Variation in Defining Retention After Onabotulinum Toxin A for Overactive Bladder: A Systematic Review

IMPORTANCE

Urinary retention is a common adverse effect after intravesical injection of onabotulinum toxin A (BTX) for overactive bladder (OAB). Reported retention rates range from 1.6% to more than 40%. This variation may be due to varying definitions of retention in the literature.

OBJECTIVE

We aimed to assess the variation in definitions of urinary retention across studies of BTX for the treatment of OAB.

STUDY DESIGN

We performed a systematic review of studies of BTX for OAB by querying MEDLINE and EMBASE according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included original research studies on adults with overactive bladder treated with BTX and urinary retention reported as an outcome from January 2000 to December 2020.

RESULTS

From 954 results, we identified 53 articles that met inclusion criteria. There were 6 definitions for urinary retention. The majority of studies (60.4%) reported initiating clean intermittent catheterization (CIC) as the metric for retention. Five (9.5%) studies provided no definition despite reporting retention as an adverse event. Twenty studies (37.7%) specified a postvoid residual volume (PVR) threshold for initiating CIC in asymptomatic patients; 19 (35.8%) specified a PVR threshold for CIC in symptomatic patients. The PVR thresholds ranged from 100 to 400 mL. Twenty-three studies (43.4%) did not address asymptomatic elevation of PVR, and 22 (41.5%) did not address how symptomatic patients were managed.

CONCLUSIONS

Urinary retention after BTX injection is inconsistently defined in the literature. Lack of standardization in reporting retention after intravesical BTX prevents accurate assessment of the risk of urinary retention and comparison of outcomes between studies.

Multimodality Imaging of Anterior Compartment Pelvic Floor Repair

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two common disorders that affect the anterior compartment of the pelvic floor in women. These can be treated conservatively or surgically. Among patients treated surgically, a substantial number present with pain, recurrent POP or SUI, or other conditions that warrant additional interventions. In many of these cases, imaging is key to identifying and characterizing the type of procedure performed, locating synthetic materials that may have been placed, and characterizing complications. Imaging may be particularly helpful when prior surgical records are not available or a comprehensive physical examination is not possible. US and MRI are the most commonly used modalities for such patients, although radiopaque surgical materials may be visible at voiding cystourethrography and CT. The authors summarize commonly used surgical treatment options for patients with SUI and POP, review imaging techniques for evaluation of such patients, and describe the normal imaging appearance and complications of pelvic floor surgical repair procedures in the anterior compartment of the pelvis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

HIF-pathway genes prognostic for progression-free and overall survival in metastatic clear cell renal cell carcinoma (mccRCC)

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Background: Clear cell renal cell carcinoma (ccRCC) is characterized by defects in the Von Hippel-Lindau/hypoxia-inducible factor (VHL/HIF) pathway. Several FDA-approved RCC therapies target the products of HIF-response genes. HIF2A is a promising new target and drugs targeting HIF2A are undergoing clinical testing. A better understanding of HIF-related genes may reveal useful biomarkers and drug targets. Methods: Gene expression was determined from 324 archival pretreatment nephrectomy specimens available from the Cancer and Leukemia Group B (CALGB) 90206, a phase III trial of patients treated with INF-α vs. INF-α plus bevacizumab. TaqMan RT-qPCR was performed on the OpenArray platform using RNA extracted from tumor tissue macrodissected based on review of H&E staining by a genitourinary pathologist. HIF pathway genes were assessed across both treatment arms, utilizing the proportional hazards model as predictors of OS and PFS, with time from randomization to death or disease progression as endpoints. Results: A total of 28 HIF-related genes (involved either in canonical or non-canonical HIF regulation) were assessed in univariate PH. Nine of these genes were associated with OS (i.e., HIF2A , VEGFC, VEGFD, TGFA, VHL, CCND1, EGFR, EGLN3 and HSP90AA1); and 6 of them were also associated with PFS (i.e., HIF2A , TGFA, VHL, CCND1 and EGLN3, and HSP90AA1). The HIF isotypes HIF1A and HIF3A were not prognostic, likewise VEGFA and VEGFB. Prolyl hydroxylase domain (PHD) proteins efficiently hydroxylate HIFα in normoxic conditions. PHD isotypes EGLN (1-3) were evaluated and only EGLN3 was associated with OS and PFS. HIF is also regulated by non-canonical pathways that function independent of oxygen concentration. HSP90AA1 was the only non-canonical pathway gene that was prognostic, and it predicted both OS and PFS. When the 9 genes that were prognostic in univariate analysis were used in a backward stepwise multivariate cox regression, VEGFD, TGFA and EGLN3 predicted OS while HIF2A, VHL and TGFA predicted PFS. Conclusions: VHL, HIF2A (but not HIF1A and HIF3A), EGLN3 (but not EGLN1 and EGLN2) and some of the HIF-response genes were prognostic of both OS and PFS. HSP90AA1 was prognostic for OS and PFS, suggesting that the non-canonical HIF pathway also plays a role in disease progression. Future studies should consider these HIF pathway genes as potential drug targets, and as predictors of response to treatments targeting the hypoxia pathway and angiogenesis.[Table: see text]

Assessing the Impact of Urology Resident Involvement on Overall Patient Satisfaction

INTRODUCTION

To assess the impact of resident participation on patient satisfaction by comparing post-discharge satisfaction scores between academic faculty, private urologists who work with residents, and private urologists with no involvement in resident education.

METHODS

Post-discharge Hospital Consumer Assessment of Healthcare Providers and Systems surveys from academic and private urologists at a single institution with an accredited Urology residency program from January 1, 2014 to December 31, 2016 (n = 530) were reviewed. The surveys were de-identified and categorized based on 3 subgroups of providers: academic faculty, private with residents, and private without residents. Overall rating, physician (MD) communication, nursing (RN) communication, discharge information, and overall management during their hospitalization were assessed.

RESULTS

The faculty group received an overall patient satisfaction score of 88.3% (percentage of 9 or 10). The private with resident group had an overall satisfaction score of 92.0% and the private without resident group had an overall satisfaction score of 96.7%. There was no statistical difference in patient satisfaction scores between groups across all categories with the exception of MD and RN communication. Private urologists with residents had better MD and RN communication scores than the 2 other groups (p < 0.001, p = 0.013, respectively).

CONCLUSIONS

Resident involvement in patient care with faculty or private attendings did not have a negative effect on patient satisfaction scores of any factor measured. Patients were more satisfied with MD and RN communication when residents worked with private attendings.

Optimal instrument length for transumbilical laparoendoscopic single site (U-LESS) surgery

The aim of our study was to recommend a novel method for measuring the distance from the umbilicus to intra-abdominal organs, as well as recommend an instrument length that would accommodate transumbilical laparoendoscopic single-site (U-LESS) surgeries to these areas. From CT scans of 50 men and 50 women, we calculated the distance from the umbilicus to 11 intra-abdominal points of interest using two triangles oriented perpendicular to each other. Using known lengths of the triangles, we used the Pythagorean theorem to calculate distances with and without insufflation. Distances were measured from the umbilicus to the xyphoid process, superior most aspect of the spleen, neck of the gallbladder, bifurcation of the descending aorta, adrenal glands, superior pole(s) of the kidneys, inferior most aspect of the inguinal canal, suprapubic margin, and the apex of the prostate (or female bladder neck). We found that an instrument working length of 43 cm would be sufficient to facilitate U-LESS surgery for all of our patients to each of the measured points of interest. The technique described in this paper serves as a useful method by which to measure the distance from the umbilicus to any intra-abdominal point of interest. These measurements would allow surgeons to correctly select instruments with adequate length when planning to perform U-LESS surgery.

Long bone structure and strength depend on BMP2 from osteoblasts and osteocytes, but not vascular endothelial cells

The importance of bone morphogenetic protein 2 (BMP2) in the skeleton is well known. BMP2 is expressed in a variety of tissues during development, growth and healing. In this study we sought to better identify the role of tissue-specific BMP2 during post-natal growth and to determine if BMP2 knockout affects the ability of terminally differentiated cells to create high quality bone material. We targeted BMP2 knockout to two differentiated cell types known to express BMP2 during growth and healing, early-stage osteoblasts and their progeny (osterix promoted Cre) and vascular endothelial cells (vascular-endothelial-cadherin promoted Cre). Our objectives were to assess post-natal bone growth, structure and strength. We hypothesized that removal of BMP2 from osteogenic and vascular cells (separately) would result in smaller skeletons with inferior bone material properties. At 12 and 24 weeks of age the osteoblast knockout of BMP2 reduced body weight by 20%, but the vascular knockout had no effect. Analysis of bone in the tibia revealed reductions in cortical and cancellous bone size and volume in the osteoblast knockout, but not in the vascular endothelial knockout. Furthermore, forelimb strength testing revealed a 30% reduction in ultimate force at both 12 and 24 weeks in the osteoblast knockout of BMP2, but no change in the vascular endothelial knockout. Moreover, mechanical strength testing of femurs from osteoblast knockout mice demonstrated an increased Young's modulus (greater than 35%) but decreased post-yield displacement (greater than 50%) at both 12 and 24 weeks of age. In summary, the osteoblast knockout of BMP2 reduced bone size and altered mechanical properties at the whole-bone and material levels. Osteoblast-derived BMP2 has an important role in post-natal skeletal growth, structure and strength, while vascular endothelial-derived BMP2 does not.