cause traumas has declined significantly during the COVID-19 pandemic. We aim to identify how a global pandemic and social distancing could affect the trends and pattern of genitourinary traumas.

Methods

We queried the National Electronic Injury Surveillance System to obtain consumer product-related genitourinary injuries leading to emergency department visits. Using three key events in 2020, we divided the study period to three intervals: January 20, when the first COVID-19 case was confirmed in the United States; March 13, when a national state of emergency was declared; April 20, when Texas became the first state to start a phased reopening of economy. We compared the injury characteristics in 2020 to their identical intervals in 2019.

Results

Daily emergency department visits dropped significantly during the national lockdown (mean 131.5 vs. 78; Δ-40.7%; p < 0.01). The genitourinary injuries decreased significantly in children ≤ 17 years (p < 0.01), males (p < 0.001), and White population (p < 0.01). However, it did not change significantly in adults 18–64 years (p = 0.92), old adults ≥ 65 years (p = 0.37), females (p = 0.60), Black population (p = 0.90), other/unknown races (p = 0.93), and for injuries sustained at home (p = 0.75) and public (p = 0.11) locations. During the lockdown period, injuries associated with toilets/toilet seats (− 320, − 74.6%), day wear (− 266, − 77.7%), beds/bedframes (− 209, − 64.2%) decreased while injuries associated with knickknacks/statues/vases (+ 154, n/a), sofas/couches/divans (+ 130, 2,684%), and razors/shavers (+ 99, n/a) increased.

Conclusions

The COVID-19 lockdown had a significant impact on genitourinary traumas. The contributing factors could be investigated further to prevent such injuries during deconfinement periods.

Hematospermia is rarely associated with urologic malignancy: Analysis of United States claims data

BACKGROUND

Hematospermia is an alarming symptom and can cause significant patient distress, but work-up is often negative.

OBJECTIVE

To characterize the clinical evaluation of hematospermia and its association with the diagnosis of urologic malignancy.

MATERIALS AND METHODS

Using MarketScan insurance claims database, we identified adult males 18-64 years old diagnosed with hematospermia from 2010 to 2018. Benign hematospermia was defined as the absence of hematuria and elevated prostate-specific antigen. Patients with urologic cancer prior to diagnosis of hematospermia were excluded. We identified those who were diagnosed with a urologic malignancy.

RESULTS

The annual average incidence rate of hematospermia was 56.6 per 100,000 (95% confidence interval 55.4-57.8 per 100,000) in 2010 and increased to 73.6 per 100,000 (95% confidence interval 71.7-75.4 per 100,000) in 2018. A total of 56,157 patients presented with benign hematospermia. Most (57.5%) underwent at least one test, with the most common being urinalysis (51.7%), followed by prostate-specific antigen testing (11.9%). All other tests were performed in less than 3% of patients. Forty-seven patients were diagnosed with a urologic cancer, including 28 with prostate cancer (0.05%), nine with testicular cancer (0.016%), six with prostate carcinoma in situ (0.01%), and four with bladder cancer (0.007%). Stratified by age, there was only one cancer diagnosis (testicular) in 15,106 patients under 40 years (0.01%) and 46 cancer diagnoses in 40,611 patients 40 years old or above (0.11%). The median age of patients diagnosed with cancer was 56 years (interquartile range 52-61).

DISCUSSION AND CONCLUSION

A small minority of patients with benign hematospermia were later diagnosed with urologic cancer in a large nationally representative sample. After excluding hematuria with urinalysis, physicians should conservatively manage and reassure patients with hematospermia, especially those under 40 years of age.

Incidence of venous thromboembolism in benign urologic reconstructive cases

PURPOSE

To evaluate the rate of perioperative venous thromboembolism (VTE) among patients undergoing common benign urologic reconstructive cases. We hypothesize that this rate will be lower than previously described.

METHODS

We utilized the American College of Surgeons National Surgical Quality Improvement Project database from 2015 to 2019 to evaluate 30-day perioperative risk of VTE. Patients ≥ 18 years old undergoing benign urologic reconstructive cases were selected using Current Procedural Terminology (CPT) codes. Demographic, comorbidity, and operative variables were captured. The primary outcome was VTE within the 30-day postoperative period.

RESULTS

We identified 8467 patients who met inclusion criteria. The majority of patients were male (> 95%) with an average age of 65 and BMI of 29.6. There were 23 VTE events (0.27%) within the 30-day perioperative period. Fourteen (14/59) procedures had a perioperative VTE. Many of the traditional factors for VTE including operative time and obesity significantly increased risk of VTE in univariate analysis. In multivariate analysis, only BMI (OR 1.09; 95% CI 1.01-1.12) and inpatient status (OR 4.42; 95% CI 1.9-10.2) were correlated with increased perioperative VTE.

CONCLUSION

The rate of VTE among patients undergoing benign urologic reconstructive cases is low. Providers should continue to have high index of suspicion particularly for inpatients with high BMI in addition to other known risk factors for VTE.

The R.E.N.A.L score’s relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience

Objective

The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors.

Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was used to compare categorical variables. Kaplan-Meier estimates and multivariable cox proportional hazard regression were performed to determine an association between the different R.E.N.A.L categories and disease recurrence or mortality.

Results

A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05–12.7, p = 0.041).

Conclusion

Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling.

Epidemiology of child playground equipment-related injuries in the USA: Emergency department visits, 1995-2019

AIM

To analyse the most recent trends and characteristics of playground equipment-related injuries in children.

METHODS

We used the National Electronic Injury Surveillance System database to acquire cases of playground equipment-related injuries in children ≤17 years old between 1995 and 2019. A total of 184 580 unweighted cases met our study inclusion criteria.

RESULTS

A total of 5 356 703 (95% confidence interval 4 235 530-6 477 876) emergency department visits for playground-related injuries in the USA were estimated during the study period which was equal to an average of 29.4 annual injuries per 10 000 US population ≤17 years. The mean age was 6.5 (standard error 0.049) years. School-aged (42.7%) and pre-school children (35.3%) accounted for most playground injuries. More than half of the injuries were reported in males (53.6%). Most injuries occurred with climbing apparatuses (36%), followed by swings (25.9%) and slides (20.9%). Overall number of injuries (∆ - 22.3%, P = 0.01) and incidence (∆ - 21.6%, P = 0.01) had a declining trend after 2012. However, reported concussion injuries showed an increasing trend during the study (∆ + 28.3%, P < 0.001). A marked seasonal variation in number of injuries existed with most injuries in May and September.

CONCLUSIONS

Although injuries arising from playground equipment have decreased during the past 8 years, there was an increase in number of reported concussions. The outcomes of this study suggested that further efforts should be directed towards such serious injuries.

Characteristics of Online Crowdfunding Campaigns for Urological Cancers in the United States

INTRODUCTION

We examined the characteristics and financial outcomes of online crowdfunding campaigns for patients with major urological cancers in the U.S.

METHODS

This cross-sectional study analyzed publicly available data from GoFundMe, the largest online medical crowdfunding service, via automated web scraping. Online campaigns from 2010 to 2018 with the following primary cancer types were included: kidney, prostate, bladder and testicular. Financial outcomes were compared using Kruskal-Wallis and Wilcoxon rank-sum tests. Multivariable analyses were utilized to identify predictors of campaign financial outcomes.

RESULTS

Kidney cancers were the most frequent online campaign type (478), followed by prostate (379), bladder (202) and testicular (175) malignancies. Urological cancer campaign recipients frequently requested funding for medical expenses (71%) during active treatment (57%). After adjustment, testicular cancer and children's cancer campaigns generated more donations than other urological and adult cancer campaigns (p <0.05). Family and friend-authored campaigns generated more donations and average donation amounts than self-authored campaigns (p <0.05). Campaign narratives focused on disheartening circumstances received fewer donations than narratives focused on the recipient's high moral character or contributions to society (p <0.05), and unclear narratives received the smallest donation amounts (p <0.05).

CONCLUSIONS

Urological cancer crowdfunding in the U.S. is primarily used to finance uncovered costs associated with medical care during active treatment. Crowdfunding financial outcomes are likely related to the campaign recipient's age, malignancy type, social network and primary appeal of the narrative. Urologists should be aware of trends in medical crowdfunding in order to better understand the financial burden this patient population faces.

5-Alpha reductase inhibitor related litigation: A legal database review

BACKGROUND

5α-reductase inhibitors are commonly prescribed medications with multiple side effects used in the treatment of male pattern hair loss and benign prostatic hyperplasia. These side effects including "post-finasteride syndrome" may result in lawsuits.

OBJECTIVES

To characterize lawsuits involving the adverse side effects of 5α-reductase inhibitor to better understand drivers of litigation and outcomes.

METHODS

Legal cases were queried from Nexis Uni using the search terms "5-alpha reductase inhibitor" as well as specific agents "finasteride," "dutasteride" in combination with "malpractice," "negligence," "damage," "loss," "side effect," and "complication." Secondary review was performed with publicly available data on "In Re: Propecia." Relevant cases were reviewed and pertinent characteristics were extracted and summarized using descriptive statistics.

RESULTS

Our search yielded 156 unique legal cases in the Nexis Uni database from April 2003 to May 2021. Only 18 of these cases met the inclusion criteria. Adverse events experienced by patients included medication side effects (n = 12, 66.7%), delayed cancer diagnosis (n = 3, 16.7%), and lack of symptom improvement (n = 3, 16.7%). The identity of the plaintiffs were most commonly patients themselves (n = 15, 83.3%). Defendants include pharmaceutical companies (n = 6, 33.3%), a combination of parties (n = 5, 27.8%), and physicians (n = 5, 27.8%) alone. The allegations included sexual side effects such as erectile dysfunction (n = 6, 33.3%) and decreased libido (n = 4, 22.2%). These prescriptions were made for benign prostatic hyperplasia (n = 9, 50%), male pattern hair loss (n = 7, 38.9%), and feminizing hormone therapy (n = 2, 11.1%). Several of these cases involved the same plaintiffs in related cases. No verdicts were against physicians. We noted a largely settled lawsuit involving more than 1000 plaintiffs with limited data on harms alleged and a $4.3 million settled amount. Of the total cases that resulted in a verdict, 9/18 were within the last 3 years.

DISCUSSION

The most common complications experienced by patients in our legal review were those involving sexual dysfunction with erectile dysfunction and decreased libido. The growing number of cases in the later years of our review suggests litigation may continue to increase in the coming future. Our review did not identify any individual cases that resulted in a monetary payout beyond a $4.3 million settlement outside of court.

CONCLUSION

5α-reductase inhibitor was alleged to have sexual, mental, and physical side effects, resulting in legal litigation. Despite this, no judgment against a physician or pharmaceutical company was identified. We do note and discuss a large number of lawsuits settled out of court. Given the increase in the number of lawsuits resulting in verdicts over the last 3 years, we suspect that the frequency of litigation around 5α-reductase inhibitors will continue for the foreseeable future.

A Legal Database Review of Circumcision Related Litigation in the United States

OBJECTIVE

To characterize circumcision-related litigation in the United States (US) and factors predictive of lawsuit outcome. Circumcision is a common urologic procedure with medical and ethical nuances.

METHODS

We reviewed the Nexis Uni legal database for state and federal cases using the term "circumcision" in combination with "medical malpractice" or "negligence" or "medical error" or "complication" or "malpractice" or "tort". Litigation primarily related to circumcision from 1939 to 2021 were reviewed for medical and legal details.

RESULTS

We identified 77 unique cases. Most cases were processed in state (87%) or appellate (59%) court systems with negligent surgical performance as the most common lawsuit reason (49%). Of reported specialties, urology was the highest proportion represented among named physicians (29%) and most patients were minors at time of circumcision (64%) and lawsuit (59%). Common complications included aesthetic dissatisfaction (20%), pain (19%), impaired sexual function (17%) and surgical trauma/injury (16%). Most verdicts favored physicians (59%), but when against physicians, the median indemnity was $175,000. Lawsuits due to negligent informed consent were significantly more likely to result in verdict favoring the physician compared to those due to negligent surgical performance.

CONCLUSIONS

Circumcision-related litigation in the US is rare and trial verdicts favor physicians, particularly in federal court cases or when parties allege negligent informed consent. Cases that favored plaintiffs successfully alleged negligent surgical technique. We recommend physicians performing circumcisions receive proper training, clearly communicate potential complications, and ensure appropriate indications for adult patients to reduce malpractice risk.

Characterizing Standardized Letters of Recommendation in Urology Residency Applications

OBJECTIVE

To identify the current formats of standardized letters of recommendation (SLORs) and evaluate their characteristics, the distribution of applicants' ratings, correlation between SLOR domain ratings and conventional application metrics, and potential biases.

METHODS

We evaluated all applications submitted to our residency program for the 2020-2021 urology match. Two main formats of SLOR were identified. We extracted application characteristics and SLOR domain ratings.

RESULTS

Ninety SLORs from 82 applicants were reviewed. Applicants were highly rated among top tiers in both formats. Some correlations were observed between domain ratings and application metrics such as Step 1 and Step 2 Clinical Knowledge scores, and percentage of Honors in core clinical clerkships. No statistically significant differences were found between female and male applicants in terms of domain ratings. Alpha Omega Alpha members received higher ratings in "urology resident potential," "academic urologist potential," and "performance as a sub-intern" domains. Applicants from top 40 US medical schools performed better as sub-interns, and were more likely to be ranked higher. Letters from home institutions were associated with higher ratings in several domains. In-person vs virtual interactions received similar ratings except for "communication".

CONCLUSION

While it is promising to observe such number of SLORs submitted for the first time in urology, the current formats could benefit from further refinement in their structures and domains to distinguish between highly qualified urology applicants more efficiently. Given the transition in Step 1 score reporting to pass/fail outcome, the need for a reliable urology-specific SLOR will be critical.

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.

Does a Positive Surgical Margin After Nephron Sparing Surgery Affect Oncological Outcome in Renal Cell Carcinoma? A Systematic Review and Meta-analysis

We systematically evaluated the impact of positive surgical margins (PSM) on oncological outcomes after partial nephrectomy for renal cell carcinoma. Forty-two studies comprising 101,153 subjects were included and five distinct meta-analyses were performed. PSM was associated with increased risk of local recurrence (hazard ratio (HR) 6.11-high certainty), metastasis (HR 3.29-moderate certainty), overall relapse (HR 2.25-high certainty), overall mortality (HR 1.30-moderate certainty), and may be associated with increased cancer-specific mortality (HR 1.91-low certainty). Patients with PSM should be counseled for the possibility of additional surgery, novel adjuvant therapies, and more rigorous surveillance.

Characterizing online crowdfunding campaigns for patients with kidney cancer

Background

Cancer patients incur high care costs; however, there is a paucity of literature characterizing unmet financial obligations for patients with urologic cancers. Kidney cancer patients are particularly burdened by costs associated with novel systemic treatments. This study aimed to ascertain the characteristics of GoFundMe® crowdfunding campaigns for patients with kidney cancer, in order to better understand the financial needs of this population.

Methods

We performed a cross‐sectional, quantitative, and qualitative analysis of all kidney cancer GoFundMe® campaigns since 2010. Fundraising metrics such as goal funds and amount raised, were extracted. Eight independent investigators collected patient, disease and campaign‐level variables from campaign stories (κ = 0.72). In addition, we performed a content analysis of campaign narratives spotlighting the primary appeal of the patient's life story.

Results

A total of 486 GoFundMe® kidney cancer campaigns were reviewed. The median goal funds were 10,000USD [IQR = 5000, 20,000] and the median amount raised was 1450USD [IQR = 578, 4050]. Most campaigns were for adult males (53%) and 62% of adults had children. A minority were for pediatric patients (17%). Thirty‐seven percent of adult patients were primary wage earners and 43% reported losing their job or substantially reducing hours due to illness. Twenty‐nine percent reported no insurance or insufficient coverage. Campaigns most frequently sought funds for medical bills (60%), nonmedical bills (27%), and medical travel (23%). Qualitative campaign narratives mostly emphasized patients’ hardship (46.3%) or high moral character (35.2%). Only 8% of campaigns achieved their target funds.

Conclusions

Despite fundraising efforts, patients with kidney cancer face persistent financial barriers, incurring both medical and nonmedical cost burdens. This may be compounded by limited or no insurance. Cancer care providers should be aware of financial constraints placed on kidney cancer patients, and consider how these may impact treatment regimens.

Playground Equipment-related Genital Injuries in Children: An Analysis of United States Emergency Departments Visits, 2010-2019

OBJECTIVE

To evaluate the demographics, epidemiology, and common mechanisms associated with playground equipment-related genital injuries in children.

METHODS

We examined the National Electronic Injury Surveillance System database to obtain playground-related genital injuries sustained in children ≤17 years from 2010 to 2019. Demographics of the patients and injury characteristics were analyzed using sample weights to produce national estimates.

RESULTS

During the study period, an estimated 27,738 (95% confidence interval 18,602-36,874) emergency department visits with an average annual incidence of 3.8 (95% confidence interval 2.5-5) per 100,000 United States population ≤17 years were reported. The mean age was 6.6 (standard error 0.152) years with most injuries occurring in pre-school children (48.1%) and females (81.1%). Over ½ of genital injuries (55.2%) were associated with climbing apparatus. This was followed by slides (10.7%), swings (9%), and seesaws (4.8%). Most genital injuries occurred at public (41.4%) and school settings (36.3%). Straddling and/or falling was the most common mechanism leading to genital injuries (84.4%). The incidence of injuries remained constant during the 10-year study period (change = + 2.6%; r² = 0.121, P = .326). Monthly variations in the number of injuries existed with peak injuries in April-May, and September-October.

CONCLUSION

Despite current safety standards, genital injuries arising from playground equipment have remained stable since 2010. By defining common devices, mechanisms, and conditions associated with genital injuries, this study may help guide efforts aimed at the prevention of such injuries in various locations.

Comparative analysis of histopathological subtypes of renal cell carcinoma in the Middle East compared to other world regions

Introduction

Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide.

Methods

A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents.

Results

One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7-13.6), Europe (11.1%, 95% CI: 10.0-12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America.

Conclusions

The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.

Evaluating the primary use, strengths and weaknesses of pelvic floor muscle training devices available online

AIMS

Treatment for urinary incontinence (UI) includes pelvic floor muscle training (PFMT). There is limited data appraising the characteristics of PFMT devices. We aimed to ascertain the primary use, strengths and weaknesses of PFMT devices available online, through evaluation of consumer reviews.

METHODS

We performed an analysis of PFMT devices on Amazon.com. Four key device categories were recognized. Reviews from the five most frequently-reviewed products per category were analyzed (n = 20). W characterized device use, strengths and weaknesses using thematic analysis.

RESULTS

We evaluated 2574 PFMT device reviews including 1168 vibrating Kegel balls, 750 non-vibrating Kegel balls, 411 pelvic floor or thigh exercisers, and 245 electric probes. Non-vibrating Kegel balls were rated highest (4.6/5 stars), followed by vibrating Kegel balls, electric probes and pelvic floor or thigh exercisers (4.4/5, 4.1/5, and 3.8/5 stars, respectively). Most reviews were positive (77%) or negative (16%) with few neutral (7%). While all were marketed to treat UI, most reviews did not mention the intended use. Vibrating and non-vibrating Kegel balls and electric probes were most likely to be used for UI, and pelvic floor or thigh exercisers for toning. Some used non-vibrating and vibrating Kegel balls for sexual function. Electric probes were the most beneficial device for incontinence control (27%, 67/245). Twenty-five percent of all product reviews praised device ease of use and good quality or design. A minority of reviewers found products difficult to use, of poor quality or design and uncomfortable.

CONCLUSION

Consumers utilized online PFMT devices for multiple purposes, including UI, toning and sexual function. Reviewers generally praised PFMT products, particularly electric probes for UI.