Long-term patient reported outcome and satisfaction after oral mucosa graft urethroplasty for hypospadias

PURPOSE: There is a paucity of long-term patient reported outcome data on surgery for hypospadias. We sought to evaluate genitourinary function and satisfaction after oral mucosa graft urethroplasty (OMGU) for hypospadias. MATERIALS AND METHODS: We identified 65 patients who had undergone OMGU at our institution between 1992 and 2003, and surveyed these patients to evaluate oral health, urinary function and satisfaction with outcomes. RESULTS: We located 51 patients who had undergone OMGU, of whom 43 (84%) agreed to participate in the study. Median followup was 6.9 years. Mean study age was 15.1 years. Of the patients 47% had severe hypospadias with failed previous repair and 42% had severe hypospadias with previous first stage surgery. Oral complaints were rare and primarily cosmetic. No patient whose oral harvest was limited to the cheek (vs lip) had cosmetic complaints. Urinary spray and stream deviation were reported by 11 patients (26%) and 12 patients (28%), respectively. American Urological Association symptom scores were generally low (mean 5.6 +/- 6.0, range 0 to 21) but 7 patients (16%) had moderate symptoms and 2 (5%) had severe symptoms. Of the patients 60% were mostly satisfied or better with urinary function. Although satisfaction with penile appearance varied (51% of patients were satisfied), most patients (84%) were satisfied with the overall hypospadias care. Urinary symptom scores were significantly worse among patients who had post-OMGU complications (p = 0.004). Of these patients 38% had moderate or severe urinary symptoms, while 95% of patients without complications had mild symptoms (p = 0.01). CONCLUSIONS: Many patients report good long-term outcomes of OMGU, although a subset of patients has significant urinary and cosmetic complaints that are more prevalent in association with surgical complications.     

Surgical repair of bladder exstrophy in the modern era: contemporary practice patterns and the role of hospital case volume

PURPOSE: Bladder exstrophy is a rare condition, and data are lacking regarding practice patterns in its surgical management. We used a large nationwide database to investigate practice patterns of bladder exstrophy repair. MATERIALS AND METHODS: We used the Nationwide Inpatient Sample (1988 to 2000) to identify patients who underwent surgical repair of bladder exstrophy (International Classification of Disease-9 code 578.6). We analyzed factors affecting practice patterns and outcomes. Hospital volume was based on caseload during the highest volume year of study participation (high volume 5 or more, mid volume 3 to 4 and low volume less than 3 cases). RESULTS: We identified 407 cases. Approximately half of the patients (53.2%) were hospitalized within 24 hours of birth, although 28% of patients were older than 1 year. Of the patients 54% were male. Exstrophy repair is extremely resource intensive. In this series mean length of hospital stay (LOS) was 24.6 +/- 22.8 days, and mean inflation adjusted hospital charges were 62,302 dollars (median 39,978 dollars). High volume hospitals (HVHs) had lower hospital charges (37,370 dollars) than mid volume (51,778 dollars) or low volume hospitals (LVHs, 50,474 dollars, p = 0.0095). On multivariate regression HVHs had lower charges even after controlling for other significant predictors, including LOS (p <0.0001). Patients at HVHs were more likely to undergo osteotomy (p = 0.007). Six patients died after exstrophy repair (1.5%), all of whom had been born prematurely (p <0.0001). Although death was more likely at LVHs, this was due to the fact that more patients at LVHs were born prematurely (4.2% at HVHs vs 5.9% at mid volume hospitals and 11.1% at LVHs, p = 0.027). CONCLUSIONS: Bladder exstrophy repair carries a high risk of morbidity and is resource intensive. Variations between high and low volume hospitals in practice patterns and case mix may contribute to observed differences in resource use, LOS and clinical outcomes.     

Establishment of status epilepticus by limbic system stimulation in previously unstimulated rats

A syndrome of convulsive status epilepticus developed in 4 of 18 rats which had been treated with continuous sine wave stimulation incrementally raised to 40 microA through limbic system electrodes. The syndrome was characterized by recurrent behavioral seizures, continuous EEG spiking, and marked neuropathology. In three other animals, the stimulation treatment produced a syndrome of nonconvulsive status epilepticus manifested by an electrophysiologic record of continuous seizure activity, without accompanying tonic-clonic movements. The poststimulatory effect was correlated with the animals' response to the stimulation, and was independent of whether the electrode was positioned in the hippocampus or amygdala. If an animal developed repeated convulsive seizures during the stimulation, such seizures were likely to persist after the stimulation offset. These results indicate that persistent limbic system activation can produce a syndrome of recurrent seizures similar to that caused by either neurotoxic drugs or by limbic system activation in kindled rats.     

Six strategies to identify and assist patients burdened by out-of-pocket prescription costs

Many patients find that their out-of-pocket costs of medications are burdensome. Physicians can help, first by remembering to ask about the problem, and then by applying simple strategies to limit the patient's costs.