Nurse perspectives on the psychosocial care of patients with urinary incontinence in home hospice: A qualitative study

BACKGROUND

Urinary incontinence is prevalent among patients receiving home hospice and presents multiple care management challenges for nurses and family caregivers.

AIM

This study sought to understand how urinary incontinence influences the psychosocial care of patients receiving home hospice and the strategies that nurses employ to maximize patient and family comfort.

DESIGN

Qualitative descriptive study using semi-structured interviews.

SETTING/PARTICIPANTS

Nurses employed at a large not-for-profit hospice agency in New York City.

RESULTS

Analyses of 32 interviews revealed three primary themes. First, nurses considered urinary incontinence to be associated with multiple psychosocial issues including embarrassment for patients and caregiver burden. Second, nurses described urinary incontinence as a threat to patient dignity and took steps to preserve their continence function. Third, nurses assisted patients and their families to cope with urinary incontinence through normalization, reframing incontinence as part of the disease process, mobilizing caregiving assistance, and encouraging use of continence supplies such as diapers and liners.

CONCLUSION

Urinary incontinence influences the psychosocial care of patients receiving home hospice and nurses employ strategies to maximize patient and family comfort. Additional research is needed to examine the psychosocial benefits of facilitated discussions with patients and family members about incontinence, provision of caregiving support, and distribution of comprehensive incontinence supplies to patients with fewer resources.

Surgical treatment options for benign prostatic obstruction: beyond prostate volume

PURPOSE OF REVIEW

Many surgical treatment options are available for patients who present with benign prostatic obstruction (BPO). This article reviews the current treatment options available and distinguishes them based on five clinical considerations: antithrombotic therapy, sexual function preservation, ambulatory procedures, anesthesia-related risks and duration of catheterization.

RECENT FINDINGS

A comprehensive review of the literature was performed on 10 BPO procedures. Laser enucleation of the prostate (LEP), bipolar plasma transurethral vaporization of the prostate and photoselective vaporization (PVP) of the prostate reduces the risk of bleeding, which is recommended for anticoagulated men. Ejaculatory function is more likely to be preserved following transurethral incision of the prostate, Rezūm, Aquablation, UroLift and iTind. Same-day discharge is possible for LEP, PVP and prostatic arterial embolization (PAE). For patients with high anesthesia-related risks, procedures compatible with local anesthesia (UroLift, Rezūm, iTind and PAE) should be favored. Catheterization duration is shorter with UroLift, PVP and LEP.

SUMMARY

BPO treatment options are growing rapidly. The optimal procedure for a given patient is based on factors such as associated risks, recovery and expected outcomes. Besides prostate volume, the clinical considerations in the present article can help elucidate the best surgical BPO treatment option for each patient based on their values, preferences, and risk tolerance.

Office-Based Procedures for BPH

PURPOSE OF REVIEW

Benign prostatic hyperplasia (BPH) is a common disease in men. A rapidly rising demand for safe and effective therapy for BPH has generated novel minimally invasive surgical treatments (MISTs). With multiple procedural options in the urology armamentarium for BPH therapy, we describe the current therapies and outcomes for office-based procedures for BPH including quality of life, voiding symptoms, and sexual function.

RECENT FINDINGS

There are three FDA-approved MISTs (Rezūm, Urolift, and iTind) and three emerging MISTs for BPH. Preliminary data suggest improvement in voiding symptoms and quality of life while minimizing unwanted sexual side effects. Long term data is required on the durability and safety of MISTs for BPH. MISTs mark a paradigm shift in BPH management. Sandwiched between conservative medical management and conventional transurethral surgery, these novel technologies promise to combine efficacy approaching that of TURP while sparing the negative side effects. We envision a future where BPH can be diagnosed and treated in an office-based setting with a standard cystoscope in one procedure.

Evaluating the acceptability of an online patient decision aid for the surgical management of lower urinary tract symptoms secondary to benign prostatic hyperplasia

INTRODUCTION

The growing number of surgical options available to treat benign prostatic hyperplasia (BPH), may overwhelm patients and urologists when deciding on an optimal treatment. Therefore, we developed an online patient decision aid (PtDA) that includes all guideline-approved surgical modalities. The objective of this study was to assess the acceptability of the PtDA among former BPH surgery patients and urologists that treat BPH surgically.

METHODS

The International Patient Decision Aids Standards were used to develop a PtDA that includes monopolar transurethral resection of the prostate (TURP), bipolar TURP, GreenLight photovaporization, endoscopic enucleation of the prostate, Rezum, Urolift, Aquablation, open retropubic prostatectomy, and robotic simple prostatectomy as management options. Eleven urologists that regularly treat BPH and 19 patients who received BPH surgery were recruited. Alpha-testing was performed using a validated acceptability scoring system.

RESULTS

For all sections of the PtDA, most urologists agreed that the language used was easy to follow (91.9%), that the amount of information provided was adequate (63.6%), that the length of the PtDA was appropriate (63.6%), and that the outcomes reported were correct (81.8%). All 19 patient participants agreed that the language used was easy to follow, and most found that the amount of information provided was adequate (84.2%), that the length of the PtDA was appropriate (84.2%), and that the outcomes reported were well-explained (89.5%).

CONCLUSIONS

Our PtDA was found to be acceptable among urologists and patients. These results demonstrate that most of the participants either recommend the use of this tool or plan to incorporate it in their clinical practice.

Assessing the Accuracy, Quality, and Readability of Information Related to the Surgical Management of Benign Prostatic Hyperplasia

Objectives: To assess the accuracy, quality, and readability of online educational health information in English related to the most common benign prostatic hyperplasia (BPH) guideline-approved surgical treatments. Methods: The terms "benign prostatic hyperplasia," "BPH," and all eight guideline-approved treatment modalities studied, were searched to retrieve the first five relevant websites and first two paid advertised websites related to the surgical treatment options for BPH. These modalities included transurethral resection of the prostate (TURP), GreenLight photovaporization, endoscopic enucleation of the prostate, Rezum, Urolift, Aquablation, open simple prostatectomy, and robotic simple prostatectomy (RSP). All relevant websites were assessed for their accuracy, quality, and readability using standardized scoring systems. Results: The mean accuracy score for each of the treatment modalities were all indicative of good accuracy, with 76%-99% of the information presented as being accurate. The median quality score was statistically different across the eight treatment modalities (p = 0.015). The median readability grade level was statistically different across the eight treatment modalities (p = 0.009). Websites that described TURP (median readability grade level, 9.00 [interquartile range (IQR) 8.00-10.80]) were significantly easier to read than those related to RSP (median readability grade level, 14.35 [IQR, 11.08-16.50]) (p = 0.011). No other statistically significant differences were found within the other treatment modality websites. Conclusions: The majority of websites retrieved were found to be of high accuracy, good quality, and poor readability. Additionally, it was found that none of the retrieved websites included descriptions for all the other included treatment modalities. Given these findings, the authors recommend the development of centralized resources with all guideline-approved treatment modalities and accurate, readable, and high-quality information related to the surgical treatment of BPH.

New Technologies for Treatment of Benign Prostatic Hyperplasia

BPH is a common disease in aging men which impacts quality of life. With advancing age expectation coupled with the rising demand for BPH therapy, new technologies have been developed that target rapid recovery and symptom relief, low complication rates, and the ability to perform the procedure in an outpatient setting with local anesthesia. MIST technologies have fostered BPH medical care with ejaculation preservation. Techniques and outcomes for BPH technologies including Aquablation, Rezūm, UroLift, iTind, Optilume BPH, XFLO, Zenflow, and Butterfly are reviewed and evaluated. Given the novelty of these technologies, long-term data are required to assess safety and efficacy.

Characterization of a Novel Implant Intended to Expand and Reshape the Prostatic Urethra for the Treatment of Benign Prostatic Hyperplasia: A Pre-Clinical Feasibility Study in the Canine Model

OBJECTIVE

To evaluate the safety, feasibility, and tissue response of a novel device for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia, using the first-generation Urocross Expander System (Mercury Expander System).

METHODS

The implant was deployed and retrieved using flexible cystoscope in 8 adult male canines, separated into three study arms by retrieval date (1-, 6-, and 12- months post-deployment). Cystoscopy and urethrograms verified implant position/diameter; bladder neck and external sphincter function/changes; prostatic tissue response; and implant condition. One-month post-retrieval, the prostate and surrounding tissue was sectioned and evaluated by a veterinary pathologist.

RESULTS

All implants were successfully deployed in the prostatic urethra. Urethral width was increased (6.9 ± 1.8 mm to 10.2 ± 0.6 mm, P = .012) and preserved through the dwell period. Urethral length and sphincter diameters didn't significantly change. All subjects (n = 8) remained continent without obstruction or retention. Adverse events included incisional site bleeding (n = 2) and transient hematuria (n = 3). One implant migrated into the bladder and spontaneously repositioned into the prostatic urethra. Post-retrieval, explant surfaces demonstrated no tissue growth, encrustation or stone formation. Imaging revealed contact site erythema and indentation, but no stones, strictures, perforations, erosions, nor ulcerations. Histopathology revealed glandular acinar changes, inflammation, and fibrosis.

CONCLUSION

The first generation of the Urocross Expander System demonstrated a favorable safety profile in the canine model. Changes in the prostatic urethra shape were noted with an increase in urethral width during the dwell period with minimal tissue changes. Further, the implant didn't demonstrate any encrustation, tissue growth or stone formation.

Prostatic urethral lift (UroLift) versus convective water vapor ablation (Rezum) for minimally invasive treatment of BPH: a comparison of improvements and durability in 3-year clinical outcomes

INTRODUCTION

Half of men aged > 60 years will develop benign prostatic hyperplasia (BPH) with 40% of these men having moderate-to-severe lower urinary tract symptoms (LUTS). There is limited knowledge on a head-to-head comparison of prostatic urethral lift (UroLift) and convective water vapor ablation (Rezum) for the treatment of LUTS secondary to BPH. We sought to compare randomized controlled trials with 3-year clinical outcome data.

MATERIALS AND METHODS

After a thorough literature search, two multicenter sham-controlled double-blind randomized trials for UroLift and Rezum were identified and compared. Both studies had similar designs, baseline characteristics, reported outcomes, and low risks of bias.

RESULTS

Rezum and UroLift resulted in significant improvement of International Prostate Symptom Score (IPSS) at 3 months (51.4% and 49.9%, respectively) and 50% reduction of IPSS Quality of Life that was durable across all time points. At 24 and 36 months, there was a statistically significant difference in IPSS between groups, favoring Rezum (-11.2 ± 7.3 versus -9.13 ± 7.62, p = 0.04, and -11.0 ± 7.1 versus -8.83 ± 7.41, p = 0.04, respectively). While Rezum had greater improvement in Qmax at 3 months (6.4 ± 7.2 versus 4.29 ± 5.16, p < 0.01), there was no difference in improvement from 12-36 months between treatments. Only UroLift experienced improvements of Men's Sexual Health Questionnaire- Ejaculatory Dysfunction (MSHQ-EjD) function from baseline and was better than Rezum at all time points (p < 0.01). Rezum failed to significantly reduce the MSHQ-EjD bother at 3 months, while UroLift demonstrated a significant reduction of 27.56% (p < 0.01). Both systems offered equal improvements in the bother score by 12-36 months. Surgical re-treatment rates favored Rezum over Urolift (4.4% vs. 10.7%, respectively).

CONCLUSIONS

Rezum achieved a greater improvement in symptom relief compared to UroLift. Improvement in ejaculatory dysfunction in patients treated with UroLift was greater than Rezum.

Quantifying the impact of SpaceOAR hydrogel on inter-fractional rectal and bladder dose during 0.35 T MR-guided prostate adaptive radiotherapy

PURPOSE

To investigate the impact of rectal spacing on inter-fractional rectal and bladder dose and the need for adaptive planning in prostate cancer patients undergoing SBRT with a 0.35 T MRI-Linac.

MATERIALS AND METHODS

We evaluated and compared SBRT plans from prostate cancer patients with and without rectal spacer who underwent treatment on a 0.35 T MRI-Linac. Each group consisted of 10 randomly selected patients that received prostate SBRT to a total dose of 36.25 Gy in five fractions. Dosimetric differences in planned and delivered rectal and bladder dose and the number of fractions violating OAR constraints were quantified. We also assessed whether adaptive planning was needed to meet constraints for each fraction.

RESULTS

On average, rectal spacing reduced the maximum dose delivered to the rectum by more than 8 Gy (p < 0.001). We also found that D3cc received by the rectum could be 12 Gy higher in patients who did not have rectal spacer (p < 9E-7). In addition, the results show that a rectal spacer can reduce the maximum dose and D15cc to the bladder wall by more than 1 (p < 0.004) and 8 (p < 0.009) Gy, respectively. Our study also shows that using a rectal spacer could reduce the necessity for adaptive planning. The incidence of dose constraint violation was observed in almost 91% of the fractions in patients without the rectal spacer and 52% in patients with implanted spacer.

CONCLUSION

Inter-fractional changes in rectal and bladder dose were quantified in patients who underwent SBRT with/without rectal SpaceOAR hydrogel. Rectal spacer does not eliminate the need for adaptive planning but reduces its necessity.

How I Do It: Temporarily Implanted Nitinol Device (iTind)

Benign prostatic hyperplasia is a common and progressive disease affecting aging men which has a significant impact on quality of life. The second-generation Temporarily Implanted Nitinol Device (iTind) is an FDA approved temporary prostatic urethral device which can be deployed using standard flexible cystoscopy without sedation or general anesthesia. The device is left in-situ for 5 to 7 days and is then entirely removed in the office, using an open-ended silicone catheter. Prospective, randomized data indicate that iTind has favorable functional and sexual patient outcomes. Readers will familiarize themselves with iTind, significant historical studies and the technique for deploying iTind using a flexible cystoscope in the office setting.

A Deep Learning Approach to Diagnostic Classification of Prostate Cancer Using Pathology-Radiology Fusion

BACKGROUND

A definitive diagnosis of prostate cancer requires a biopsy to obtain tissue for pathologic analysis, but this is an invasive procedure and is associated with complications.

PURPOSE

To develop an artificial intelligence (AI)-based model (named AI-biopsy) for the early diagnosis of prostate cancer using magnetic resonance (MR) images labeled with histopathology information.

STUDY TYPE

Retrospective.

POPULATION

Magnetic resonance imaging (MRI) data sets from 400 patients with suspected prostate cancer and with histological data (228 acquired in-house and 172 from external publicly available databases).

FIELD STRENGTH/SEQUENCE

1.5 to 3.0 Tesla, T2-weighted image pulse sequences.

ASSESSMENT

MR images reviewed and selected by two radiologists (with 6 and 17 years of experience). The patient images were labeled with prostate biopsy including Gleason Score (6 to 10) or Grade Group (1 to 5) and reviewed by one pathologist (with 15 years of experience). Deep learning models were developed to distinguish 1) benign from cancerous tumor and 2) high-risk tumor from low-risk tumor.

STATISTICAL TESTS

To evaluate our models, we calculated negative predictive value, positive predictive value, specificity, sensitivity, and accuracy. We also calculated areas under the receiver operating characteristic (ROC) curves (AUCs) and Cohen's kappa.

RESULTS

Our computational method (https://github.com/ih-lab/AI-biopsy) achieved AUCs of 0.89 (95% confidence interval [CI]: [0.86-0.92]) and 0.78 (95% CI: [0.74-0.82]) to classify cancer vs. benign and high- vs. low-risk of prostate disease, respectively.

DATA CONCLUSION

AI-biopsy provided a data-driven and reproducible way to assess cancer risk from MR images and a personalized strategy to potentially reduce the number of unnecessary biopsies. AI-biopsy highlighted the regions of MR images that contained the predictive features the algorithm used for diagnosis using the class activation map method. It is a fully automatic method with a drag-and-drop web interface (https://ai-biopsy.eipm-research.org) that allows radiologists to review AI-assessed MR images in real time.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Nurse Perspectives on Urinary Incontinence in the Home Hospice Setting

CONTEXT

To date, no studies have characterized the impacts of urinary incontinence (UI) at the end of life in the home hospice (HH) setting. UI is highly prevalent at the end of life and adversely affects quality of life.

OBJECTIVES

To characterize HH nurses' perspectives on UI in HH patients.

METHODS

We conducted a qualitative descriptive study of interviews between HH nurses and the study investigator. Thirty-two interviews with HH nurses were transcribed and analyzed. Nurses were mostly female, college-educated, and had several years of experience in HH nursing.

RESULTS

We identified findings in four major themes: 1) HH nurses' definition and identification of UI, 2) the absence of formal guidelines for diagnosing UI in HH patients, 3) UI's adverse effect on HH patients and their families, and 4) the lack of standardized guidelines for the management of UI in the HH setting. We found that there was a general lack of clarity on the subtypes of UI and no standardized guidelines for management of UI in the HH setting. Nurses reported that UI was bothersome to HH patients and their caregivers, citing patient discomfort, loss of dignity, and additional labor burden as reasons for this. Management strategies for UI lacked standardization.

CONCLUSION

UI is a prevalent and debilitating condition in HH patients. There is a need for studies to further characterize the impacts of UI on HH patients and their caregivers. Formal training on UI subtypes and management is needed to facilitate proper documentation, research, and improve patient outcomes.

The Mechanism of Action of cTIND for Minimally Invasive Ischemic Incision of the Prostate: In Vivo Study

OBJECTIVES

To understand the histologic changes of prostate tissue induced by temporary implantable nitinol device (cTIND) in a canine model.

METHODS

The cTIND is a small, symmetric device comprised of nitinol wire loops welded together on an axis, which exert radial force on the tissue to induce a targeted ischemic effect. The cTIND was implanted in three live canine models, which were monitored for 14 days post-index procedure. Device placement was monitored via serial fluoroscopy and biologic effects of cTIND were studied via histopathology.

RESULTS

The cTIND was successfully placed in the canine models and remained securely in position until the animal was sacrificed on postoperative day 14. The cTIND treated tissue demonstrated an abrupt transition from normal, viable prostatic glandular tissue to an area of shrunken necrosis and fibrosis between the two.

CONCLUSION

In the canine models, the cTIND created focal areas of ischemic necrosis resulting in incisions in the peri-urethral prostate with minimal inflammation.

Cost-Effectiveness and Budget Impact of Emerging Minimally Invasive Surgical Treatments for Benign Prostatic Hyperplasia

Background: Benign prostatic hyperplasia (BPH) is one of the most prevalent and costly chronic conditions among middle-aged and elderly men. Prostatic urethral lift (PUL) and convective water vapor thermal therapy (WVTT) are emerging minimally invasive surgical treatments as an alternative to traditional treatment options for men with moderate-to-severe BPH. This study evaluated the cost-effectiveness and budget impact of PUL and WVTT for men with BPH using long-term clinical outcomes. Methods: The cost-effectiveness and budget impact models were developed from a US Medicare perspective over a 4-year time horizon. The models were populated with males with a mean age of 63 and an average International Prostate Symptom Score (IPSS) of 22. Clinical inputs were extracted from the LIFT and Rezum II randomized controlled trials at 4 years. Utility values were assigned using IPSS and BPH severity levels. Procedural, adverse event, retreatment, follow-up, and medication costs were based on 2019 Medicare payment rates and Medicare Part D drug spending. One-way and probabilistic sensitivity analyses (PSAs) were performed. Results: At 4 years, PUL was associated with greater retreatment rates (24.6% vs 10.9%), lower quality-adjusted life-years (QALYs) (3.490 vs 3.548) and higher total costs (US$7393 vs US$2233) compared with WVTT, making WVTT the more effective and less costly treatment strategy. The 70% total cost difference of PUL and WVTT was predominantly driven by higher PUL procedural (US$5617 vs US$1689) and retreatment (US$976 vs US$257) costs. The PSA demonstrated that relative to PUL, WVTT yielded higher QALYs and lower costs 99% and 100% of the time, respectively. Conclusions: Compared to PUL, WVTT was a cost-effective and cost-saving treatment of moderate-to-severe BPH. These findings provide evidence for clinicians, payers, and health policy makers to help further define the role of minimally invasive surgical treatments for BPH.

Ejaculatory Hood-Sparing Photoselective Vaporization of the Prostate vs Bipolar Button Plasma Vaporization of the Prostate in the Surgical Management of Benign Prostatic Hyperplasia

Introduction and Objectives: After transurethral prostatectomy, erectile dysfunction and ejaculatory dysfunction are significant concerns for patients. We compared ejaculatory hood-sparing technique in patients who underwent photoselective vaporization of the prostate using the GreenLight Laser (EjS-PVP) with the ejaculatory hood-sparing technique in patients who underwent bipolar button plasma vaporization of the prostate (EjS-BPVP) in the surgical management of benign prostatic hyperplasia (BPH). Materials and Methods: Twenty-seven patients were randomized to either undergo EjS-PVP or EjS-BPVP from August 2016 to March 2018. All of the patients were sexually active with antegrade ejaculation before prostatectomy. We evaluated International Prostate Symptom Score (IPSS), quality of life (QoL), peak flow rate (Qmax), postvoid residual volume (PVR), International Index of Erectile Function and ejaculatory function by the Male Sexual Health Questionnaire (MSHQ). Men were evaluated preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was ejaculation preservation measured as no change or preservation in antegrade ejaculate at the last follow-up visit by MSHQ (6 months). Results: Twenty-seven patients with a mean age of 65.6 ± 8.4 years underwent either EjS-BPVP or EjS-PVP (Table 1). There were no differences in baseline characteristics between the two groups. Improvements in IPSS, QoL, Qmax, and PVR were durable throughout the study period in both groups. There was no difference in outcomes between groups. Postoperatively, there was no change in ejaculatory function with EjS-BPVP utilizing either 180 W EjS-PVP or bipolar energy. The change in MSHQ Ejaculation Scale was -2.1 and -5.4 at 6 months in both arms. The 6-month ejaculatory preservation rate was 85% in the EjS-PVP group and 78% in the EjS-BPVP group. Conclusions: EjS GreenLight photoselective vaporization and bipolar plasma button vaporization is a safe and effective method for treating men with lower urinary tract symptoms secondary to BPH with maintenance of antegrade ejaculation.

Opioid prescribing and risks among commercially insured women undergoing pelvic organ prolapse repair

PURPOSE

Opioid use after surgical repair for pelvic organ prolapse (POP) is intended for short-term post-operative pain. This study compared the incidence of opioid prescribing in women undergoing POP transabdominal repair with mesh and transvaginal native tissue repair.

METHODS

A retrospective cohort of women undergoing POP transabdominal repair with mesh or transvaginal native tissue repair, was derived from a 10% random sample of enrollees from 2007 to 2015 within the IQVIA PharMetrics® Plus Database. Primary outcomes were any prescription of opioids and cumulative days of opioids prescribed in the 14- 180 days following surgical intervention. Inverse probability of treatment weights controlled for observed baseline confounders. Any opioid prescription was estimated using logistic regression and generalized linear regression for cumulative days of opioids prescribed.

RESULTS

The cohort of 49 052 women who underwent POP surgical repair included 46 813 women with transvaginal native tissue repair and 2239 women with transabdominal repair with mesh. Women with a transabdominal repair with mesh had a 1.19 (95%CI: 1.09-1.31) significantly higher odds of receiving an opioid prescription than women with transvaginal native tissue repair. Post-operatively, over 29% of women received opioid prescriptions. Mean cumulative days of post-surgical opioid prescribing was 32.2 (SD = 43.1), and was not statistically different between groups. Thirteen percent of women were prescribed opioids for 90 days or more.

CONCLUSIONS

Women undergoing POP with transabdominal mesh are more likely to receive prescriptions for opioids after surgery compared to transvaginal native tissue repair. Treatment plans that address pain while mitigating the risks associated with prolonged opioid prescribing should be employed.

Differences in Urinary Bacterial Anti-Adhesion Activity after Intake of Cranberry Dietary Supplements with Soluble versus Insoluble Proanthocyanidins

A number of clinical trials support the use of standardized cranberry supplement products for prevention of urinary tract infections; however, products that are not well-characterized for sufficient levels of bioactive components may contribute to negative clinical outcomes. Cranberry supplements for consumer use are not regulated and can be formulated different ways using cranberry juice, pomace or various combinations. This can lead to consumer confusion regarding effectiveness of individual products. The current study compared two commercial supplement products, one made from cranberry juice extract and the other from a blend of whole cranberry. The influence of formulation and proanthocyanidin (PAC) solubility on in vitro and ex vivo P-fimbriated Escherichia coli bacterial anti-adhesion activity (AAA) was determined. Both supplement products as well as whole, frozen cranberries were chromatographically separated into crude polyphenolic, sugar and acid fractions. In vitro AAA testing of all fractions confirmed that only those containing soluble PACs elicited activity. The cranberry juice extract product had higher soluble PAC content than the whole cranberry blended product, which contained mainly insoluble PACs. The influence of soluble and insoluble PAC levels in each product on the urinary (ex vivo) AAA was determined following ingestion. The juice extract product was associated with significantly higher urinary AAA than that of the whole berry blended product when consumed once daily over the 1-week intervention period.

Is it time to offer True Minimally Invasive Treatments (TMIST) for BPH? - A review of office-based therapies and introduction of a new technology category

INTRODUCTION The options for treating benign prostatic hyperplasia (BPH) beyond medication and traditional transurethral surgery continue to expand. Undesirable side effects to medication and surgeries have driven interest toward minimally invasive surgical therapies (MISTs), including convective water vapor ablation (Rezum) and prostatic urethral lift (UroLift). While these treatments can be performed outside of the operating room, they do require special equipment and the use of rigid cystoscopy. A new class of treatments, which utilize no special equipment beyond a flexible cystoscope are emerging, the first of which, the temporary implantable nitinol device (iTind) is already FDA approved.

MATERIALS AND METHODS

A comprehensive review of the literature using PUBMED, EMBASE, Scopus focused on the two commercially available MISTs, Rezum and UroLift, was performed. Additionally, we evaluated the existing literature for the novel iTind.

RESULTS

UroLift and Rezum have demonstrated significant improvements in validated questionnaires such as IPSS and IPSS QoL. They generally maintain erectile function (IIEF) and ejaculatory function (MSHQ). The short term recovery seems to slightly favor UroLift, while re-treatment rates seem to favor Rezum. The iTind also appears to improve subjective and objectives outcomes, though longer term follow up is still maturing.

CONCLUSION

The currently available MISTs have changed the way we treat BPH, offering a middle ground for men between oral medial therapy and more invasive transurethral surgery. While these MIST treatments require specialized and costly equipment, the proposed a new category, the True Minimally Invasive Surgical Therapy, or TMIST, offers an off-the-shelf, affordable and comfortable solution for men suffering from LUTS secondary to BPH.

Putting Patients Ahead by Leaving Nothing Behind: An Emerging Treatment Paradigm in Minimally Invasive Surgical Therapy for Benign Prostatic Hyperplasia

Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) are highly prevalent in older men. The long-term clinical utility of lifestyle modification and oral medications for LUTS is limited. There is a great clinical need for safe, effective, and durable BPH therapies for men who unsuccessfully attempt conservative measures. Enthusiasm for transurethral resection of the prostate has declined due to surgical risk, high rates of postoperative sexual dysfunction, and the perceived invasive nature therein. Consequently, interest has grown in developing minimally invasive surgical treatments (MISTs) that are efficacious but with a more favorable risk profile in order to better align with patient preferences. This review evaluates currently available MISTs for BPH. Further, we critically examine a “Leave Nothing Behind” philosophy in MIST for BPH since implantation of permanent metallic devices may be associated with increased long-term failure rates.

Food and Drug Administration Safety Communication on the Use of Transvaginal Mesh in Pelvic Organ Prolapse Repair Surgery: The Impact of Social Determinants of Health

OBJECTIVE

This study was to examine the impact of the July 2011 Food and Drug Administration (FDA) safety communication on the use of transvaginal mesh in pelvic organ prolapse (POP) repair by patients' race and ethnicity.

METHODS

We conducted an observational cohort study of women undergoing POP repairs in 2008 to 2015 in New York State. We examined the changes in transvaginal mesh use in POP repairs before and after the FDA communication by patients' race and ethnicity. Piecewise logistic regression models were used to assess the trends of mesh use, adjusting for patient characteristics. We performed a subgroup analysis of the trends of transvaginal mesh use by racial groups, stratifying by patients' neighborhood socioeconomic status.

RESULTS

We included 49,848 women (78% white, 7% black, and 15% Hispanic) with an average ± SD age of 60.2 ± 13.0 years. After the safety communication, the use of transvaginal mesh in POP repairs decreased among white women (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.41-0.50) and African Americans (OR, 0.48; 95% CI, 0.35-0.67) but remained stable among Hispanic women (OR, 0.88; 95% CI, 0.70-1.11). Only in the subgroup of patients from high-income areas, there was a trend toward decreasing mesh use among Hispanic patients after 2011 (OR, 0.71; 95% CI, 0.49-1.04).

CONCLUSIONS

The communications related to the safety of transvaginal mesh did not have an equal impact across racial groups. Mesh use decreased among white and African American women but not among Hispanic women after the 2011 FDA safety communication. Particular attention is warranted for patients from disadvantaged groups, especially low-income minorities, when disseminating medical device safety messages.

The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicenter, Randomized, Controlled Trial

OBJECTIVE

To report the results of a multicenter, randomized, controlled trial with a temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Hadera, Israel) compared to sham for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

MATERIALS AND METHODS

Men 50 years or older were randomized 2:1 between iTind and sham procedure arms. A self-expanding, temporary nitinol device was placed for 5-7 days and an 18F Foley catheter was inserted and removed for the iTind and sham group, respectively. Patients were assessed at baseline, 1.5, 3, and 12 months postoperatively using the IPSS, peak urinary flow rate, residual urine, quality of life, and the International Index of Erectile Function. Unblinding occurred at 3 months.

RESULTS

A total of 175 men (mean age 61.1 ± 6.5) participated (118 iTind vs 57 sham). A total of 78.6% of patients in the iTind arm showed a reduction of ≥3 points in IPSS, vs 60% of patients in the control arm at 3 months. At 12 months, the iTind group reported a 9.25 decrease in IPSS (P< .0001), a 3.52ml/s increase in peak urinary flow rate (P < .0001) and a 1.9-point reduction in quality of life (P < .0001). Adverse events were typically mild and transient, most Clavien-Dindo grade I or II, in 38.1% of patients in the iTind arm and 17.5% in the control arm. No de novo ejaculatory or erectile dysfunction occurred.

CONCLUSION

Treatment with the second-generation iTind provided rapid and sustained improvement in lower urinary tract symptoms for the study period while preserving sexual function.

Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials

INTRODUCTION

Traditional benign prostatic hyperplasia treatment options, such as transurethral resection of the prostate and laser, have focused on addressing urinary symptoms for men; however, these options are associated with a high risk of sexual dysfunction.

OBJECTIVE

The objective of this study was to assess newer technologies (Aquablation therapy, UroLift, and Rezum) for the treatment of benign prostatic hyperplasia and the impact of preserving sexual function compared with transurethral resection of the prostate.

METHODS

A comprehensive review of Food and Drug Administration randomized studies from each of the technologies was carried out. A comparison of 3-year outcomes for International Index of Erectile Function-5 and Male Sexual Health Questionnaire Ejaculatory Function domain short form was analyzed.

RESULTS

Aquablation and prostatic urethral lift were the only therapies to show permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment.

CONCLUSION

For prostates less than 80 cc, Aquablation and prostatic urethral lift were able to demonstrate permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment. Bhojani N, Yafi FA, Misrai V, et al. Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials. Sex Med Rev 2021;9:169-173.