Have You Read? April 2021

By: Daniel A. Shoskes, MD | Posted on: 01 Apr 2021

Jacobson DL, Balmert LC, Holl JL et al: Nationwide circumcision trends: 2003 to 2016. J Urol 2021; 205: 257-263.

Neonatal circumcision has become a controversial issue, and despite the American Academy of Pediatrics recommending access and reimbursement public funding it is not uniform in the U.S. How has this impacted the number of procedures?

This study examines national neonatal circumcision trends before and after the 2012 American Academy of Pediatrics recommendation for neonatal circumcision reimbursement. This was a retrospective cohort study of boys aged 28 days or less using the Kids’ Inpatient Database (2003 to 2016). Boys who underwent neonatal circumcision prior to discharge were compared to boys who did not. Boys with coagulopathies, penile anomalies or a history of prematurity were excluded. An estimated 8,038,289 boys comprised the final cohort. Boys were primarily White (53.7%), privately insured (49.1%) and cared for at large (60.8%) teaching (49.4%) hospitals in metropolitan areas (84.1%). While 55.0% underwent circumcision prior to discharge, neonatal circumcision rates decreased significantly over time (p <0.0001). Black (68.0%) or White (66.0%) boys, boys in the highest income quartile (60.7%) and Midwestern boys (75.0%) were most likely to be circumcised. Neonatal circumcision was significantly more common among privately (64.9%) than publicly (44.6%) insured boys after controlling for demographics, region, hospital characteristics and year (p <0.0001). The odds of circumcision over time were not significantly different in the years before vs after 2012 (p=0.28).

The authors conclude that among approximately 8 million boys sampled over a 13-year period 55.0% underwent neonatal circumcision. The rate of neonatal circumcision varied widely by region, race and socioeconomic status. The finding that boys with public insurance have lower circumcision rates in all years may be related to lack of circumcision access for boys with public insurance.

Chughtai B, Mao J, Matheny ME et al: Long-term safety with sling mesh implants for stress incontinence. J Urol 2021; 205: 183-190.

Staying on the theme of controversial topics, we move on to mesh for stress incontinence. In this study the authors examined risk and predictors of mesh erosion and reoperation after mid-urethral sling procedures for stress incontinence. Women older than 18 years who received a mid-urethral sling for stress urinary incontinence between 2008 and 2016 in outpatient surgical settings in New York State were included. Those who underwent concomitant mesh pelvic organ prolapse repair were excluded.

Primary outcomes were post-implantation time to erosion and reoperations. There were 36,195 women with a mean±SD age of 53.7±12.4 years. Estimated risks of erosions and reoperations at 7 years after sling procedures were 3.7% and 6.7%, respectively. Older age and high volume facilities were associated with a lower risk of erosion. History of hysterectomy was associated with a higher risk of erosion. Predictors of reoperation included concurrent abdominal or native tissue transvaginal prolapse repair, previous hysterectomy and depression. The authors conclude that one in 27 women had sling erosions and one in 15 had invasive reoperations at 7 years after sling procedures. The highest erosion cases were observed among younger White women treated at low volume facilities.

DeWitt-Foy ME, Gam K, Modlin C et al: Race, decisional regret and prostate cancer beliefs: identifying targets to reduce racial disparities in prostate cancer. J Urol 2021; 205: 426-433.

Finishing strong with another controversial topic, we do know that there are significant racial disparities in outcomes for prostate cancer. How can we identify targets to address these? In this study the authors aimed to identify sources of prostate cancer decisional regret with a focus on racial disparities. A cohort of 1,112 patients with localized prostate cancer treated at the Cleveland Clinic between 2010 and 2016 were matched by race, Gleason score, treatment, prostate specific antigen at diagnosis, age at treatment and time since treatment. All patients received 4 surveys, including the Expanded Prostate Cancer Index Composite (EPIC) 26, the Decisional Regret Scale, their novel Prostate Cancer Beliefs Questionnaire and a modified EPIC demographics form. Descriptive and comparative statistics and multivariable logistic regression were used to compare survey outcomes by race and treatment method. Of 1,048 deliverable surveys 378 (36.07%) were returned. African American men had worse decisional regret than non-African American men even after adjusting for relevant covariates (OR 2.46, p <0.0001). African American men also had higher Prostate Cancer Beliefs Questionnaire medical mistrust and masculinity scores, both of which predicted worse decisional regret independent of race (1.415 and 1.350, respectively, p=0.0001).

The authors conclude that African American men suffer worse decisional regret than non-African American men, which may be partially explained by higher medical mistrust and concerns about masculinity as captured by the Prostate Cancer Beliefs Questionnaire. This novel survey may facilitate identifying targets to reduce racial disparities in prostate cancer.

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