Farnoosh Nik-Ahd

Our goal was to understand the association between frailty and postoperative complications after artificial urinary sphincter (AUS) and male urethral sling placement. This was a retrospective study of Medicare beneficiaries undergoing AUS or sling from 2014 to 2016. Baseline frailty was quantified using the Claims-Based Frailty Index (CFI): not frail (P = .0001), age (75-84 aRR 1.2, ≥85 aRR 1.4, compared with 66-74, global P = .0007), and Charlson Comorbidity Index (1-3 aRR 1.2, ≥4 aRR 1.8, compared with 0, global P = .0001). Device revision/removal was associated with increasing CFI (prefrail aRR 1.2, mildly-to-severely frail aRR 1.3, compared with not frail global P = .04) and age (75-84 aRR 1.3, ≥85 aRR 1.5, compared with 66-74, global P = .0002), but not Charlson Comorbidity Index (global P = .2). Frailty, independent of age and comorbidity, was associated with increased odds of 30-day complications and device revision/removal. Thus, frailty, more than comorbidity, is an important yet often unrecognized factor that should be considered during preoperative decision-making for AUS or sling procedures.

Introduction: Surgeries for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are commonly performed in older adults, many of whom are also frail. A surgical risk calculator for older adults undergoing POP/SUI surgeries that incorporates frailty, a factor known to increase the risk of surgical complications, would be helpful for preoperative counseling but currently does not exist.Materials and Methods: Medicare Carrier, Outpatient, and MedPAR files were examined for beneficiaries undergoing POP and SUI surgery between 2014 and 2016. A total of 15 POP/SUI categories were examined. The Claims‐Based Frailty Index (CFI), a validated measure of frailty in Medicare data, and Charlson Comorbidity Index were deconstructed into their individual variables, and individual variables were entered into stepwise logistic regression models to determine which variables were most highly predictive of 30‐day complications and 1‐year mortality. To verify the prognostic accuracy for each model for surgical complications of interest, calibration curves and tests of model fit, including C‐statistic, Brier scores, and Spiegelhalter p values, were determined.Results: In total, 108 479 beneficiaries were included. Among these, 4.7% had CFI scores consistent with mild to severe frailty (CFI≥0.25). A total of 13 prognostic variable categories were found to be most highly predictive of postoperative complications. Calibration curves for each outcome of interest showed models were well‐fit. Most models demonstrated high c‐statistic values (≥0.7) and high Spiegelhalter p values (≥0.9), indicating good model calibration and excellent discrimination, and low Brier scores (<0.02), indicating high model accuracy.Conclusions: Urologic surgery for older Adults Risk Calculator serves as a novel surgical risk calculator that is readily accessible to both patients and clinicians that specifically factors in components of frailty. Furthermore, this calculator accounts for the heterogeneity of an aging population and can assist in individualized surgical decision‐making for these common procedures.

Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist. Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter P values, were calculated to ensure the prognostic accuracy for postoperative complications. In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter P values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit. This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.

This study examines prostate-specific antigen values among transgender women in the Veterans Health Administration receiving estrogen.

Aims: There is limited evidence to support the efficacy of sacral neuromodulation (SNM) for older adults with overactive bladder (OAB). This study aims to report outcomes following SNM among nursing home (NH) residents, a vulnerable population with high rates of frailty and comorbidity.Methods: This is a retrospective cohort study of long‐stay NH residents who underwent a trial of percutaneous nerve evaluation (PNE) or Stage 1 permanent lead placement (Stage 1) between 2014 and 2016. Residents were identified using the Minimum Data Set linked to Medicare claims. The primary outcome of this study was successful progression from trial to implant. Rates of 1‐year device explant/revisions were also investigated.Results: Trial of SNM was observed in 1089 residents (mean age: 77.9 years). PNE was performed in 66.9% of residents and 33.2% underwent Stage 1. Of Stage 1 procedures, 23.8% were performed with simultaneous device implant (single‐stage). Overall, 53.1% of PNEs and 72.4% of Stage 1 progressed to device implant, which was associated with Stage 1 procedure versus PNE (adjusted relative risk [aRR]: 1.34; 95% confidence interval [95% CI]: 1.21–1.49) and female versus male sex (aRR: 1.26; 95% CI: 1.09–1.46). One‐year explant/revision was observed in 9.3% of residents (6.3% for PNE, 10.5% for Stage 1, 20.3% single‐stage). Single stage procedure versus PNE was significantly associated with device explant/revision (aRR: 3.4; 95% CI: 1.9–6.2).Conclusions: In this large cohort of NH residents, outcomes following SNM were similar to previous reports of younger healthier cohorts. Surgeons managing older patients with OAB should use caution when selecting patients for single stage SNM procedures.

Transgender women retain their prostate even after gender-affirmation surgery and thus remain at risk of prostate cancer. Studies to date are limited to case reports.¹ We describe a large case series of transgender women with prostate cancer within the Veterans Affairs (VA) health system.