Nocturia is a highly prevalent symptom that affects multiple aspects of health. However, it is often underrecognized and undertreated, leading to problems both within the genitourinary system and systemically. The goal of this paper is to further characterize the pathophysiology behind the most common medical factors that contribute to nocturia by performing a focused literature review in a structured format. This will aid clinicians when evaluating and treating patients with nocturia. Based on expert opinion, we recognized six main common pathologies associated with nocturia: obesity, diabetes mellitus, hypertension, obstructive sleep apnea, benign prostatic hyperplasia, and lifestyle habits. Our literature review identified 49 articles including randomized controlled trials, observational studies, systematic reviews, and meta-analyses. Each condition has its own unique pathophysiology that is associated with the development of nocturia. These etiologies also present various ways upon which nocturia can be intervened. These six pathologies are the most common medical etiologies for nocturia based on expert opinion. This paper demonstrates the multifactorial nature of nocturia and highlights assessment and treatment strategies.

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety II (MP33)1 May 2024MP33-05 SINGLE-USE CYSTOSCOPES OFFERS FASTER TIME-TO-SCOPE WITH EQUIVALENT PERCEIVED FUNCTIONALITY VS REUSABLE SCOPES IN THE INPATIENT SETTING Stephen Hassig, Matthew Steidle, Carl Ceraolo, Jason Fairbourn, Denzel Zhu, Ashley Li, Galen Chen, Kelvin Lim, Christopher Wanderling, Aaron Saxton, Laena Hines, Trevor Hunt, Mark Ninomiya, Austin Lee, Rajat Jain, and Scott O. Quarrier Stephen HassigStephen Hassig , Matthew SteidleMatthew Steidle , Carl CeraoloCarl Ceraolo , Jason FairbournJason Fairbourn , Denzel ZhuDenzel Zhu , Ashley LiAshley Li , Galen ChenGalen Chen , Kelvin LimKelvin Lim , Christopher WanderlingChristopher Wanderling , Aaron SaxtonAaron Saxton , Laena HinesLaena Hines , Trevor HuntTrevor Hunt , Mark NinomiyaMark Ninomiya , Austin LeeAustin Lee , Rajat JainRajat Jain , and Scott O. QuarrierScott O. Quarrier View All Author Informationhttps://doi.org/10.1097/01.JU.0001009520.30626.80.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Single-use (SU) cystoscopes have increased in frequency both in the literature and in urologic practices, but incremental changes in workflow compared to reusable (RU) scopes are understudied. We hypothesized that SU cystoscopes reduce time in supply gathering and scope return for in-hospital consults requiring beside cystoscopy, without decreasing perceived functionality during real cystoscopy. METHODS: Urology residents from a single institution were randomized to a SU or RU cystoscope to complete a sham "difficult catheter placement" in the Emergency Department of the same hospital. Subjects collected equipment, set up and then tore down as if doing a cystoscopy at bedside, and returned equipment. Travel paths were standardized and all sections timed. Residents performing real cystoscopies over a 4-month period were also randomized by month to SU or RU scope, and afterwards filled out a NASA Task Load Index (TLX). T-test was used to compare continuous variables. Linear regression was used to assess difference in overall time. RESULTS: 10 urology residents volunteered and were randomized to SU or RU, with an average of 2.8 years of post-graduate training per group. Neither residency year nor resident height was statistically different between the two groups. At all examined time points aside from "other walking time," the SU times were less compared to RU (Table 1). RU scope acquisition depends on central processing and demonstrated high variability. Overall, SU scope saved 8 min 53 sec (p<0.01). Table 2 shows there were no significant differences across all 6 of the RAW TLX parameters, including "assessment of success." CONCLUSIONS: Single-use cystoscopes reduce time-to-scope for hospital bedside cystoscopy leading to more timely delivery of care and a decrease in non-clinical time burden related to preparing for cystoscopy compared to RU scopes without compromising the actual task, as measured by TLX. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e562 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Stephen Hassig More articles by this author Matthew Steidle More articles by this author Carl Ceraolo More articles by this author Jason Fairbourn More articles by this author Denzel Zhu More articles by this author Ashley Li More articles by this author Galen Chen More articles by this author Kelvin Lim More articles by this author Christopher Wanderling More articles by this author Aaron Saxton More articles by this author Laena Hines More articles by this author Trevor Hunt More articles by this author Mark Ninomiya More articles by this author Austin Lee More articles by this author Rajat Jain More articles by this author Scott O. Quarrier More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023MP49-12 ADVANCING COMPREHENSIVE URO-ONCOLOGIC CARE FOR THE URBAN UNDERSERVED Kit Yuen, Alexis Steinmetz, Mark Ninomiya, and Divya Ajay Kit YuenKit Yuen More articles by this author , Alexis SteinmetzAlexis Steinmetz More articles by this author , Mark NinomiyaMark Ninomiya More articles by this author , and Divya AjayDivya Ajay More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003297.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Racial and socioeconomic disparities in the incidence, treatment, and outcomes of urologic cancers are well documented; solutions to these inequities are not. The purpose of this study was to assess the feasibility and effectiveness of integrating a urologic specialty care clinic into an existing primary care infrastructure. We also aimed to increase trainees’ awareness of health inequities in urologic cancer care. METHODS: St. Joseph’s Neighborhood Center (SJNC) is a Catholic charity organization that provides health care and social services to individuals without health insurance. University of Rochester Medical Center (URMC) has a long-standing partnership with SJNC through a student-led primary care clinic. In February 2021, URMC residents organized bi-monthly urology clinics at SJNC staffed by attending, resident, and student volunteers. A preliminary analysis of clinic records was conducted. Qualitative data was obtained through direct observation of program processes and informal feedback with volunteers. RESULTS: Twelve clinics have been held. Four to 6 patients referred by SJNC’s primary care team were seen in each 2-hour evening clinic. Patients were evaluated by student/resident teams, followed by discussion with an attending urologist. Approximately 40% of patients were referred for suspected genitourinary malignancy. Multiple barriers to oncologic diagnostics were identified (Table 1). Hematuria evaluations were the most difficult to coordinate due to cost and logistics of imaging and procedures. Trainees reported an increased awareness of cancer care disparities and the practical challenges of overcoming access to specialty care in a medically underserved community. CONCLUSIONS: Comprehensive cancer care is routinely fragmented or unavailable to medically underserved populations. Despite a nationally recognized cancer center in Rochester, NY, many individuals living within the urban area struggle to obtain routine cancer screening and evaluations for potentially treatable or curable cancers. We outlined a feasible model of integrating access to uro-oncologic care into a primary care system with sustainable buy-in from local partners. Future directions are to increase the frequency of clinics, access to clinical trials, and decreasing the financial burdens of care. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e683 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.Metrics Author Information Kit Yuen More articles by this author Alexis Steinmetz More articles by this author Mark Ninomiya More articles by this author Divya Ajay More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023HF01-15 THE ILEAL URETER: OVER A CENTURY OF UROLOGIC INNOVATION Mark Ninomiya, Linda Hasman, Ronald Rabinowitz, and Divya Ajay Mark NinomiyaMark Ninomiya More articles by this author , Linda HasmanLinda Hasman More articles by this author , Ronald RabinowitzRonald Rabinowitz More articles by this author , and Divya AjayDivya Ajay More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003243.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Early descriptions of the ileal ureter date back to the late 19th century. While this was an innovative technique to address ureteral substitution, multiple complications were reported, and novel methods to address them continue to be studied today. We review the history and evolution of the ileal ureter and subsequent surgical advancements. METHODS: A comprehensive literature review was performed in conjunction with our University’s librarian (LH). We used PubMed to identify contemporary medical literature, ILLiad to access archived texts and old surgical and urological textbooks to obtain additional historical information and references. RESULTS: The first use of ileum to replace ureter was described in 1888 by Tizzoni and Foggi in a canine model. Fenger, in 1893, proposed the concept in humans. The first successful in vivo procedure was reported by Shoemaker in 1909 in a two-stage model. The patient was a young woman suffering from tuberculosis who had a solitary kidney. Her strictured ureter was replaced with ileum which was brought to the skin much like an ileal conduit initially. Subsequently, it was anastomosed to the bladder. This was the basis for modern ileal ureter. In 1940, Nissen reported a similar case and in 1950, Muller attached the ureters to a loop of ileum that was anastomosed to the bladder in a woman with bilateral iatrogenic ureteral injuries due to gynecologic surgery for uterine malignancy. For a case of bilateral stenosis, Foret and Heugshem replaced both ureters with a single segment of ileum in 1953. In 1959, Goodwin reported a case series of various configurations of ileal ureters. As experience with bowel reconstruction for ureters increased through the 1960s and 1970s, complications became more apparent and resulted in refinements including metabolic, reflux, and minimally invasive techniques. CONCLUSIONS: Though the complications associated with this procedure have led to novel surgical advances, the modern ileal ureter utilizes the same method as first described more than a century ago. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e261 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark Ninomiya More articles by this author Linda Hasman More articles by this author Ronald Rabinowitz More articles by this author Divya Ajay More articles by this author Expand All Advertisement PDF downloadLoading ...

Objectives Surgical techniques to repair a ureteral stricture may depend on the stricture’s etiology, length, and location. Options may range from primary ureteral reimplantation for short, distal strictures, buccal mucosa onlay ureteroplasty for complex proximal or mid ureteral defects, to Boari flap or even autotransplantation for longer mid to distal ureteral defects. Replacement of the entire ureter with a segment of ileum is rare but may provide durable results when indicated. Our objective was to illustrate how the history and evolution of the ileal ureter entered the contemporary surgical armamentarium. Methods A comprehensive literature review was performed in conjunction with library resources in the History of Medicine section at the University of Rochester. We used PubMed to identify contemporary medical literature, ILLiad to access archived texts and historic surgical and urological textbooks to obtain additional historical information and references. Results We documented perhaps the first description of the ileal ureter in a canine model by Guido Tizzoni and Alfonso Foggi in 1888. Adaptations of ileal ureters over the next century, and beyond, have increased the safety, feasibility, and reproducibility of thre procedure for replacement of the ureter rendered unsalvageable by strictural disease, trauma, or malignancy. Conclusions Tizzoni and Foggi described the first ileal ureter in the canine model in 1888.

Introduction and Objective: Holmium laser enucleation of the prostate (HoLEP) is often offered for symptomatic prostatic enlargement at high risk for bleeding. However, prior studies define clinically significant hematuria (CSH) narrowly as the need for blood transfusion or significant decrease in hemoglobin. We sought to evaluate risk factors contributing to a broader definition of CSH, which may contribute to alteration of clinical course. Methods: We analyzed 164 patients in a prospectively maintained database who underwent HoLEP at a single institution across two surgeons from November 2020 to April 2023. HoLEP was performed using Moses 2.0 (Boston Scientific) laser and the Piranha enucleation system (Richard Wolf). We defined CSH broadly as follows: clot retention, return to operating room, perioperative management variation due to hematuria, or continued gross hematuria past 1 month postoperatively. Univariable and multivariable ANOVAs were used. Multivariable analysis of CSH risk based on the use of antiplatelet (AP) agents or anticoagulants included correction for age, enucleation time (surrogate for case difficulty), and prostate volume. Results: 17.7% (29/164) of our patients developed CSH after HoLEP. Longer enucleation time was a mild risk factor for developing CSH (multivariate odds ratio [OR] 1.01, p = 0.02). The strongest predictor of CSH was the use of anticoagulation or AP agents (OR 2.71 p < 0.02 on univariable analysis, OR 2.34 p < 0.02 on multivariable analysis), even when aspirin 81 mg was excluded. Conclusion: With a broadened definition, 18% of patients developed CSH following HoLEP, which impacted the clinical course. Our data suggest that the current definition of significant hematuria is too narrow and does not capture many patients whose clinical course is affected by hematuria. While safe, anticoagulants and APs significantly predicted an increased CSH risk, and patients should be counseled accordingly.

Antibiotic-loaded bone cement (ALBC) is broadly used to treat orthopaedic infections based on the rationale that high-dose local delivery is essential to eradicate biofilm-associated bacteria. However, ALBC formulations are empirically based on drug susceptibility from routine laboratory testing, which is known to have limited clinical relevance for biofilms. There are also dosing concerns with nonstandardized, surgeon-directed, hand-mixed formulations, which have unknown release kinetics. On the basis of our knowledge of in vivo biofilms, pathogen virulence, safety issues with nonstandardized ALBC formulations, and questions about the cost-effectiveness of ALBC, there is a need to evaluate the evidence for this clinical practice. To this end, thought leaders in the field of musculoskeletal infection (MSKI) met on 1 August 2019 to review and debate published and anecdotal information, which highlighted four major concerns about current ALBC use: (a) substantial lack of level 1 evidence to demonstrate efficacy; (b) ALBC formulations become subtherapeutic following early release, which risks induction of antibiotic resistance, and exacerbated infection from microbial colonization of the carrier; (c) the absence of standardized formulation protocols, and Food and Drug Administration-approved high-dose ALBC products to use following resection in MSKI treatment; and (d) absence of a validated assay to determine the minimum biofilm eradication concentration to predict ALBC efficacy against patient specific micro-organisms. Here, we describe these concerns in detail, and propose areas in need of research.

Staphylococcus aureus and Streptococcus agalactiae (Group B streptococcus, GBS) are common causes of deep musculoskeletal infections (MSKI) and result in significant patient morbidity and cost to the healthcare system. One of the major challenges with MSKI is the lack of faithful diagnostics to correctly identify the primary pathogen, as standard culture-based assays are prone to false positives in the case of polymicrobial infections, and false negatives due to limitations in sample acquisition and antibiotic use before presentation. To improve upon our current diagnostic methods for MSKI, we developed a multiplex immunoassay for antigen-specific IgGs in serum (Luminex), and medium enriched for newly synthesized antibodies (MENSA) for anti-S. aureus and GBS generated from cultured peripheral blood mononuclear cells (PBMCs) of orthopedic infection patients undergoing surgical treatment. Samples were obtained from 110 MSKI patients: 80 diabetic foot ulcer, 21 periprosthetic joint infection, 5 septic arthritis, 2 spine, 1 hand, and 1 fracture-related infection (FRI). Anti-S. aureus and anti-GBS antibody titers were compared to culture results to assess their concordance in identifying the pathogens. Immunoassay, particularly MENSA, showed high diagnostic potential for monomicrobial S. aureus and GBS orthopedic infections (AUC > 0.95). MENSA also demonstrated diagnostic potential for GBS polymicrobial orthopedic infection and for GBS DFU (AUC > 0.83 for both). Serum showed high diagnostic potential for S. aureus PJI (AUC > 0.95). Taken together, these findings support the development of species-specific immunoassays for the identification of causal pathogens in active MSKI, especially in conjunction with standard culture.

Osteomyelitis is a devastating disease caused by microbial infection of bone. While the frequency of infection following elective orthopedic surgery is low, rates of reinfection are disturbingly high. Staphylococcus aureus is responsible for the majority of chronic osteomyelitis cases and is often considered to be incurable due to bacterial persistence deep within bone. Unfortunately, there is no consensus on clinical classifications of osteomyelitis and the ensuing treatment algorithm. Given the high patient morbidity, mortality, and economic burden caused by osteomyelitis, it is important to elucidate mechanisms of bone infection to inform novel strategies for prevention and curative treatment. Recent discoveries in this field have identified three distinct reservoirs of bacterial biofilm including: Staphylococcal abscess communities in the local soft tissue and bone marrow, glycocalyx formation on implant hardware and necrotic tissue, and colonization of the osteocyte-lacuno canalicular network (OLCN) of cortical bone. In contrast, S. aureus intracellular persistence in bone cells has not been substantiated in vivo, which challenges this mode of chronic osteomyelitis. There have also been major advances in our understanding of the immune proteome against S. aureus, from clinical studies of serum antibodies and media enriched for newly synthesized antibodies (MENSA), which may provide new opportunities for osteomyelitis diagnosis, prognosis, and vaccine development. Finally, novel therapies such as antimicrobial implant coatings and antibiotic impregnated 3D-printed scaffolds represent promising strategies for preventing and managing this devastating disease. Here, we review these recent advances and highlight translational opportunities towards a cure.

Osteomyelitis is a chronic bone infection that is often treated with adjuvant antibiotic-impregnated poly(methyl methacrylate) (PMMA) cement spacers in multi-staged revisions. However, failure rates remain substantial due to recurrence of infection, which is attributed to the poor performance of the PMMA cement as a drug release device. Hence, the objective of this study was to design and evaluate a bioresorbable calcium phosphate scaffold (CaPS) for sustained antimicrobial drug release and investigate its efficacy in a murine model of femoral implant-associated osteomyelitis. Incorporating rifampin and sitafloxacin, which are effective against bacterial phenotypes responsible for bacterial persistence, into 3D-printed CaPS coated with poly(lactic co-glycolic) acid, achieved controlled release for up to two weeks. Implantation into the murine infection model resulted in decreased bacterial colonization rates at 3- and 10-weeks post-revision for the 3D printed CaPS in comparison to gentamicin-laden PMMA. Furthermore, a significant increase in bone formation was observed for 3D printed CaPS incorporated with rifampin at 3 and 10 weeks. The results of this study demonstrate that osteoconductive 3D printed CaPS incorporated with antimicrobials demonstrate more efficacious bacterial colonization outcomes and bone growth in a single-stage revision in comparison to gentamicin-laden PMMA requiring a two-stage revision.

The incidence of complications from prosthetic joint infection (PJI) is increasing, and treatment failure remains high. We review the current literature with a focus on Staphylococcus aureus pathogenesis and biofilm, as well as treatment challenges, and novel therapeutic strategies. S. aureus biofilm creates a favorable environment that increases antibiotic resistance, impairs host immunity, and increases tolerance to nutritional deprivation. Secreted proteins from bacterial cells within the biofilm and the quorum-sensing agr system contribute to immune evasion. Additional immunoevasive properties of S. aureus include the formation of staphylococcal abscess communities (SACs) and canalicular invasion. Novel approaches to target biofilm and increase resistance to implant colonization include novel antibiotic therapy, immunotherapy, and local implant treatments. Challenges remain given the diverse mechanisms developed by S. aureus to alter the host immune responses. Further understanding of these processes should provide novel therapeutic mechanisms to enhance eradication after PJI.

Management of foot salvage therapy (FST) for diabetic foot infections (DFI) is challenging due to the absence of reliable diagnostics to identify the etiologic agent and prognostics to justify aggressive treatments. As Staphylococcus aureus is the most common pathogen associated with DFI, we aimed to develop a multiplex immunoassay of IgG in serum and medium enriched for newly synthesized anti-S. aureus antibodies (MENSA) generated from cultured peripheral blood mononuclear cells of DFI patients undergoing FST. Wound samples were collected from 26 DFI patients to identify the infecting bacterial species via 16S rRNA sequencing. Blood was obtained over 12 weeks of FST to assess anti-S. aureus IgG levels in sera and MENSA. The results showed that 17 out of 26 infections were polymicrobial and 12 were positive for S. aureus While antibody titers in serum and MENSA displayed similar diagnostic potentials to detect S. aureus infection, MENSA showed a 2-fold-greater signal-to-background ratio. Multivariate analyses revealed increases in predictive power of diagnosing S. aureus infections (area under the receiver operating characteristic curve [AUC] > 0.85) only when combining titers against different classes of antigens, suggesting cross-functional antigenic diversity. Anti-S. aureus IgG levels in MENSA decreased with successful FST and rose with reinfection. In contrast, IgG levels in serum remained unchanged throughout the 12-week FST. Collectively, these results demonstrate the applicability of serum and MENSA for diagnosis of S. aureus DFI with increased power by combining functionally distinct titers. We also found that tracking MENSA has prognostic potential to guide clinical decisions during FST.

ABSTRACT Although Staphylococcus aureus osteomyelitis is considered to be incurable, the major bacterial reservoir in live cortical bone has remained unknown. In addition to biofilm bacteria on necrotic tissue and implants, studies have implicated intracellular infection of osteoblasts and osteocytes as a mechanism of chronic osteomyelitis. Thus, we performed the first systematic transmission electron microscopy (TEM) studies to formally define major reservoirs of S. aureus in chronically infected mouse (Balb/c J) long bone tissue. Although rare, evidence of colonized osteoblasts was found. In contrast, we readily observed S. aureus within canaliculi of live cortical bone, which existed as chains of individual cocci and submicron rod-shaped bacteria leading to biofilm formation in osteocyte lacunae. As these observations do not conform to the expectations of S. aureus as non-motile cocci 1.0 to 1.5 μm in diameter, we also performed immunoelectron microscopy (IEM) following in vivo BrdU labeling to assess the role of bacterial proliferation in canalicular invasion. The results suggest that the deformed bacteria: (1) enter canaliculi via asymmetric binary fission; and (2) migrate toward osteocyte lacunae via proliferation at the leading edge. Additional in vitro studies confirmed S. aureus migration through a 0.5-μm porous membrane. Collectively, these findings define a novel mechanism of bone infection, and provide possible new insight as to why S. aureus implant-related infections of bone tissue are so challenging to treat. © 2016 American Society for Bone and Mineral Research.