INTRODUCTION:Anesthesia choice during the procedural management of suspected renal colic during pregnancy may vary based on available resources and patient or provider preferences, as there are no specific recommendations. Our objective was to evaluate whether preterm birth (<37 weeks) was associated with anesthesia type, anesthesia timing by trimester, or procedure type. METHODS:We retrospectively identified pregnant patients who required procedural management with ureteral stent, percutaneous nephrostomy (PCN), or ureteroscopy (URS) for suspected renal colic based on laboratory and imaging findings from 2009-2021 at our center. Analyzed data included anesthesia type (local analgesia only, monitored anesthesia care [MAC], spinal anesthesia, or general anesthesia), trimester of procedure, procedure type, and obstetric outcomes, including preterm birth. RESULTS:The study cohort included 96 patients who underwent 231 total procedures, including primary URS, PCN, and stent, as well as PCN and stent change. The median gestational age was 38.7 weeks (37.1-39.5), and preterm birth rate was 15.8%. The most common anesthetic used across all procedures and trimesters was MAC. PCN was associated with the use of less invasive analgesia or anesthesia, whereas endoscopic procedures were more commonly performed with spinal or general anesthesia. Using multivariable logistic regression, procedure type was associated with preterm birth, but not anesthesia type or timing by trimester. CONCLUSIONS:Anesthesia type and timing were not associated with preterm birth, and selection may be influenced by resources, clinical scenario, or patient and provider preferences.

You have accessJournal of UrologyStone Disease: Medical & Dietary Therapy (MP26)1 May 2024MP26-08 OBSTETRIC AND NEONATAL OUTCOMES IN PREGNANT WOMEN PRESCRIBED TAMSULOSIN FOR MEDICAL EXPULSIVE THERAPY Louisa Ho, Sailakshmi Senthil Kumar, Cyrus Chehroudi, Madison Lyon, Alec Sun, Anup Shah, Natalia Llarena, Carrie Bennet, Sri Sivalingam, Anna Zampini, and Smita De Louisa HoLouisa Ho , Sailakshmi Senthil KumarSailakshmi Senthil Kumar , Cyrus ChehroudiCyrus Chehroudi , Madison LyonMadison Lyon , Alec SunAlec Sun , Anup ShahAnup Shah , Natalia LlarenaNatalia Llarena , Carrie BennetCarrie Bennet , Sri SivalingamSri Sivalingam , Anna ZampiniAnna Zampini , and Smita DeSmita De View All Author Informationhttps://doi.org/10.1097/01.JU.0001009408.66023.77.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Tamsulosin is commonly used for medical expulsive therapy (MET) in patients with ureteral stones. The off-label use of tamsulosin (FDA Category B) in pregnant women with symptomatic urolithiasis is controversial. We aimed to evaluate obstetric and neonatal outcomes for pregnant women prescribed tamsulosin as MET for suspected renal colic. METHODS: A retrospective review of pregnant patients with suspected symptomatic urolithiasis at our institution from 2009 to 2021 was performed. All patients who underwent surgical intervention (stent, nephrostomy tube, or ureteroscopy) were included, along with a similar number of the most recent patients who matched criteria and were managed expectantly. Symptomatic urolithiasis was defined as flank pain with documented hydronephrosis and one of the following: microscopic or gross hematuria, stone crystals on urinalysis, pyuria, absent ureteral jets, or definitive stones on imaging. Obstetric outcomes included preterm labor and time from initial presentation to first surgical intervention. Neonatal outcomes included APGAR scores and severe neonatal complications. RESULTS: We identified 196 women with suspected urolithiasis during pregnancy of whom 89 received tamsulosin and 107 did not (control). There was no significant difference in mean gestational age (GA) at initial presentation between groups. Mean duration of tamsulosin prescription was 26 days (range 1 to 175), occurring during the first, second, and third trimester in 15 (8%), 97 (49%), and 84 (43%) patients, respectively. Among patients who required intervention, there was a longer time to intervention in those who were prescribed tamsulosin (mean 2.1 vs. 7.9 days, p=.01), with no difference in narcotic utilization. Conversely, patients who did not require a procedure and were prescribed tamsulosin were more likely to be prescribed narcotics as well during the stone event (82% vs. 37%, p<.0001). There was no difference in preterm labor rates between the tamsulosin and control groups (11% vs. 12%). No significant differences in neonatal outcomes were identified including APGAR scores, GA at delivery, neonatal intensive care unit admission, respiratory distress syndrome, and intraventricular hemorrhage. CONCLUSIONS: In pregnant women with renal colic, use of tamsulosin was not associated with adverse maternal or neonatal outcomes in this cohort. In those requiring a procedure, use of tamsulosin was associated with prolonged time to intervention. Patients managed non-surgically using tamsulosin were more likely to be co-prescribed a narcotic. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e416 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Louisa Ho More articles by this author Sailakshmi Senthil Kumar More articles by this author Cyrus Chehroudi More articles by this author Madison Lyon More articles by this author Alec Sun More articles by this author Anup Shah More articles by this author Natalia Llarena More articles by this author Carrie Bennet More articles by this author Sri Sivalingam More articles by this author Anna Zampini More articles by this author Smita De More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023MP48-03 QUALITY MEASURES REPORTED BY UROLOGISTS IN THE MERIT-BASED INCENTIVE PAYMENT SYSTEM Avinash Maganty, Noah Krampe, Anup Shah, and Vishnukamal Golla Avinash MagantyAvinash Maganty More articles by this author , Noah KrampeNoah Krampe More articles by this author , Anup ShahAnup Shah More articles by this author , and Vishnukamal GollaVishnukamal Golla More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The majority of urologists are required to participate in merit-based incentive payment system (MIPS) –a Medicare-mandate reporting system in which physicians must track and report quality measures. Medicare adjusts physician reimbursement based on performance across these measures, with the intention to improve the quality of patient care. However, very few MIPS measures are relevant to urology patients and it is unclear what measures urologists are choosing to track and report. METHODS: We performed a cross-sectional analysis of MIPS measures reported by urologists for the most recent performance year. Urologists were categorized by their reporting affiliation (i.e., individual, group, or alternative payment model [APM]). We identified the measures which were most frequently reported by urologists. Among all measures reported, we identified those that were “topped out” (i.e., measures considered indiscriminate by Medicare because high performance is easily achieved) and those which were relevant for patients with urologic conditions (i.e., MIPS urology measures, qualified urologic registry measures, or those relevant to surgical care). RESULTS: 8,297 urologists reported in MIPS during the 2020 performance year, of whom 14% reported as an individual, 56% as a part of a group, and 30% as part of an APM. Among the top 10 most frequently reported measures, none were specific for urologic care (Table 1). 65% of individual urologists, 58% of those in groups, and 92% in APMs reported at least 1 or more “topped out” measures. Only 11% of urologists reported measures that were directly relevant to patients with urologic conditions. CONCLUSIONS: Most measures reported by urologists are not directly relevant to patients with urologic conditions and remain a poor indicator of the quality of urologic care provided. As Medicare transitions MIPS to condition specific quality measures, it will be important for the urology community to develop and submit measures that will be most impactful for patients. Source of Funding: Avinash Maganty is supported by funding from the National Cancer Institute Ruth L. Kirschstein Postdoctoral Award F32 Grant F32 CA275021-01 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e655 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Avinash Maganty More articles by this author Noah Krampe More articles by this author Anup Shah More articles by this author Vishnukamal Golla More articles by this author Expand All Advertisement PDF downloadLoading ...

OBJECTIVE To identify the differences in radiation exposure per suspected stone episode between percutaneous nephrostomy tube (PCN), stent, and primary ureteroscopy (URS).The incidence of nephrolithiasis in pregnancy is low; however, repercussions for both mother and fetus can be significant. In cases of suspected obstructing nephrolithiasis, intervention may be required, including ureteral stent, PCN, or URS, with the potential for multiple subsequent procedures that often utilize fluoroscopy.METHODS Pregnant patients who required an intervention (stent, PCN, or URS) for suspected obstructing nephrolithiasis were retrospectively reviewed. The primary outcome was total fluoroscopy exposure per suspected stone episode. Secondary outcomes included fluoroscopic exposure per procedure and number of procedures required.RESULTS After excluding patients with renal anomalies and incomplete radiation data, 78 out of 100 patients were included in the analysis. Forty patients (51.3%) underwent initial stent placement, 22 (28.2%) underwent initial PCN placement, and 16 (20.5%) underwent primary URS. Total mean radiation exposure per stone episode was significantly higher in patients who underwent PCN, (286.9 mGy vs 3.7 mGy (stent) and 0.2 mGy (URS), P < .001). In addition, patients who underwent initial PCN placement had significantly more procedures (P < .001) and mean radiation exposure per procedure was higher (P < .001). More than 40% of PCNs experienced dysfunction, and mean duration between PCN exchanges was 16.5 days.CONCLUSION In pregnant patients with suspected obstructing nephrolithiasis requiring intervention, initial PCN placement was associated with a significantly higher number of procedures, radiation exposure per procedure, and total radiation exposure per suspected stone episode compared to stent and URS. UROLOGY 182: 61-66, 2023.(c) 2023 Elsevier Inc. All rights reserved.

You have accessJournal of UrologyCME1 May 2022MP14-07 COMPARATIVE RADIATION EXPOSURE FOR PREGNANT PATIENTS WHO REQUIRED INTERVENTION FOR SYMPTOMATIC NEPHROLITHIASIS Madison Lyon, Alec Sun, Anup Shah, Natalia Llarena, Carrie Bennet, Sri Sivalingam, Juan Calle, Anna Zampini, and Smita De Madison LyonMadison Lyon More articles by this author , Alec SunAlec Sun More articles by this author , Anup ShahAnup Shah More articles by this author , Natalia LlarenaNatalia Llarena More articles by this author , Carrie BennetCarrie Bennet More articles by this author , Sri SivalingamSri Sivalingam More articles by this author , Juan CalleJuan Calle More articles by this author , Anna ZampiniAnna Zampini More articles by this author , and Smita DeSmita De More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002543.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The incidence of nephrolithiasis in pregnancy is low; however, the repercussions for both mother and fetus can be significant. Pregnancies with stones have an increased risk of adverse birth outcomes and are associated with significant morbidity. In cases of obstructing nephrolithiasis, intervention may include double-J stent (DJS), percutaneous nephrostomy tube (PCN), or ureteroscopy (URS) with the potential for subsequent procedures such as frequent DJS or PCN exchanges. These interventions often utilize intra-procedural fluoroscopy, which could result in harmful levels of radiation to the fetus. In the present study, we sought to identify the differences in radiation dose per stone episode between initial intervention with PCN, DJS and URS. METHODS: After IRB approval, pregnant patients undergoing a procedure for urolithiasis were retrospectively reviewed at a large multi-center hospital system. Patients who presented during an active pregnancy with acute renal colic and imaging suggestive of obstructing calculi, and who subsequently required an intervention (DJS, PCN, or URS) were included in the analysis. The primary outcome was total fluoroscopy dose per stone episode. Secondary outcomes included fluoroscopic exposure per procedure and average number of procedures required per stone episode. Kruskal-Wallis Rank-Sum Tests were used to assess statistical significance. If significant with a 2-sided p-value of 0.05, post-hoc pairwise testing was performed with a Wilcoxon Rank-Sum test. RESULTS: 85 patients met inclusion criteria, of whom 40 (55.6%) were managed with DJS, 22 (30.6%) PCN, and 10 (13.9%) primary URS. 13 patients were excluded due to incomplete radiation data. Median total number of procedures was significantly higher in those who underwent initial PCN placement (4.5) compared to primary URS (1) or stent (2) (p <0.001). Those that underwent PCN were more likely to undergo procedures that required radiation (p<0.001), with a mean radiation per procedure of 61.5 mGy, compared to 0.1 mGy for stent and URS. Total radiation exposure per stone episode was significantly higher in patients that underwent PCN placement (mean 250.8 mGy for PCN, 2.0 mGY for DJS, and 2.2 mGy for URS, p<0.001). CONCLUSIONS: In pregnant patients with suspected acute renal colic requiring intervention, initial PCN placement was associated with a significantly higher number of procedures, higher radiation dose per procedure, and higher total radiation exposure per stone episode compared to DJS and URS. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e234 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Madison Lyon More articles by this author Alec Sun More articles by this author Anup Shah More articles by this author Natalia Llarena More articles by this author Carrie Bennet More articles by this author Sri Sivalingam More articles by this author Juan Calle More articles by this author Anna Zampini More articles by this author Smita De More articles by this author Expand All Advertisement PDF DownloadLoading ...

You have accessJournal of UrologyCME1 May 2022MP14-08 NEONATAL OUTCOMES AFTER INTERVENTION FOR RENAL COLIC IN PREGNANCY Alec Sun, Carrie Bennett, Anup Shah, Madison Lyon, Sri Sivalingam, Juan Calle, Anna Zampini, and Smita De Alec SunAlec Sun More articles by this author , Carrie BennettCarrie Bennett More articles by this author , Anup ShahAnup Shah More articles by this author , Madison LyonMadison Lyon More articles by this author , Sri SivalingamSri Sivalingam More articles by this author , Juan CalleJuan Calle More articles by this author , Anna ZampiniAnna Zampini More articles by this author , and Smita DeSmita De More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002543.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephrolithiasis in pregnant patients is rare but has been linked to obstetric complications including preterm labor, premature rupture of membranes, and loss of pregnancy. For pregnant patients with renal colic who fail conservative management, the American Urological Association (AUA) guidelines recommend primary ureteroscopy (URS), double-J stent (DJS), or percutaneous nephrostomy (PCN). To our knowledge, this is the first study to examine neonatal outcomes following 3 different interventions in pregnant women presenting with an acute stone event. METHODS: After IRB approval, women undergoing a procedure for renal colic during pregnancy at a large multi-center, high-volume institution were retrospectively identified and categorized by initial intervention into 3 groups: DJS, PCN, and URS. Procedural and obstetric outcomes were recorded; neonatal outcomes were linked to maternal data. Intervention groups were compared by a Kruskal-Wallis or Fisher’s Exact Test, as appropriate. If statistical significance was reached at α=0.05, pairwise post-hoc significance testing was performed with a Wilcoxon rank-sum test (α=0.05). RESULTS: Eighty-one patients met inclusion criteria and were analyzed. Of these, 25 patients were managed with PCN, 45 with DJS, and 11 with URS. Maternal age at presentation, BMI, and maternal comorbidities including diabetes, hypertension, and chronic kidney disease were similar between groups. Gestational age at delivery did not significantly differ between groups (p=0.17). Neonatal Intensive Care Unit (NICU) admission and neonatal abstinence syndrome (NAS) rates were higher in mothers managed with PCN versus DJS (p=0.003 and p=0.01, respectively). No NAS was noted in the URS group. Although not statistically significant, hospital length of stay and respiratory distress syndrome trended higher in the PCN group (p=0.07 and p=0.08, respectively). Rates of other neonatal complications, including pre-term labor and APGAR scores at 1 and 5 minutes did not differ between groups. CONCLUSIONS: Current AUA guidelines list DJS and PCN as safe alternative interventions to URS for managing nephrolithiasis in pregnancy, but our study demonstrates for the first time a higher rate of NAS and NICU admissions for babies born to mothers managed with PCN. All cases of NAS observed in our study occurred in the PCN group, with narcotic use directly linked to management of pain due to PCN. Larger multi-institutional studies are warranted to further explore these possible associations. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e235 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alec Sun More articles by this author Carrie Bennett More articles by this author Anup Shah More articles by this author Madison Lyon More articles by this author Sri Sivalingam More articles by this author Juan Calle More articles by this author Anna Zampini More articles by this author Smita De More articles by this author Expand All Advertisement PDF DownloadLoading ...

Purpose: We aimed to identify predictor variables associated with pituitary abnormalities in hypogonadal men with mild hyperprolactinemia. We also sought to develop a decision-making aid to select patients for evaluation with pituitary magnetic resonance imaging. Materials and Methods: We retrospectively examined men with mild hyperprolactinemia (15.1-50.0 ng/ml) who presented with symptoms of hypogonadism and underwent pituitary magnetic resonance imaging. Demographics, laboratory values and clinical data were obtained from the electronic medical record. Selected predictor variables were included in multivariable logistic regression and partitioning models. Cost avoidance analysis was performed on models achieving sensitivities >= 90%. Results: A total of 141 men were included in the study, of whom 40 (28%) displayed abnormalities on pituitary magnetic resonance imaging. Patients with pituitary abnormalities exhibited higher prolactin (p=0.01), lower testosterone (p=0.0001) and lower luteinizing hormone (p=0.03) levels than those with normal anatomy, as well as higher prolactin-to-testosterone ratios (p <0.0001) and lower luteinizing hormone-to-follicle-stimulating hormone ratios (p=0.0001). These serological variables were identified as the best performing predictor variables. The partition incorporating a prolactin-to-testosterone ratio cutoff of 0.10 and prolactin cutoff of 25 ng/ml achieved 90% sensitivity and 48% specificity, and reduced diagnostic expenses by 28%. Conclusions: Hypogonadal men presenting with mild hyperprolactinemia and pituitary abnormalities declare themselves via endocrine studies routinely ordered to evaluate these conditions. The prolactin-to-testosterone ratio is the best independent predictor of finding a pituitary abnormality on magnetic resonance imaging, although sensitivity improves by referencing additional serological parameters. Significant cost avoidance may result from screening this population prior to ordering pituitary magnetic resonance imaging.

Abstract Background : Serum prolactin (PRL) and testosterone (T) levels are routinely evaluated in men presenting with clinical symptoms of hypogonadism. Persistent mild elevations in PRL are often benign, but may reflect structural pathology. Though pituitary magnetic resonance imaging (pitMRI) is often obtained to assess for anatomic lesions, it remains unclear how to optimize screening in hypogonadal men with mild hyperprolactinemia. Objective : We sought to identify risk factors associated with detection of pituitary pathology among hypogonadal men with mild hyperprolactinemia and aimed to improve selection of those indicated for pitMRI. Methods : A retrospective, case-control study was performed. Men under 75 presenting with clinical hypogonadism and mild hyperprolactinemia (15-50 ng/dL) who underwent pitMRI at a single tertiary care center were included. Individuals presenting with clinical symptoms strongly suggestive of a pituitary mass (e.g. visual change, headache, panhypopituitarism) were excluded, as were patients who had been previously evaluated for hyperprolactinemia. Age, body mass index (BMI), presenting symptoms, prescription history, and pitMRI findings were abstracted from the electronic medical record. Results : 141 men met inclusion criteria. A minority exhibited pituitary pathology (n=40, 28%) with adenoma being the most common finding (n=35, 88%). Empty sella variants and non-neoplastic cysts comprised the remainder of pathologies (n=5, 12%). Mean PRL was higher in men with pituitary pathology than in controls (27.2 vs. 23.3 ng/mL; p=0.0106), while mean T levels were lower (190 vs 287 ng/dL; p=0.0001). Mean PRL/T ratio values were greater in cases (0.34 vs. 0.08; p<0.0001), as were median values (0.15 vs. 0.09). PRL/T outperformed PRL or T in predicting positive pitMRI findings (AUC: 0.75 vs. 0.64 vs. 0.71, respectively). A PRL/T ratio >0.08 was 90% sensitive, detecting 36/40 lesions, and 42% specific, excluding 42/101 patients with normal anatomy (p=0.0003). If applied to the study cohort, this cutoff would have reduced pitMRI burden by 30%. Ordering pitMRI when the PRL/T ratio >0.08 or when PRL >25 increases sensitivity (98%, 39/40 lesions detected) at the cost of decreased specificity (32%, 32/101 controls excluded). Presenting symptoms including fatigue, decreased libido, erectile dysfunction, and gynecomastia did not vary between cases and controls. Though patients with pituitary lesions were more likely to receive dopamine agonists than controls (40% vs. 23%; p=0.0392), they were not more likely to be prescribed testosterone, antipsychotics, or antidepressants. Conclusions : The PRL/T ratio is superior to PRL or T alone in identifying pituitary pathology in hypogonadal men with mild hyperprolactinemia. Ordering pitMRI when the PRL/T >0.08 is sensitive for detecting pituitary lesions and may reduce pitMRI burden in this population by 30%.

Objective: We compared cervico-vaginal cytokines in hormone therapy (HT)-treated postmenopausal women with premenopausal women and explored the association of serum estradiol (E2) and progesterone (P4) with cervico-vaginal cytokines. Methods: Postmenopausal women were treated with oral E2 1 mg/day for 28 days, with oral P4 100 mg/day added for the last 14 days. Premenopausal women were evaluated over one menstrual cycle. Serum E2 and P4 levels and cervico-vaginal cytokines interleukin (IL)-8 and IL-1 beta were measured at baseline, 14 days, and 28 days and were estimated by specific enzyme-linked immunosorbent assays. Results: Among nine postmenopausal and seven premenopausal women, cervico-vaginal IL-8 levels were highest at baseline, decreased on day 14, and remained stable thereafter. Cervico-vaginal IL-1 beta levels were highest at baseline, decreased on day 14, and remained stable with HT in postmenopausal women while they increased in premenopausal women. Postmenopausal women treated with HT and premenopausal women had similar changes in IL-8 and IL-1 beta. Serum E2 levels negatively correlated with IL-8 and IL-1 beta levels. Increased serum E2 from HT was correlated with the decreased IL-8 level from baseline to day 14 (p = 0.03). Conclusion: Exogenous E2 and P4 decreased the cervico-vaginal IL-1 beta and IL-8 to those levels found in premenopausal women. These findings require confirmation in a larger prospective study.

You have accessJournal of UrologySexual Function/Dysfunction: Evaluation II (MP78)1 Apr 2020MP78-07 PROLACTIN TO TESTOSTERONE RATIO PREDICTS PITUITARY ADENOMAS IN MALE PATIENTS WITH MILD HYPERPROLACTINEMIA Anup Shah*, Bryan Naelitz, Darren Bryk, Nicholas Farber, Daniel Shoskes, Betul Hatipoglu, and Sarah Vij Anup Shah*Anup Shah* More articles by this author , Bryan NaelitzBryan Naelitz More articles by this author , Darren BrykDarren Bryk More articles by this author , Nicholas FarberNicholas Farber More articles by this author , Daniel ShoskesDaniel Shoskes More articles by this author , Betul HatipogluBetul Hatipoglu More articles by this author , and Sarah VijSarah Vij More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000964.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Mild hyperprolactinemia often prompts pituitary magnetic resonance imaging (pitMRI) in men presenting with hypogonadism; however, the clinical yield of this test is low. We sought to identify a combination of lab results that more accurately predicts clinically significant MRI findings in patients with mild hyperprolactinemia and reduce unnecessary pitMRIs. METHODS: Male patients mild hyperprolactinemia (15-50 ng/ml) who presented with erectile dysfunction, low libido, hypogonadism, or infertility who had undergone pitMRI were included. Those with a prior diagnosis of prolactinoma, hormonal or dopaminergic therapy, or incomplete data were excluded. Symptoms, age, prolactin (PRL), body mass index (BMI), testosterone (T), lutenizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), creatinine (SCr), all medications, and MRI findings were collected. Means of continuous variables were compared with the Wilcoxon-Rank Sum test, and categorical variables were compared with Fisher Exact or Chi-squared tests. Fitted binomial distributions were used to generate Receiver Operating Characteristics (ROCs). RESULTS: 141 men met inclusion criteria. Pituitary adenomas were identified in 35 patients (24.8%) with a median adenoma size of 4 mm (range 1.2 – 38 mm). The ratio of PRL (ng/mL) to T (ng/dL) (PRL/T) outperforms PRL or T alone in predicting positive pitMRI findings (Area Under the Curve (AUC) 0.77 vs 0.70, 0.70 respectively). A PRL/T ratio cutoff >0.1 identified adenomas (p < 0.001) with high sensitivity (83%, 29/35 adenomas identified). 51% of pitMRIs could have been prevented if this metric were applied prior to imaging. A PRL/T ratio cutoff of >0.08 identified adenomas with higher sensitivity 91% (32/35), and 33% of pitMRIs could have been avoided if this metric were applied prior to imaging. CONCLUSIONS: To our knowledge, this study of pitMRI findings among men with hypogonadism and mild hyperprolactinemia is the largest of its kind. The use of PRL/T ratio in lieu of prolactin or testosterone alone retains high sensitivity for identifying patients with prolactinoma (83-91%) and may reduce unnecessary MRIs by up to 51%. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1175-e1176 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anup Shah* More articles by this author Bryan Naelitz More articles by this author Darren Bryk More articles by this author Nicholas Farber More articles by this author Daniel Shoskes More articles by this author Betul Hatipoglu More articles by this author Sarah Vij More articles by this author Expand All Advertisement PDF downloadLoading ...

Abstract Background : Hyperprolactinemia is a common laboratory finding in men with symptomatic hypogonadism. Persistent elevations in serum prolactin (PRL) are typically evaluated with pituitary magnetic resonance imaging (pitMRI) to assess for structural pathology. However, this practice pattern may result in overutilization of pitMRI and unnecessary healthcare expenditures. Objective: We sought to examine the cost savings associated with utilizing combinations of serum PRL and the prolactin to testosterone ratio (PRL/T) to predict positive findings on pitMRI and obviate the need for unnecessary imaging studies. Methods : A retrospective case-control study was performed. Men <75 presenting with symptomatic hypogonadism and mild hyperprolactinemia (15-55 ng/ml) who obtained pitMRI at a tertiary care center were included. Individuals previously evaluated for pituitary abnormality were excluded, as were those presenting with symptoms strongly concerning for a pituitary abnormality (e.g. visual change, headache). Laboratory studies were abstracted from the electronic medical record and pitMRI results were reviewed. A cost analysis was performed based on the institutional expense of pitMRI and laboratory evaluations. The cost of measuring PRL and T was calculated for all patients. The expense of pitMRI was calculated for those screening positive. Results : 141 men were included in the study. Pituitary lesions were identified in 40/141 men (28%). The total cost of evaluation was calculated at $458,814. Ordering pitMRI when PRL/T >0.10 is 80% sensitive (32/40 lesions captured) and 64% specific (65/101 with normal anatomy excluded). 68/141 are indicated for pitMRI, while 73 patients avoid imaging. Employing this threshold reduces expenses by 46% with cost savings calculated at $212,795. The cost of identifying each lesion was estimated at $7,688. Ordering pitMRI when PRL/T >0.10 or when PRL >25 is 90% sensitive (36/40 lesions captured) and 48% specific (48/101 with normal anatomy excluded). 89/141 are indicated for pitMRI, while 52 patients avoid imaging. Employing this threshold reduces expenses by 33% with cost savings calculated at $151,580. The cost of identifying each lesion was estimated at $8,534. Ordering pitMRI when PRL/T >0.08 or when PRL >25 is 98% sensitive (39/40 lesions captured) and 32% specific (32/101 with normal anatomy excluded). 108/141 are indicated for pitMRI, while 33 patients avoid imaging. Employing this threshold reduces expenses by 21% with cost savings calculated at $96,195. The cost of identifying each lesion was estimated at $9,011. Conclusions : Serum PRL and PRL/T correctly predict the vast majority of pituitary lesions in patients with mild hyperprolactinemia, with screening costs increasing as more sensitive thresholds are employed. Future guidelines should establish a reasonable cutoff for pitMRI to minimize the expense of unnecessary imaging.

INTRODUCTION AND OBJECTIVE: Hyperprolactinemia is a common laboratory finding in a population of men with symptomatic hypogonadism or infertility. If serum prolactin (PRL) is above the upper limit of normal on two laboratory analyses, current practice is to recommend further workup with a pituitary magnetic resonance imaging (pitMRI) study to assess for a pituitary adenoma. However, this practice pattern may lead to unnecessary healthcare costs secondary to the overutilization of pitMRI. Recent data has suggested serum prolactin:testosterone (PRL/T) ratio may predict pitMRI findings. We sought to examine the cost savings associated with utilizing combinations of serum PRL and serum PRL/T to predict pitMRI positive findings and obviate the need for unnecessary pitMRI. METHODS: We performed a retrospective review of all men <75 years old with infertility or symptomatic hypogonadism who had mild hyperprolactinemia (15-55 ng/ml) and underwent pitMRI at a tertiary care center. Exclusion criteria included a prior pituitary adenoma or symptoms concerning for a pituitary abnormality (e.g. visual changes, galactorrhea). pitMRI findings were reviewed. Baseline clinicodemographic (symptoms, age, BMI, medications) and laboratory variables (PRL, T, LH, FSH, SCr) were collected. Receiver Operating Characteristics and Area Under the Curve metrics were created from fitted binomial distributions. A cost analysis was performed based on the institutional cost of a pitMRI. RESULTS: 136 men met inclusion criteria. Pituitary adenomas were found on pitMRI in 35 men (25.7%). Of the various combinations of serum PRL and PRL/T, PRL/T > 0.10 had greatest specificity while PRL/T > 0.08 OR PRL > 25 had the greatest sensitivity (Table 1). Cost savings were significant for all combinations (Table 1). CONCLUSIONS: The combination of serum PRL and PRL/T correctly predicts the vast majority of pituitary adenomas in patients with mild hyperprolactinemia. Further, this laboratory combination avoids a substantial proportion of unnecessary pitMRIs, resulting in a significant healthcare cost savings. Future clinical guidelines should consider incorporating a screening threshold using serum PRL and PRL/T prior to ordering pitMRI for mild hyperprolactinemia.Source of Funding: None

To discuss the surgical management of deep infiltrating endometriosis involving the rectosigmoid colon. Here we demonstrate a case of a 34-year-old female with chronic pelvic pain, infertility, and a 1-cm rectosigmoid endometriotic implant noted on preoperative MRI. She underwent segmental bowel resection of the involved rectosigmoid colon with colorectal reanastomosis. There are several surgical approaches to managing endometriosis involving the rectosigmoid colon, including rectal shaving, disc resection, and segmental resection. Segmental resection allows for complete resection of endometriotic lesions and histologic analysis of the specimen.

Background: Laparoscopic energy results in thermal injury to the ovary during adnexal surgery that may contribute to a decrease in reproductive function postoperatively. Plasma energy is an alternative to traditional laparoscopic energy sources that is created by passing an inert gas over an electrically charged surgical blade designed to energize the gas to a plasma stream for coagulation and dissection. Data suggest that plasma may have less thermal spread than traditional energy sources. but its effects on ovarian histology have not been compared to other electrosurgical modalities. Materials and Methods: Thermal injuries were created on porcine ovaries and uterine horns with bipolar forceps, monopolar pencil, ultrasonic shears. and a helium plasma device. The depth of thermal injury was evaluated histologically. Results: Monopolar electrosurgery resulted in the greatest depth of thermal injury in ovarian tissue (mean 0.99 +/- 0.82 mm), whereas the helium plasma device produced the smallest injury (mean 0.57 +/- 0.4 mm) (p = 0.018). In uterine tissue, the bipolar instrument produced the greatest depth of injury (mean 1.15 +/- 0.2 mm) and plasma device resulted in the lowest level of injury (mean 0.42 +/- 0.13 mm) (p = 0.0002). The ultrasonic shears also resulted in less injury to the uterus than the bipolar device (mean 0.48 +/- 0.23 mm) (p = 0.0027). Conclusion: Helium plasma energy may represent a less injurious alternative to the monopolar device for use during adnexal surgery.

Serum prolactin (PRL) levels are routinely obtained in men presenting with clinical hypogonadism or infertility with mild hyperprolactinemia, often prompting pituitary magnetic resonance imaging (pitMRI) to assess for adenoma. The utility of obtaining pitMRI in this population has not been adequately studied, and no society guidelines exist to inform this decision. We hypothesize that a combination of laboratory findings predicts positive pitMRI findings in patients with mild hyperprolactinemia and, given the high rate of negative pitMRIs among young men with mild hyperprolactinemia, sought to identify patients in whom pitMRI can safely be avoided. Retrospective, case-control chart review. Male patients under the age of 50 with mild hyperprolactinemia (15-55 ng/ml) who presented with erectile dysfunction, low libido, hypogonadism, or infertility who had undergone pitMRI were included. Those with a prior diagnosis of prolactinoma, hormonal or dopaminergic therapy, or incomplete clinical data were excluded. Presenting symptoms, age, PRL, body mass index (BMI), testosterone (T), lutenizing hormone (LH), follicle-stimulating hormone (FSH), creatinine (SCr), all medications, and MRI findings were collected. Means of continuous variables were compared with the Wilcoxon-Rank Sum test, and categorical variables were compared with Fisher Exact or Chi-squared tests. Fitted binomial distributions were used to generate Receiver Operating Characteristics (ROCs) and Area Under the Curve (AUC) calculations. 62 men met inclusion criteria. Pituitary adenomas were identified in 18 patients (29%) with a mean adenoma size of 5.4 ± 5 mm. Mean PRL differed in men with and without adenomas (37.8 ng/ml vs 24.9 ng/ml, p < 0.001), as did mean T (198 ng/dl vs 301 ng/dl, p < 0.01) with considerable overlap. Age, BMI, LH, FSH, and SCr were not associated with presence of adenoma (p > 0.05). A novel ratio of PRL (ng/mL) to T (ng/dL) (PRL/T) was superior to PRL or T alone in predicting positive pitMRI findings. PRL/T outperformed PRL or T when PRL < 30 ng/ml (AUC 0.88 vs 0.76, 0.83 respectively) and when T < 300 ng/dl (AUC 0.83 vs 0.80, 0.73). A PRL/T ratio > 0.1 identified adenomas (p < 0.001) with high sensitivity (89%, 16/18 adenomas identified). 43% of pitMRIs could have been prevented if this metric were applied. No patients had pituitary abnormalities when PRL/T < 0.1 and PRL < 30 ng/ml. A more conservative approach of ordering pitMRI when PRL/T ratio > 0.1 and/or PRL ≥ 30 retains 100% sensitivity for identifying adenomas (18/18; p < 0.01). This more conservative guideline would have prevented 32% of pitMRIs when applied to the study cohort. The PRL/T ratio is a superior metric to PRL or T alone in identifying young male hypogonadal patients with mild hyperprolactinemia who have imaging-confirmed pituitary abnormalities. A conservative clinical heuristic of ordering pitMRI in patients with hypogonadism with PRL/T > 0.1 and/or PRL ≥ 30 ng/ml detects adenomas with 100% sensitivity and prevents 32% of pitMRIs without changing clinical management, thereby reducing healthcare costs.

Objective: To compare the histologic effects of four laparoscopic energy sources on the porcine ovary and uterus, with the goal of identifying a device that minimizes damage to the ovary.

Determine differences in vaginal cytokines IL8 and IL1B in pre- and postmenopausal women and determine change in cytokines levels following treatment with hormone therapy Prospective comparative trial 10 premenopausal and 10 postmenopausal women were recruited. All participants were screened for vaginal pH, maturation index and vaginal infection. Postmenopausal women underwent a baseline cervico-vaginal lavage (CVL), peripheral blood for estradiol (E2) and progesterone (P4). Postmenopausal women began oral estradiol 1.0mg daily and CVL with peripheral blood for E2 and P4 was obtained after 2 weeks. Postmenopausal women then began oral progesterone 100mg daily with oral E2 and CVL with peripheral blood for E2 and P4 was obtained after 2 weeks. Premenopausal women underwent CVL with peripheral blood for E2 and P4 in the early follicular phase (days 7-10), ovulatory phase (days 12-16), and luteal phase (days 19-23). Specific ELISA kits for IL-8 and IL-1B were used to measure vaginal cytokine levels in CVL samples. Vaginal cytokine levels as well as vaginal maturation index over the menstrual cycle was compared between pre- and postmenopausal women using t-test. Pearson correlation was also calculated between serum estradiol, serum progesterone, and cytokine levels. No significant difference between IL8 and IL1B levels were seen between pre- and postmenopausal women at any visit. Postmenopausal women on average had higher IL-8 levels at baseline compared to premenopausal women (2.94 pg/um vs 2.73 pg/ug). When treated with E2 and P4 postmenopausal women displayed the same downward trend in IL8 as premenopausal women over the menstrual cycle decreasing by 40% from baseline compared to 56% decrease from follicular to luteal phase in premenopausal women. When comparing baseline IL1B levels postmenopausal women had lower levels than premenopausal women, .042 pg/ug vs .118 pg/ug. When treated with oral E2 and P4 postmenopausal women displayed a downward trend in IL-1B as premenopausal women over the course of the menstrual cycle decreasing by 26% from baseline compared to 70% decrease in premenopausal women. Postmenopausal women had significantly higher pH at baseline, 6.1 vs 4.0, p = .0001. After treatment with E2 and P4 there was no difference in pH, 4.1 vs 4.4, p = .06. Postmenopausal had a significantly decreased percent of superficial cells at baseline, 2.5% vs 30%, p = .005. After treatment there was no significant difference, 37% vs 34%, p = .8. Postmenopausal have higher IL-8 and lower IL-1B cytokine levels at baseline compared to premenopausal women. Treatment with E2 and P4 decreases cytokine levels in a simulated cycle. This mimics the same trend seen in premenopausal women, however, the decrease is not as great in postmenopausal. Hormone therapy normalizes pH and percent of superficial cells despite not completely normalizing cytokine levels.

Background: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is often associated with pelvic floor muscle spasm. While pelvic floor physical therapy (PFPT) is effective, some men are unable to resolve their symptoms and have residual trigger points (TPs). TP injection has been used for treatment in several neuromuscular pain syndromes. The objective of this study was to examine the efficacy and side effects of TP injection in men with CP/CPPS and pelvic floor spasm refractory to PT.Methods: Using an IRB approved Men's Health Registry we reviewed the records of all men with a diagnosis of CP/CPPS who received at least 1 TP injection. Patients were phenotyped with UPOINT (all had the "T" domain for tenderness of muscle) and symptoms measured with the NIH Chronic Prostatitis Symptom Index (CPSI). Response was measured by a 5-point Global Response Assessment (GRA) and change in CPSI (paired t-test). For pelvic TPs, a pudendal block was done in lithotomy position and then each TP was identified transrectally by palpation. A nerve block needle was passed through the perineum into the TP confirmed by palpation. Between 0.5-1 cc was injected into each TP of a local anesthetic mixture (30: 70 of 2% lidocaine and 0.25% bupivacaine). For anterior TPs, an ultrasound guided ilioinguinal block was done first and then each TP injected by direct palpation through the abdominal skin. Men were offered up to three sets of injections separated by 6 weeks each.Results: We identified 37 patients who had a total of 68 procedures. Three men had no follow-up after their first injection and were included for side effects but not included for outcome. The indication was failure to progress on PT in 33, recurrent symptoms in 1 and refusal to do PT in 3. Mean age was 43.7 years (range 21-70 years) and median UPOINT domains was 3 (range 1-5). Initial CPSI was pain 13.7 +/- 3.4, urinary 5.3 +/- 2.2, quality of life 9.8 +/- 2.1 and total 28.8 +/- 6.0. 16 men had 1 injection, 11 had 2 and 10 had 3. All had pelvic TPs injected and 9 also had anterior TPs. By GRA, 12 had significant improvement (35.3%), 10 had some improvement (29.4%), 11 had no change (32.3%) and 1 was worse (2.9%). Mean CPSI dropped from 28.8 +/- 6.0 to 21.8 +/- 7.2 (P<0.0001). 18 men had a drop of 6 or more points in CPSI (53%). Of note, none of 3 men who were noncompliant with PT had benefit. 3 men had temporary numbness in the lateral thigh after the injection (4.4%) and 1 had difficulty weight bearing on 1 leg for about 30 minutes.Conclusions: TP injection in CP/CPPS patients as an adjunct to PT is well tolerated and leads to symptom improvement in about half. Durability and long term results are yet to be determined.