Objective Patients with overactive bladder (OAB) refractory to first‐ and second‐line therapy may pursue third‐line therapies, including intradetrusor onabotulinum toxin‐A (BTX), peripheral tibial nerve stimulation (PTNS), and sacral neuromodulation (SNM). The factors that influence patient preference for each treatment modality have not yet been explored. This study sought to investigate the specific parameters that patients consider in choosing a third‐line therapy for OAB. Methods Patients refractory to first‐ and second‐line therapies for OAB were identified in our outpatient clinic and asked to watch an educational video providing information on the risks and benefits of each third‐line treatment option. They were then given a questionnaire to rank their preference of therapy and select reasons for why they found each therapy favorable and unfavorable. Patients under age 18 years, non‐English speakers, those with a developmental disability, and those with a diagnosis of neurogenic bladder were excluded. Results Of the 98 patients included in the study, 40 participants (40.8%) chose intradetrusor BTX injections, 34 (34.7%) chose PTNS, and 16 (16.3%) chose SNM as their first choice. Seven patients (7.1%) chose none of the offered therapies, and one patient (1.0%) chose all three therapies with equal preference. BTX was found most attractive for its long efficacy (47%); its least attractive feature was the potential need for self‐catheterization due to urinary retention (54%). PTNS was found most attractive for being a nonsurgical option (32%) and having no reported significant complications (39%); its least attractive feature was need for frequent office visits (61%). SNM was found most attractive for its potential for long‐term relief without frequent office visits (53%); its least attractive feature was need for an implanted device (33%). Patients opting for SNM had higher scores on Urinary Distress Inventory‐6 and Incontinence Impact Questionnaire‐7 questionnaires when compared to patients opting for BTX injections or PTNS (p < 0.05). 47.4% of patients eventually pursued a third‐line therapy. Of those, there was a 67.6% concordance rate between the therapy patients ranked first and the therapy they eventually underwent. Conclusions Patients with more severe OAB symptoms opt for more invasive and less time‐consuming therapy with the potential for long‐term relief, namely SNM. Despite thorough counseling, many patients do not progress to advanced OAB therapies. Understanding factors that influence patients' affinity toward a specific type of treatment can aid with individualized counseling on third‐line OAB therapies.
Introduction:As part of its mission to provide the highest standards of clinical care, the AUA publishes guidelines on numerous urological topics. We sought to evaluate the caliber of evidence used establish the currently available AUA guidelines.Methods:All available AUA guideline statements in 2021 were reviewed for their level of evidence and recommendation strength. Statistical analysis was performed to identify differences between oncological and nononcologic topics, and statements pertinent to diagnosis, treatment, and follow-up. A multivariate analysis was utilized to identify factors associated with strong recommendations.Results:A total of 939 statements across 29 guidelines were analyzed; 39 (4.2%) were backed by Grade A evidence, 188 (20%) Grade B, 297 (31.6%) Grade C, 185 (19.7%) Clinical Principle, and 230 (24.5%) Expert Opinion. There was a significant association of oncology guidelines (6% vs 3%, P = .021) with more grade A evidence and less Grade C Evidence (24% vs 35%, P = .002). Statements pertaining to diagnosis and evaluation were more likely backed by Clinical Principle (31% vs 14% vs 15%, P < .01), treatment statements backed by B (26% vs 13% vs 11%, P < .01) and C (35% vs 30% vs 17%, P < .01) grade evidence, and follow-up statements backed by Expert Opinion (53% vs 23% vs 24%, P < .01). On multivariate analysis, strong recommendations were more likely supported by high-grade evidence (OR = 12, P < .01).Conclusions:The majority of evidence for the AUA guidelines is not high grade. Additional high-quality urological studies are needed to improve evidence based urological care.
significantly change over time, though it was associated with increasing patient age.CONCLUSIONS: While the majority of patients are satisfied with telemedicine for management of genitourinary malignancies, satisfaction has decreased after the early months of the COVID-19 pandemic, particularly with regard to patient counseling and time spent.Additionally, technological barriers to telemedicine implementation remain common, particularly among the elderly.
risk of a vaginal hysterectomy (vascular and bowel injury, increased operative time), is exceeded by the benefit of eliminating the risk of endometrial or cervical cancer, pyometria or difficulty assessing abnormal uterine bleeding. We assessed the utility of vaginal hysterectomy at the time of colpocleisis by describing the probability of endometrial cancer and death after LeFort (uterine sparing) colpocleisis repair using a contemporary population-based dataset.METHODS: Women undergoing colpocleisis in California (2005-2019) were identified using the Office of Statewide Health Planning and Development (OSHPD) datasets. A competing risk analysis with each of three outcomes (alive, endometrial cancer, or death) was modeled for women undergoing Lefort colpocleisis.RESULTS: A total of 2707 women had colpocleisis performed, of which 381 had concomitant (14.1%) or prior hysterectomy (8.6%). Mean age at time of surgical repair was 78.6 years. Among the 2,093 women undergoing LeFort colpocleisis, 18 (0.9%) incurred an endometrial cancer diagnosis. A total of 280 (13.4%) subjects died over a mean follow up of 10.2 years. Number needed to treat (NNT) with hysterectomy to prevent 1 endometrial cancer diagnosis was 1141 at 3 years. Subsequently, NNT decreased from 283 at 5.5 years to 166 at 10-13 years. Women with endometrial cancer diagnosis lived a median difference of 2242.5 days (6.1 years) less than their counterparts without cancer.CONCLUSIONS: As previously published reports from this dataset indicate, there is an increased risk of complications when concommitant hysterectomy is performed and the benefits of hysterectomy at time of colpocleisis in women over age 70, particularly frail patients with a short overall life expectancy, are minimal. Overall rates of endometrial cancer in the setting of uterine preserving colpocleisis are low, below the published prevalence rates for similarly aged women. Concomitant hysterectomy at time of colpocleisis does not significantly reduce mortality of women at highest risk of endometrial cancer in this cohort.
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