Urology - Articles in Press

Ketorolac is Underutilized After Ureteral Reimplantation Despite Reduced Hospital Cost and Reduced Length of Stay - Corrected Proof

Jonathan C. Routh, Dionne A. Graham, Caleb P. Nelson — 2010-02-08

Objectives: To examine patterns of ketorolac use and its association with hospital outcomes. Although ureteral reimplantation (UR) reliably corrects vesicoureteral reflux, postoperative pain and bladder spasm often occur. Multiple studies show that ketorolac markedly reduces postoperative pain after UR, but there is no information on whether ketorolac is routinely used.Methods: The Pediatric Health Information System is a national database collected by over 40 US children's hospitals. We identified children with primary vesicoureteral reflux who underwent UR between 2003 and 2008. Billing data were reviewed to identify patients who received ketorolac during hospitalization. Multivariate models were used to examine ketorolac use and postoperative outcomes including complication rates, length of stay, and hospital costs.Results: We identified 12 239 children undergoing UR, 6362 (52%) of whom received ketorolac postoperatively. Factors associated with ketorolac use include older age, female gender, and decreased disease severity (all P <.0001). Ketorolac use was associated with reduced length of stay (2 vs 3 days, P <.0001) and decreased hospital costs ($14 223 vs $16 382, P <.0001). Complication rates were slightly higher in patients not receiving ketorolac (4% vs 3%). After adjusting for confounding factors, ketorolac use remained highly associated with decreased length of stay (P = .01) and decreased costs (P = .002), with no significant differences in complication rates (P = .4).Conclusions: In a contemporary nationwide sample, only half of children undergoing UR received ketorolac. Ketorolac use is independently associated with reduced procedure costs and reduced length of stay after UR, without increased complications. This suggests underutilization of ketorolac after UR.

The Effect of Epigenetic Therapy on Congenital Neurogenic Bladders—A Pilot Study - Corrected Proof

Steve J. Hodges, James J. Yoo, Nilamadhab Mishra, Anthony Atala — 2010-02-08

Objectives: To demonstrate that human smooth muscle cells derived from neurogenic bladders produce more collagen in vitro than smooth muscle cells derived from normal bladders, and that epigenetic therapy may normalize this increased collagen production.Methods: Human smooth muscle cells from normal (n = 3) and neurogenic bladders (n = 3) were cultured in normal culture media and at different concentrations of the histone deacetylase inhibitors trichostatin A, valproic acid, and the DNA methylation inhibitor 5-azacytidine (5-aza). Collagen type I and III gene expression was measured using real-time quantitative reverse transcription-polymerase chain reaction after varying doses of drug exposure. Cell viability was measured using trypan blue.Results: The smooth muscle cells from neurogenic bladders released significantly more collagen than the normal bladder cells (mean 4.1 vs 1.8 μg/mL in control media) when grown in normal conditions. Treatment with trichostatin A at 50 ng/mL decreased the collagen level in cells from neurogenic bladders to almost normal levels (2.1 μg/mL). In addition, valproic acid treatment decreased collagen types I and III gene expression relative to controls, with maximal effect at 300 mg/mL. These treatments had little effect on cell viability.Conclusions: Histone deacetylase inhibitors decreased collagen production of smooth muscle cells from neurogenic bladders in vitro. These agents may be a means of effectively preventing bladder fibrosis in patients with this condition.

Subcutaneous Cod Liver Oil Injection for Penile Augmentation: Review of Literature and Report of Eight Cases - Corrected Proof

2010-02-08

Abstract: Objectives: To study the presentations and treatment outcome of 8 consecutive patients for whom cod liver oil was injected in the subcutaneous area of their penises by a lay person for purpose of augmentation.Methods: Various amounts of cod liver oil were injected in the subcutaneous area of the penis of 8 low socioeconomic class patients by a nonmedical person. They presented by various complications ranging from paraphimosis up to abscess formation and necrosis of penile skin. All the patients underwent emergency initial surgical intervention ranging from dorsal preputial slit to skin debridement. Definitive surgical treatment was carried out using local penile flap and V–Y plasty.Results: The severity of complications was correlated to the amount of oil injected and the time interval between injections and presentation. All the 8 patients were cured after different staged surgical procedures. The postoperative course was uneventful in 6 patients, and 2 patients suffered from wound infection after the secondary treatment. All patients had acceptable cosmetic and functional outcome, and were satisfied regarding the length of the penis. None reported erectile dysfunction.Conclusions: Increased public awareness is indicated to avoid this problem. Early detection and prompt treatment give acceptable anatomic and functional results.

A Novel 5-Part Percutaneous Access Needle With Glidewire Technique (5-PANG) for Percutaneous Nephrolithotomy: Our Initial Experience - Corrected Proof

Ashish V. Patil — 2010-02-08

Objectives: To describe the use of an innovative 5-part Percutaneous Access Needle with Glidewire (5-PANG), a novel technique in an attempt to make percutaneous nephrolithotomy (PCNL—a routinely performed procedure) tract establishment a fast, safe, and less cumbersome procedure.Methods: An access needle (5-PANG needle) was designed and fabricated at the Institute of Urology, Dhule, and used for percutaneous renal access during PCNL.Results: The 5-PANG technique was used in 55 cases (57 renal units). It was used for all calyceal punctures, all types of stones, renal anatomies, and for second-time surgeries (8 cases). The mean time required (from the stage of the successful puncture using the first 3 parts of the needle till the placement of Alken's rod) was 44.54 seconds. The radiation time was a mean of 3.34 seconds. Punctured calyx and tract size did not affect the results. Visual clarity was good in 85.9% cases. No case had to be converted to conventional method or abandoned. There were no intra- or postoperative complications related to the 5-PANG.Conclusions: We find the 5-PANG technique safe, fast, effective, and inexpensive. It is easy to learn and master. We recommend this technique over the standard initial tract dilatation techniques.

The Impact of Income and Education on Dietary Habits in Stone Formers - Corrected Proof

2010-02-08

Purpose: To evaluate the impact of socioeconomic status (SES) on dietary habits in stones formers (SF) as there is an obvious association between dietary habits and risks of urolithiasis.Methods: SF were selected to complete the Diet History Questionnaire (DHQ) and an SES questionnaire. Meaningful dietary constituents were generated from DHQ raw data. SF were considered of lower SES if they had less than 12 years of education and lived below the poverty level.Results: Ninety-nine SF completed the DHQ and SES questionnaires. Thirty-seven SF had low education, whereas 62 high education levels. Significant mean dietary constituents by education level (lower vs higher) were calcium (1058.4 vs 705.0 mg/d), carbohydrate (394.9 vs 253.4 g/d), cholesterol (398.7 vs 253.4 mg/d), dietary fiber (24.6 vs 17.9 g/d), food energy (3307.9 vs 2051.5 kcal/d), phosphorus (1903.9 vs 1220.1 mg/d), potassium (4195.6 vs 2861.5 mg/d), and sodium (5136.8 vs 3050.5 mg/d) (P <.05). Thirty-four SF were below the poverty level and 60 above it. Significant mean dietary constituents by annual income (below vs above poverty level) were carbohydrate (397.6 vs 259.3 g/d), dietary fiber (26.1 vs 17.8 g/d), magnesium (481.8 vs 316.7 mg/d), and potassium (4141.9 vs 3031.6 mg/d), (P <.05).Conclusions: SES impacts dietary habits and this may strongly influence stone formation and recurrence. Therefore, dietary counseling and modification as prevention for further stone formation should be more emphasized in SF of lower SES.

Gender and Renal Cancer: Do Variations in Clinical Presentation and Imaging Patterns Explain Observed Differences Between Males and Females? - Corrected Proof

Lipika R. McCauley, Carla J. Beckham, Tim B. Hunter, Mike M. Nguyen — 2010-02-08

Objectives: To determine whether gender variations in imaging and healthcare access are contributing to observed differences in renal cancer, we examine the initial events in the diagnosis of renal masses in a cohort of patients and correlate it with detailed data on imaging patterns over the same period.Methods: A total of 308 patients diagnosed with a renal mass over 11 years were reviewed. Information on symptoms, imaging, diagnosing physician, demographics, and pathology was gathered. Data on imaging for 1 862 485 patients at our institution over the same period were also collected. The data were analyzed for temporal trends, gender variations, and differences between incidental and nonincidental masses.Results: Females presented with smaller masses (4.8 vs 6.0 cm, P = .0064), and were less likely to have clear cell tumors (58.7% vs 63.4%, P = .049). A total of 66.9% of female and 61.1% of male cases were incidental (not significant). In both males and females, primary care physicians were the most common diagnosing physicians (47.4% and 49.6%, respectively). Gynecologic complaints were an uncommon cause of diagnosis for women (5.3%). Computerized tomography was the most common diagnosing modality for both males and females (69.1% and 63.2%, respectively). Ultrasound as the diagnosing modality did not reach statistical significance between males and females (23.4% and 28.6%, respectively). During the 11- year period, women underwent more imaging studies overall than men (19.7% difference), but the difference was lower when only considering studies that can diagnose renal masses (6.4% difference).Conclusions: Gender variations in imaging rates and presentation for obstetrics/gynecology concerns by females did not lead to a significant difference in incidental diagnosis and do not appear adequate to explain gender differences in renal cancer presentation.

An Unusual Complication During Inflatable Penile Prosthesis Implantation - Corrected Proof

Ahmed Eldefrawy, Bruce R. Kava — 2010-02-08

Bladder injury during inflatable penile prosthesis implantation is a rare complication. Previous pelvic surgery or radiation can predispose to this unusual complication. We describe a case where the inflatable penile prosthesis reservoir was implanted into the urinary bladder.

Hand Metastasis From Renal Carcinoma - Corrected Proof

2010-02-08

Renal carcinoma may develop metachronous distant metastases without evidence of regional or local disease recurrence. These lesions may be misdiagnosed because of its benign-like appearance and lack of evidence of other disease spread.

Retroperitoneal Castleman's Disease - Corrected Proof

A. Ari Hakimi, Izak Faiena, Ronald N. Kaleya, Reza Ghavamian — 2010-02-08

A 56-year-old postmenopausal woman with a history of colon cancer status after left hemicolectomy presented to our institution with abdominal pain, early satiety, and weight loss. Computerized tomography scan showed a large, enhancing, fat-containing mass displacing the left kidney posteriolaterally suspicious for a retroperitoneal liposarcoma. The lesion was also encasing the renal hilum. The patient underwent a wide excision of the mass as well as a radical nephrectomy and lymph node dissection by means of a thoracoabdominal approach. Final pathology revealed a large lymphatic mass consistent with Castleman's disease.

Utility of Urine Cytology in the Workup of Asymptomatic Microscopic Hematuria in Low-risk Patients - Corrected Proof

2010-02-08

Objectives: To evaluate performance and cost-effectiveness of voided cytology in patients with pure asymptomatic microscopic hematuria (AMH). Although voided cytology has been validated for use in patients with a history of urothelial carcinoma (UC), its use in low-risk patients with AMH is controversial.Methods: A total of 200 consecutive low-risk patients (median age, 64 years) with AMH were referred to the urology clinic between 2005 and 2007. All underwent cystoscopy, upper tract imaging, and voided urinary cytology. Results of voided cytology were classified as positive, atypical, or negative. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and costs were calculated.Results: None had positive cytology, 23 (11.5%) had atypical cytology, and 177 (88.5%) had negative urinary cytology. Of 200 patients, 8 (4%) were found to have low-grade UC of bladder via cystoscopy; the cytology was negative in 4 patients and atypical in 4. Of 8, 4 were Ta and 4 were pT1 tumors. There was no upper urinary tract or renal malignancy identified. If atypical cytology was considered as positive, the sensitivity, specificity, PPV, and NPV of cytology were 50%, 90%, 17%, and 98%, respectively. If atypical cytology was considered as negative, the sensitivity, specificity, PPV, and NPV of cytology were 0%, 100%, 0%, and 96%, respectively. Cost of performing urinary cytology was estimated at $262.50 per patient.Conclusions: Although this study supports evaluating patients with AMH because a significant percentage of patients will have UC, voided urine cytology added a significant cost without any diagnostic benefit in the work-up of low-risk patients with AMH.

Clinical Parameters and Semen Analysis in 716 Austrian Patients With Varicocele - Corrected Proof

2010-02-08

Objectives: To evaluate different clinical parameters in association with the presence and severity of varicocele in a large group of Austrian men.Methods: Records of 716 consecutive patients with clinical varicocele and infertility, who visited our andrology unit from 2001 to 2007, were retrospectively evaluated. The presence, grade, and side of any varicocele were recorded; varicoceles were confirmed by Doppler sonography. Semen samples, serum follicle-stimulating hormone, luteinizing hormone, estradiol, and testosterone levels were also assessed in all patients.Results: Mean age was 29.6 ± 0.3 years; 30% of patients presented with grade I varicocele, 39.0% with grade II, and 30.3% with grade III varicocele. About 33.3% of patients presented with normozoospermia, followed by asthenozoospermia (17.9%), oligoasthenoteratozoospermia syndrome (14.2%), and oligozoospermia (13.2%). Sperm density significantly decreased with increasing grade of varicocele. Body mass index was inversely proportional to varicocele. Serum testosterone levels were higher in grade III varicoceles (5.7 ± 0.2 nmol/L) compared with grade I (4.9 ± 0.2 nmol/L) and grade II (5.0 ± 0.1 nmol/L) varicoceles (P <.001; range, 0.4-16.6 nmol/L).Conclusions: To our knowledge the current report is the first to describe a direct relationship between grade of varicocele and semen quality. Grade III varicocele was associated with decreased semen quality and, interestingly, with higher testosterone levels. Our study confirmed previous reports regarding the relationship between varicoceles and body mass index.

Modified Technique to Prevent Complications Related to Stoma and Ileoureteral Anastomosis in Patients Undergoing Ileal Conduit Diversion - Corrected Proof

2010-01-28

Objectives: To introduce a modified technique for preventing complications related to stoma and ileoureteral anastomosis in patients undergoing ileal conduit diversion.Methods: A urinary stoma was created intracorporeally and was pulled out to the abdominal wall through a retroperitoneal tunnel. The ileal conduit was fixed by nonabsorbable sutures that incorporated all abdominal wall fascia and the bowel seromuscular layer. The terminal ureter was spatulated and anastomosed to the conduit in an end-to-side fashion by a continuous lock-stitch suture after stoma maturation and conduit fixation. A 24F multiorifice catheter was introduced into the ileal conduit as a stent, but a ureteral stent was not used. The peritoneum underlying the stoma was preserved intact, and the ureters and the conduit were completely extraperitonealized. A urine collection device was attached to the matured stoma immediately after surgery.Results: The modified technique was used in 56 consecutive patients who underwent ileal conduit diversions. The median operative time was 327 minutes. No early complications, such as urine or intestinal leakage, occurred. Two patients, however, developed ileus. The median follow-up was 36 months. Forty-five patients survived disease-free, whereas 11 died during the follow-up. There were no stoma-related complications or stenosis at the ileoureteral anastomotic site. No metabolic complications were observed and renal function was normal in all patients.Conclusions: Complications related to stoma and ileoureteral anastomosis in patients undergoing ileal conduit diversion can be prevented using our modified technique. However, further clinical investigation is required to confirm the advantage and long-term effects of our modified technique.

Intravesical Injections of Botulinum Toxin Type A for Management of Neuropathic Bladder: A Comparison of Two Methods - Corrected Proof

2010-01-28

Objectives: To evaluate and compare the efficacy of botulinum toxin intravesical injections with and without injections in external urethral sphincter in treating bladder hyper-reflexia in children suffering from myelomeningocele.Methods: A total of 60 patients with bladder hyper-reflexia due to myelomeningocele were randomly allocated to treatment groups A and B and were followed up for 6 months. Under cystoscopic guidance, 10 IU/kg of botulinum toxin A was injected into the detrusor muscle, sparing the trigone and ureteral orifices in group A. Group B received 8 IU/kg of toxin via the same method compared with group A and 2 IU/kg of toxin through 4 injections in external urethral sphincter. Conventional urodynamics, daily incontinence score, constipation, and creatinine level were evaluated at baseline, 3 months, and 6 months after intervention. Vesicoureteral reflux was also assessed before and after 3 months of injections.Results: All patients showed significant improvement in bladder capacity (P <.01), maximal detrusor pressure (P <.01), and detrusor-sphincter dyssynergia (P <.01) after 3 and 6 months of receiving injections. Significant improvement in postvoiding residual volume was observed only among patients of group B (P <.05). Both methods resulted in a significant reduction in daily incontinence grade, constipation, and vesicoureteral reflux (P <.05), but comparison between the study groups showed better outcomes for group B in relation to incontinency, constipation, vesicoureteral reflux, and creatinine level.Conclusions: Botulinum toxin type A injections in both sphincter and detrusor seems to have extra benefits such as decreasing postvoiding residual volume and more symptom diminution compared with intradetrusal injections alone.

Robot-assisted Pelvic Lymphadenectomy for Bladder Cancer—Where Have We Reached By 2009 - Corrected Proof

Iqbal Singh — 2010-01-28

Objectives: To review the current status and role of robot-assisted laparoscopic pelvic lymphadenectomy. To review the need, extent, lymph node yield, oncological feasibility, and outcome of robot-assisted pelvic lymphadenectomy for invasive bladder cancer in patients undergoing a robot-assisted laparoscopic radical cystectomy.Methods: The National Library of Medicine and the Pub Med were extensively searched for the cases of robot-assisted laparoscopic pelvic lymphadenectomy performed in conjunction with robot-assisted laparoscopic radical cystectomy for bladder cancer using the following keywords: bladder cancer, pelvic lymphadenectomy, cystectomy, laparoscopy, robot, and robot-assisted radical cystectomy. These were reviewed and analyzed (using certain tabulated parameters) to determine the current status of robot-assisted pelvic lymphadenectomy.Results: The search yielded about 12 major published series (278 cases) of “robot-assisted radical cystectomy with pelvic lymphadenectomy,” with an overall acceptable mean operating time(s), complication rate, blood loss, and hospital stay.Conclusions: Robot-assisted laparoscopic pelvic lymphadenectomy in conjunction with robot-assisted laparoscopic radical cystectomy is an oncologically feasible and technically safe procedure with acceptable early operative outcomes that appear to be comparable to those achieved with open/laparoscopic surgery.

Decline of the Red Blood Cell Count in Patients Receiving Androgen Deprivation Therapy for Localized Prostate Cancer: Impact of ADT on Insulin-like Growth Factor-1 and Erythropoiesis - Corrected Proof

2010-01-28

Objectives: To elucidate the mechanism of blood hemoglobin loss in patients with prostate cancer during androgen deprivation therapy (ADT), and to examine the activity of the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis during ADT, which plays an important role in hematopoiesis.Methods: A total of 83 patients with localized prostate cancer, who received ADT, were prospectively studied on the basis of their blood samples at the baseline and after ADT for 6 months.Results: Before ADT, the IGF-1 level was correlated with the red blood cell (RBC) count (Spearman's rank correlation coefficient analysis [rs]= 0.315, P = .011), hemoglobin (rs = 0.278, P = .018), and mean corpuscular volume (rs = 0.266, P = .020), but such relationships disappeared after ADT. After ADT, the serum IGF-1 level increased compared with that at the baseline (21 ± 6 vs 18 ± 5 nmol/L, respectively, P <.001), but no change was observed in the serum GH level (P = .691). There was no difference between erythropoietin and interleukin-6 concentrations before and after ADT (P = .852 and P = .208, respectively). The hemoglobin concentration and RBC count declined after ADT compared with those before treatment (P <.001 for each). Although the mean corpuscular volume declined after ADT (P = .002), the mean cell hemoglobin was comparable between before and after ADT (P = .676).Conclusions: Despite the unaffected GH, erythropoietin, and interleukin-6 levels, the serum IGF-1 concentration was elevated by ADT. Even with the increased IGF-1 level, the RBC count and hemoglobin concentration declined after ADT. IGF-1 in the bone marrow erythroid progenitor cells might be functionally inactivated during ADT.

Expression of hepaCAM and Its Effect on Proliferation of Tumor Cells in Renal Cell Carcinoma - Corrected Proof

Chunhua Xun, Chunli Luo, Xiaohou Wu, Qiaolin Zhang, Ling Yan, Shali Shen — 2010-01-28

Objectives: To evaluate hepaCAM (hepatocyte cell adhesion molecule) gene expression in patients with renal cell carcinoma (RCC) and to explore its effect on proliferation of 786-0 cells. hepaCAM is a tumor suppressor gene, which has been identified as a member of immunoglobulin superfamily cell adhesion molecule.Methods: Two-step reverse transcription–polymerase chain reaction was used to determine hepaCAM expression in 30 paired (RCC and the adjacent non-RCC) renal specimens. Transfection studies were carried out by expressing green fluorescent protein and green fluorescent protein-fused hepaCAM in 786-0 cells.Results: Significant downregulation of hepaCAM was detected in 25 of 30 RCC patients tested. When transfected into 786-0 cells, the number of colony formation was reduced by 5-fold according to colony formation assay. MTT (3-diphenyltetrazolium bromide) showed the inhibition rates on the fourth, fifth, and sixth days of culturing were 26.5%, 38.1%, and 35.7%, respectively.Conclusion: Our data show that hepaCAM is frequently downregulated in RCC, and that exogenous hepaCAM exhibits antiproliferative effect on 786-0 cells, suggesting that silencing of hepaCAM may be associated with carcinogenesis of RCC.

Late Recurrence and Progression in Non-muscle–invasive Bladder Cancers After 5-year Tumor-free Periods - Corrected Proof

2010-01-28

Objectives: To evaluate the recurrence and progression in patients with non-muscle–invasive bladder tumors who remained tumor-free for at least 5 years, which should assist in the development of schedules of their follow-up evaluations. Non-muscle–invasive bladder tumors that recur or progress at a late time point are not rare.Methods: Between 1985 and 2002, 814 cases diagnosed with non-muscle–invasive bladder cancer were treated with transurethral resection. Of these 814 cases, 262 patients with no tumor recurrence for more than 5 years were included in the study. The median follow-up interval was 10.0 years.Results: During the follow-up period, 39 tumors (14.9%) showed tumor recurrence. The 5- and 10-year recurrence-free survival rates were 81.6% and 76.0%, respectively. There was no significant difference in tumor recurrence among the low-, intermediate-, and high-risk groups based on the current clinical guideline. Only the use of intravesical mitomycin C was determined to be a significant unfavorable risk factor for late recurrence. Five patients (1.9%) experienced stage progression, 3 of whom did not have metastases at the time of diagnosis of the progression but died because of bladder cancer disease.Conclusions: After a 5-year tumor-free period, even in the low-risk group, recurrence occurred at a late time point to a degree that was the same as that for the intermediate- and high-risk groups. Finally, some of the high-risk patients experienced late progression with a high degree of malignant behavior, suggesting longer follow-up is needed for each patient.

What Is the Role of Percutaneous Needle Core Biopsy in Diagnosis of Renal Masses? - Corrected Proof

2010-01-28

Objective: To define the accuracy and acceptability of ultrasonography-guided percutaneous needle core biopsy in diagnosis of renal masses.Methods: The data of 42 consecutive patients on whom needle biopsies were performed and were surgically treated for suspicious renal masses in our clinic between January 2001 and April 2008 were evaluated. In all patients, needle biopsies were done percutaneously with an 18-gauge needle under local anesthesia in prone position with ultrasonography guidance. Two cores were taken from each tumor. The pathology results of biopsy and surgical specimens were compared.Results: The mean age was 56.1 years (range, 21-77 years). The mean follow-up period was calculated as 44.8 months (range, 10-85 months). The abdominal computed tomography imaging showed that the mean mass size was 63.9 mm (range, 25-140 mm). Of 42 patients, 39 were diagnosed (92.8%) after the first biopsy. The accuracy of percutaneous needle biopsy in differentiating between malignant and benign masses was calculated as 90% (36/40).The accuracy of histopathological diagnostic typing as against the postsurgical pathologic examination results was 77.5% (31/40) and the accuracy in the Fuhrman grade was 51.5% (17/33). The sensitivity was calculated as 91.4% and specificity as 60%. Its negative predictive value was 50% and positive predictive value was 94.1%.Conclusions: In conclusion, percutaneous renal needle core biopsy has an acceptable sensitivity and specificity in the diagnosis of renal masses. The major limitation of percutaneous core biopsy is the technical failure that leads to insufficient material for accurate diagnosis.

Pyelovesical Bypass Graft for Palliative Management of Malignant Ureteric Obstruction: Optimizing the Technique by Percutaneous Access to the Bladder Using a Split Amplatz Sheath - Corrected Proof

Alireza Aminsharifi, Alireza Taddayun, Mohammadreza Jafari, Ehsan Ghanbarifard — 2010-01-28

Objectives: To introduce a simple modification to the original technique of pyelovesical bypass graft placement to make the procedure more minimally invasive.Methods: During the study period 2 patients with malignant ureteric obstruction underwent pyelovesical bypass graft placement using Detour stent (Mentor-Porges). The technique simply comprised tract dilatation of the previously placed percutaneous nephrostomy to place the proximal end of the graft in the renal collecting system, making a subcutaneous tunnel from a 1-cm suprapubic incision to the flank area, percutaneous access to the bladder under fluoroscopic guide and placement of the distal end of the stent into the bladder through a split Amplatz sheath. The operative outcome was analyzed prospectively.Results: Both patients tolerated the procedures well with no intra- and postoperative complications. Renal function remained stable during the follow-up period with acceptable urine output through the urethra. Abdominal wall complications such as fistula formation or pain along the subcutaneous tract as well as stent encrustation did not occur during the follow-up period.Conclusions: Despite our small sample size and short follow-up period, percutaneous access to the bladder using a split Amplatz sheath during placement of the Detour stent, may be considered as a promising simple modification to optimize the technique by obviating the need for open cystostomy incision.

The Feasibility of Laparoendoscopic Single-Site Nephrectomy: Initial Experience Using Home-made Single-port Device - Corrected Proof

2010-01-27

Objectives: To report our early experience with laparoendoscopic single-site (LESS) nephrectomy using home-made single-port device for benign nonfunctioning kidney.Methods: A total of 14 patients with benign nonfunctioning kidney underwent transperitoneal LESS nephrectomy by 2 experienced laparoscopic surgeons. The indications for nephrectomy were nonfunctioning kidney associated with ectopic kidney (n = 2), ureteropelvic junction obstruction (n = 5), genitourinary tuberculosis (n = 4), ureter stone (n = 2), and ureter stricture (n = 1).Results: All procedures were completed successfully. The mean operative time was 151 (85-230) minutes, estimated blood loss 108 (negligible-500) mL, and postoperative hospital stay 3.1 (2-6) days. There were no major complications.Conclusions: LESS nephrectomy is a feasible and safe surgical option for benign nonfunctioning kidney.

SIU Scholarship: Dr. Abdulwahab-Ahmed Abdullahi - Corrected Proof

Dr. Abdulwahab-Ahmed Abdullahi — 2010-01-27

The Société Internationale d'Urologie offers Training Scholarships for young doctors with basic surgical or urological qualifications. The SIU Scholarships involve training in a recognized Urological center of excellence located in the candidate's geographical region. These SIU-accredited centers provide an excellent environment for learning and, in many instances, hands-on experience, so that candidates may acquire knowledge and skills that they will be able to transfer to their own setting of practice. In this series of short communications, SIU Scholars write about the impact that these training opportunities facilitated by the SIU had on their quality of care and career development. Information about applying for an SIU Scholarship is available at http://www.siu-urology.org/.I was fortunate to be one of the beneficiaries of the SIU-sponsored scholarship training at the Urology Department of Al-Azhar University in Cairo, where Professor Ismail Khalaf was my supervisor.

Focal Positive Surgical Margins Decrease Disease-free Survival After Radical Prostatectomy Even in Organ-confined Disease - Corrected Proof

Alison M. Lake, Chang He, David P. Wood — 2010-01-27

Abstract: Objectives: To investigate the significance of focal positive margins (FPM) in prostatectomy patients. The significance of FPM after radical prostatectomy is unclear. The implication is that FPM are surgically induced, may not represent true tumor extension beyond the prostate, and thus would not affect disease-free survival (DFS).Methods: Data were retrospectively reviewed from 2468 patients undergoing radical prostatectomy between January 1996 and October 2008. The DFS probabilities were compared among different margin statuses (negative [NM], FPM, and extensively positive [EPM]) with the log-rank test. FPM was defined as less than/equal to 3 mm. EPM was greater than 3 mm. A multivariate Cox analysis was performed to evaluate the significance of FPM in patients with prostate cancer.Results: Of all patients, 2022 (82%) had NM, 344 (14%) had FPM, and 99 (4%) had EPM. Of the 1997 patients with pT2 disease, 1716 (86%) had NM, 229 (11.5%) had FPM, and 52 (2.6%) had EPM. The 10-year DFS for all patients was 84%, 64%, 38% for NM, FPM, and EPM, respectively (P < .0001). The 10-year DFS for organ-confined disease was 90%, 76%, and 53% for NM, FPM, and EPM, respectively (P <.0001). The risk of biochemical recurrence for all patients increases with worsening margin status. Margin status affects biochemical recurrence and depends on the Gleason grade on surgical pathology for all patients (P = .0005) and patients with pT2 disease (P = .0233).Conclusions: FPM and EPM after radical prostatectomy confer a decreased DFS even in patients with otherwise organ-confined disease.

An Unbiased Prospective Report of Perioperative Complications of Robot-assisted Laparoscopic Radical Prostatectomy - Corrected Proof

2010-01-27

Abstract: Objectives: To analyze and classified our single-institution experience with the perioperative complications associated with robot-assisted laparoscopic radical prostatectomy (RALRP).Methods: A total of 239 patients with a mean age of 60.6 years were evaluated (January 2007 to June 2008). Data were collected through an institutional review board–approved blinded prospective database by an independent third party committee. The data-points accrued were set forth by a 5-member panel including 3 robotic urological surgeons (J. R., G. H., G. P.), the chief of general surgery (H. S.), and a member of the hospital's outcomes committee. The Modified Clavien system was used to grade complications, with grade I and II representing minor and grade III, IV, and V major complications.Results: Of our 239 patients, 198 (82.9%) had an uneventful postoperative course, defined as discharged home from the hospital within 2 days postoperatively with no unscheduled procedures/studies/hospital admissions or emergency room visits. On review of the remaining 41 patients, 55 complications were found. Of these, 24 were grade I, 17 grade II, 7 grade IIIa, 5 grade IIIb, 1 grade IVa, and 1 grade V complications. There was 1 perioperative mortality (0.4%) attributed to a pulmonary embolism on autopsy. Blood loss data revealed 1 (0.4%) intraoperative transfusion and 9 (3.8%) postoperative transfusions.Conclusions: RALRP is associated with major and minor complication rates of 5.0% and 14.6%, respectively. Prospective and blinded data on complications associated with RALRP are lacking in the published data. Our prospective, unbiased data provide an important tool to help counsel patients on complications associated with robot-assisted laparoscopic radical prostatectomy.

The Risk of Recurrent Urolithiasis in Children Is Dependent on Urinary Calcium and Citrate - Corrected Proof

2010-01-27

Objectives: To determine which risk factors help predict recurrent stone formation. Urinary stone disease is relatively rare in children. At our institution, a full urinary metabolic evaluation is initiated after the first stone episode.Methods: A retrospective cohort study was performed to assess urinary metabolic profiles in children with urolithiasis. Twenty-four–hour urine collections were performed and evaluated. Urine chemistries were adjusted for creatinine and weight. Abnormal thresholds were obtained from the available published data. The patients were stratified into solitary or recurrent stone formers by review of the medical record. Multivariate analysis was performed with a logistic regression model to assess for independent risk factors for stone recurrence.Results: A total of 148 samples from 88 patients with solitary stones and 84 samples from 51 patients with recurrent stones were evaluated. Age and gender were well-matched between the 2 groups. Most known stones were calcium oxalate, and there were no radiolucent stones in those with unknown composition. A significantly higher number of patients with recurrent stones had abnormal values for calcium (73% vs 57%) and citrate (30% vs 13%) by univariate analysis. Both calcium (odds ratio, 2.3, P <.01) and citrate (odds ratio, 3.5, P <.001) remained independent risk factors for stone recurrence by multivariate analysis.Conclusions: There are significant differences in the urinary calcium and citrate levels between children with solitary and recurrent calcium stone formation. This may allow identification of patients at risk for stone recurrence that may benefit from more aggressive dietary and/or pharmacologic intervention.

SIU Scholarship: Dr. Anselm Okwudili Obi - Corrected Proof

Anselm Okwudili Obi — 2010-01-22

The Société Internationale d'Urologie offers Training Scholarships for young doctors with basic surgical or urological qualifications. The SIU Scholarships involve training in a recognized Urological center of excellence located in the candidate's geographical region. These SIU-accredited centers provide an excellent environment for learning and, in many instances, hands-on experience, so that candidates may acquire knowledge and skills that they will be able to transfer to their own setting of practice. In this series of short communications, SIU Scholars write about the impact that these training opportunities facilitated by the SIU had on their quality of care and career development. Information about applying for an SIU Scholarship is available at http://www.siu-urology.org/.I qualified as a Fellow of the West African College of Surgeons (Urology) in October 2001 and obtained the SIU Scholarship in June 2004. During this period, I knew I had limitations in several areas of Urology because of the limited facilities and scope of training in my country, Nigeria, and I yearned for an opportunity to improve myself.

Altered Expression of NDRG2 in the Testes of Experimental Rat Model of Cryptorchidism - Corrected Proof

2010-01-21

Objectives: To examine the expression of N-Myc downstream regulated gene 2 (NDRG2) in the cryptorchid testes and its potential association with germ cell apoptosis in a rat model of cryptorchidism.Methods: Groups of pubertal Sprague-Dawley rats were subjected to surgical procedure for the induction of experimental unilateral cryptorchidism. The weight of the abdominal and scrotal testes was measured and their apoptotic cells and NDRG2 expression were examined longitudinally by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling, immunohistochemistry, and immunofluorescence analyses. The expression of NDRG2 and p53 in the purified germ cells and Leydig cells was determined by Western blot assay.Results: Compared with the control scrotal testes, the mean weights of the abdominal testes were significantly reduced at 7 and 14 days after surgery, accompanied by significantly increased numbers of apoptotic germ cells. Although the NDRG2 expression was detected in Leydig cells and spontaneous apoptotic germ cells in the scrotal testes, it was significantly upregulated predominately in apoptotic spermatocytes and round spermatids in the abdominal testes. However, the NDRG2 expression was downregulated in Leydig cells in the abdominal testes. Western blot analysis revealed that the expression of NDRG2 and p53 was upregulated significantly in purified germ cells 7 days after surgery, whereas NDRG2 was downregulated in the purified Leydig cells from the abdominal testes 7 and 14 days after surgery.Conclusions: The upregulated expression of NDRG2 was associated with germ cell apoptosis in the cryptorchid testes, suggesting that the NDRG2 may be a positive regulator for germ cell apoptosis in rat cryptorchidism.

Testicular Fusion in a Patient With Transverse Testicular Ectopia and Persistent Mullerian Duct Syndrome - Corrected Proof

Evisa Zhapa, Marco Castagnetti, Rita Alaggio, Enrico Talenti, Waifro Rigamonti — 2010-01-21

We report a case of fused testes in a patient with transverse testicular ectopia and persistent Mullerian duct syndrome. A laparoscopy performed to confirm the diagnosis showed a single vas deferens on the left side. Treatment included excision of the Mullerian remnant through a left inguinal incision and orchidopexy of the fused testes via the left inguinal canal after sectioning of the right internal spermatic vessels. Follow-up ultrasound has so far confirmed viability of both testes.

Overactive Bladder Is Not Only Overactive but Also Hypersensitive - Corrected Proof

Seung Ryeol Lee, Hyung Joon Kim, Ayoung Kim, Jang Hwan Kim — 2010-01-21

Objectives: To evaluate differences in bladder filling sensations and current perception threshold (CPT) values between patients with and without overactive bladder (OAB), and to further investigate the correlation between CPT values and voiding patterns in OAB patients.Methods: Detrusor overactivity and bladder volumes at first sensation of bladder filling, first desire to void, and strong desire to void during filling cystometry were compared between 55 female patients with OAB and 42 with non-OAB. CPT measurements from the bladder mucosa taken after neuroselective electrostimulation at frequencies of 2000, 250, and 5 Hz were compared between the 2 groups. In OAB patients, the correlations between CPT values and voiding variables based on 3-day bladder diaries were investigated.Results: OAB patients showed significantly more detrusor overactivity than non-OAB patients (P <.05). Bladder volumes at first sensation of bladder filling, first desire to void, and strong desire to void were significantly lower in OAB patients than in non-OAB patients (P <.05). CPT values at all 3 frequencies were also significantly lower in OAB patients (P <.05). The total number of urgency episodes correlated with CPT values at 250 (r = −0.274, P = .045) and 5 Hz (r = −0.293, P = .032). The total number of urge incontinence episodes also correlated with CPT values at 250 (r = −0.279, P = .041) and 5 Hz (r = −0.272, P = .046).Conclusions: Bladder sensory profiles displayed a more sensitive bladder in OAB patients compared with non-OAB subjects. OAB patients may have bladders that are not only overactive, but also hypersensitive.

Robot-assisted Partial Nephrectomy: A Large Single-institutional Experience - Corrected Proof

2010-01-18

Objectives: To report experience with 100 robot-assisted partial nephrectomy (RAPN) operations performed at our institution. Nephron-sparing surgery is an established treatment for patients with small renal masses. The laparoscopic approach has emerged as an alternative to open nephron-sparing surgery, but it is recognized to be technically challenging. The robotic surgical system may enable faster and greater technical proficiency, facilitating a minimally invasive approach to more difficult lesions while reducing ischemia time.Methods: A total of 100 RAPN operations were performed for suspicious solid renal lesions during a 21-month period. Clinicopathologic variables, nephrometry scores, operative parameters, and renal functional outcomes were prospectively recorded and analyzed.Results: Median tumor size was 2.8 cm (range, 1.0-8). Nephrometry scores of resected lesions were low in 47.9% of patients, medium in 45.7%, and high in 6.4% of patients. Forty-seven percent of patients had tumors >50% intraparenchymal, and 61.7% had tumors located less than 7 mm away from the renal sinus or collecting system. In 17% of patients, the tumors were touching a first-order vessel in the renal hilum. Mean warm ischemia time was 25.5 minutes (range, 0-53). Mean change in postoperative glomerular filtration rate improved 6.32 mL/min/1.73 m2 (range, −41.9 to 68.9). Histology was renal cell carcinoma in 81% (87/107) of tumors. There were 5 microscopically positive margins on final pathology (5.7%). Major and minor complication rates were 6% and 5%, respectively. There were 2 conversions to open surgery.Conclusions: RAPN seems to be a safe and technically feasible minimally invasive approach to nephron-sparing surgery even in more complex cases, with acceptable pathologic and renal function outcomes.

Androgen Receptor Is a Potential Therapeutic Target for Bladder Cancer - Corrected Proof

Ji-Tao Wu, Bang-Min Han, Sheng-Qiang Yu, Hui-Ping Wang, Shu-Jie Xia — 2010-01-18

Objectives: To investigate whether androgen receptor (AR) could serve as a potential molecular target for the treatment of bladder cancer.Methods: Cell proliferation, apoptosis, and migration capacity were determined in human transitional carcinoma cell lines T24 and 253-J treated with small interfering RNA directed against AR, and expression levels of growth- and metastasis-related genes were assessed using quantitative reverse transcriptase-polymerase chain reaction. Tumor cell growth and apoptosis were also evaluated in vivo in T24 tumor-bearing nude mice receiving electroporation-assisted administration of anti-AR small interfering RNA.Results: AR expression knockdown produced increased apoptosis, decreased proliferation, and migration of bladder cancer cells. Cyclin D1, Bcl-xL, and matrix metallopeptidase-9 gene expression were also reduced with AR knockdown, which might have contributed to the altered biological behavior of cancer cells. In vivo experiments showed that silencing AR expression, by interference aided by electroporation, significantly suppressed AR-positive bladder tumor growth with decreased cell proliferation and increased apoptotic rates.Conclusions: Downregulation of AR expression inhibits bladder cancer cell growth in vitro and in vivo, implying that its use might be a potential therapeutic target for the treatment of bladder cancer.

Lack of Pharmacodynamic Interaction of Silodosin, a Highly Selective α1a-Adrenoceptor Antagonist, With the Phosphodiesterase-5 Inhibitors Sildenafil and Tadalafil in Healthy Men - Corrected Proof

Scott A. MacDiarmid, Lawrence A. Hill, Weining Volinn, Gary Hoel — 2010-01-18

Objectives: To evaluate the orthostatic effects and safety of coadministration of silodosin with the phosphodiesterase-5 inhibitors sildenafil and tadalafil.Methods: In this placebo-controlled, open-label crossover study, 22 healthy men aged 45-78 years received 8 mg silodosin for 21 days. On days 7, 14, and 21, subjects also received a single dose of sildenafil 100 mg, tadalafil 20 mg, or placebo in random sequence. Orthostatic tests were performed before (baseline) and 1-12 hours after single-dose treatment. A positive orthostatic test was defined as decrease in systolic blood pressure (SBP) >30 mm Hg, decrease in diastolic blood pressure (DBP) >20 mm Hg, increase in heart rate (HR) >20 bpm, or presence of orthostatic symptoms. Treatment effects were compared by analysis of covariance.Results: In comparison with placebo, sildenafil or tadalafil caused small but statistically significant reductions in blood pressure; however, no statistically significant orthostatic changes in SBP, DBP, or HR (P >.05) were caused. Time-matched maximum mean difference (95% confidence interval) vs placebo in 1-minute orthostatic change was −2.3 (−6.8-2.2) mm Hg for SBP, −2.2 (−5.6-1.2) mm Hg for DBP, and 1.7 (−1.5-4.9) bpm for HR. The number of postdose positive orthostatic tests was similar for all treatments (sildenafil, 57; tadalafil, 59; placebo, 53). Adverse events (in 7 subjects) were mild (26) or moderate (2). No orthostatic symptoms occurred.Conclusions: Coadministration of silodosin and maximum therapeutic doses of sildenafil or tadalafil in healthy men caused no clinically important orthostatic changes in blood pressure or HR and no orthostatic symptoms.

Post-transplantation Lymphoproliferative Disorder in the Renal Transplant Ureter - Corrected Proof

Mary K. Samplaski, Joshua Coleman, David Goldfarb — 2010-01-18

Dr. MKS: A 68-year-old Caucasian woman with a history of end-stage renal disease secondary to diabetic nephropathy underwent cadaveric renal transplantation in December 2008, using a standard criteria donor. The donor tested positive for cytomegalovirus (CMV) and Epstein Barr virus (EBV), and the recipient was negative for both. A stented Lich-Gregoir extravesical ureteroneocystostomy was used for ureteral reimplantation. Her immediate postoperative course was unremarkable. She received basiliximab induction and was maintained on an immunosuppressive regimen of tacrolimus, mycophenolate mofetil, and steroids. The serum creatinine nadir was 1.2 mg/dL. She received 3 months of prophylaxis for CMV with acyclovir 400 mg 3 times daily. Valacyclovir would have been the preferred antiviral medication; however, her insurance would not cover it, and acyclovir was believed to be an acceptable alternative. The ureteral stent was removed at 6 weeks postoperatively.

Classification System: Organ Preserving Treatment for Prostate Cancer - Corrected Proof

John F. Ward, J. Stephen Jones — 2010-01-18

A “perfect storm” of events has now challenged the concept that all men diagnosed with localized prostate cancer (PCa) require treatment to the entire prostate gland to effectively modulate the natural history of the disease. Prostate screening programs, patient education, and serum prostate-specific antigen (PSA) testing have all contributed to the dramatic 2-decade shift toward predominantly organ-confined disease. “Watchful waiting” programs for older men with advanced disease morphed into “active surveillance with selective delayed therapy” programs for younger men with minimal disease, based on the recognition that the overwhelming majority of patients with PCa are at minimal risk of morbidity or mortality from their disease, regardless of whether it is detected, and at a significantly higher risk of morbidity from radical therapy. Thermal ablative and imaging technology improved parallel to these events to allow for controlled, definitive, and reliable delivery of energy to a specific target, thereby minimizing collateral damage. Thus, large numbers of patients and growing legions of urologists now seek treatment options offering morbidity more balanced with the risk of the disease.

Developing Selection Criteria for Prostate-sparing Cystectomy: A Review of Cystoprostatectomy Specimens - Corrected Proof

2010-01-18

Abstract: Objectives: To determine risk factors for prostate pathology, which may serve as guidelines for identifying patients who may be inappropriate for prostate-sparing cystectomy for treatment of transitional cell cancer of the bladder.Methods: After obtaining Institutional Review Board approval, we reviewed the clinical and pathologic data from consecutive men treated with radical cystoprostatectomy (RCP) between January 2003 and September 2008. We reviewed the RCP pathology for prostatic involvement by transitional cell carcinoma (PI-TCC) as well as presence of prostate cancer (PCa). Univariate analysis was used to test for association of clinical parameters with prostatic involvement in RCP specimens.Results: A total of 96 patients with a median age of 67 (interquartile range: 47, 79) underwent RCP between January 2003 and September 2008. PI-TCC was present in 24 patients (25%) of which 6 (25%) had carcinoma in situ (CIS) only and 18 (75%) had stromal invasion. We identified PCa in 40 patients (42%). CIS (odds ratio, 3.2, P = .018) and tumor situated at or below the trigone (odds ratio, 3.3, P = .046) at the pre-RCP transurethral bladder tumor resection were associated with PI-TCC.Conclusions: PI-TCC and PCa are common findings at RCP. The location of the bladder tumor situated at or below the trigone and the presence of CIS at transurethral bladder tumor resection is associated with increased risk for PI-TCC and should be considered at least relative contraindications for prostate-sparing cystectomy. A thorough investigation for PCa should be conducted for all possible candidates.

Importance of Additional “Extreme” Anterior Apical Needle Biopsies in the Initial Detection of Prostate Cancer - Corrected Proof

2010-01-18

Objectives: To describe our experience of adding extreme apical cores in men undergoing initial biopsy. Prostate cancer detection efforts have focused on increasing the number of cores. A more significant factor, however, may be their location. Laterally directed and apical cores have been associated with the highest cancer detection rate, especially the apical cores for men undergoing repeated biopsies.Methods: A prospective trial was conducted between September 2007 and April 2009. A total of 181 men with increased prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE), or both, underwent an initial transrectal ultrasound-guided biopsy (TRUS-BX). All patients underwent a standard 12-core biopsy scheme plus 2 additional cores taken from the extreme anterior apex, defined as the site immediately lateral to the junction of apex and urethra. Each core was marked by a special colored ink for identification. Site-specific detection and tumor characteristics were reported.Results: Prostate cancer was detected in 86 patients (47.5%). The apical cores (3 on each side) achieved the highest cancer detection rate (73.6% of all cancers), and the additional extreme anterior apical cores (1 on each side) achieved the highest rate of unique cancer detection (P = .011).Conclusions: From our experience, the apical cores, especially the extreme apical cores, increase prostate cancer detection on initial TRUS-BX and minimize the potential for misdiagnosis and need for repeat biopsy.

Direct-to-consumer Advertising for Urological Pharmaceuticals: A Cross-sectional Analysis of Print Media - Corrected Proof

Craig Folsom, Susan F. Fesperman, Bayo Tojuola, Shahnaz Sultan, Philipp Dahm — 2010-01-18

Objective: To investigate direct-to-consumer advertising (DTCA) of prescription drugs that are relevant to urological conditions. Evidence suggests that DTCA of prescription drugs increase pharmaceutical sales. Concern about such advertising methods has recently increased owing to the market withdrawal of heavily marketed drugs that were found to have serious health risks.Methods: Three consecutive issues of 26 popular magazines during a 3-month period were screened for urology-related DTCA. Advertisements were abstracted using a standardized evaluation form that was pilot-tested in a separate sample of nonurological advertisements. Variables analyzed included the type of advertisement, claims of effectiveness, references of research studies, inducements, and use of tables, figures, and pictures.Results: We identified 8 unique DTCA in 4 different magazines (Ladies Home Journal, Golf Digest, Sports Illustrated, and Good Housekeeping). All advertisements were disease-specific and targeted patients with benign prostatic hyperplasia-related symptoms (n = 3), incontinence (n = 3), or erectile dysfunction (n = 2). The median number of claims made per DTCA was 3 (range, 2-6). None of the claims made were supported by research data, as presented in tables or figures, or referenced peer-reviewed publications. The most common types of appeals addressed symptom control (8/8), lifestyle improvement (7/8), effectiveness (4/8), and dependability (3/8), while none addressed drug safety.Conclusions: DTCA of prescription drugs for urological conditions are found in select journals and focus on few highly prevalent conditions. None of the advertisement claims identified in this study were supported by research data. There seems to be significant room for improvement in the quality of information provided by urological advertisements.

Periprostatic Local Anesthesia With Pudendal Block for Transperineal Ultrasound-guided Prostate Biopsy: A Randomized Trial - Corrected Proof

2010-01-18

Objectives: To investigate the effectiveness of adding pudendal block to periprostatic anesthesia for transperineal ultrasound-guided needle prostate biopsy.Methods: A total of 150 patients were randomized to receive periprostatic anesthesia (group 1, n = 75) or combination of periprostatic anesthesia and bilateral pudendal block (group 2, n = 75). Visual analog scale was used to evaluate discomfort at each of the following stages: anesthetic infiltration, probe insertion, biopsy punctures, and 1 hour after biopsy.Results: The overall cancer detection rate was 34.7% for the entire cohort. Injection of the local anesthetic agent was significantly more painful in group 2 (combined periprostatic and pudendal block). However, this group showed statistically significantly better pain control throughout the probe insertion, biopsy punctures, and at 1 hour after biopsy. The mean pain score of the whole procedure, calculated by averaging the pain scores at all 4 steps, was 2.41 ± 1.01 and 1.83 ± 0.65 in group 1 and 2, respectively (P <.001). Minor and transient complications were observed in both groups with similar frequency with the exception of penile and scrotal numbness that was reported only by patients from group 2, and in all cases resolved without treatment within 8 hours.Conclusions: A combination of pudendal and periprostatic nerve block is a safe, effective, and useful technique that is well tolerated by the patients and improves pain reduction during transperineal prostate biopsy compared with the periprostatic anesthesia only, with no alteration in the severe complication rates.

The Vanishing Prostate Cancer Phenomenon - Corrected Proof

Stacy Loeb, Edward M. Schaeffer, Jonathan I. Epstein — 2010-01-15

The widespread use of prostate-specific antigen (PSA) for the screening of prostate cancer (CaP) has led to a considerable stage migration. Correspondingly, a greater frequency of low-volume disease has been found at radical prostatectomy (RP), and in about 4.2% of cases, no residual tumor has been found. Anecdotally, we have recently noted several cases of pathological stage T0 (pT0) disease. Although this finding is more frequently encountered after neoadjuvant therapy or transurethral resection of the prostate (TURP), these conditions are not always present. The objective of this study was to review the literature regarding pT0 CaP.

Median 5 Year Follow-up of 125Iodine Brachytherapy as Monotherapy in Men Aged ≤ 55 Years With Favorable Prostate Cancer - Corrected Proof

2009-12-25

Objectives: To report the genitourinary (GU) and gastrointestinal (GI) toxicity rates, erectile function preservation, and biochemical outcome (bNED) in men aged ≤ 55 years treated with 125iodine (125I) brachytherapy (BT).Methods: Between May 1999 and November 2005, 96 men with clinical stage T1-T2 prostate cancer received 125I prostate BT without androgen deprivation or supplemental external radiotherapy. Median age was 53 years (range 45-55). Minimum follow-up was 30 months and median 63 months (range: 30-108). Biochemical failure was defined as “nadir + 2.” GI and GU toxicity are reported using common terminology criteria for adverse events (CTCAE) v3.Results: Only 1 patient experienced a biochemical failure; the actuarial 7-year bNED rate is 98.9%. Median nadir is 0.05 ng/mL, reached at 48 months of follow-up. Median 5- and 7-year prostate specific antigen were 0.09 and 0.06 ng/mL, respectively. Grade 2 acute and late GU toxicity rates (urinary frequency, urgency, and/or dysuria) were 9.8% and 10.6%, respectively. Grade 3 GU toxicity (urethral stricture) was observed in 3 men and was corrected with urethral dilatation or transurethral resection. Two (2.2%) patients developed grade 2 GI toxicity (proctitis). Erectile function was preserved in 85 of 91 men with prior good function (93.4%); 41 (45%) used phosphodiesterase-5 inhibitors.Conclusions: Men aged ≤ 55 years treated with 125I prostate BT without androgen deprivation or supplemental external beam radiotherapy experienced excellent bNED rates with low toxicity. Men in this age group should be offered low dose rate prostate BT as an option to consider.

Repeated Injections of Botulinum Toxin-A for Idiopathic Detrusor Overactivity - Corrected Proof

2009-12-25

Objectives: To report the efficacy and safety of repeated injections of botulinum toxin-A (BTX-A) in treating idiopathic detrusor overactivity refractory to anticholinergics. Furthermore, we describe whether dose alteration in patients with poor responses or voiding dysfunction after initial treatment can improve outcomes.Methods: A cohort of 34 patients who participated in a clinical trial was followed up and their progress reported. Twenty from this group had >1 BTX-A injection. Each patient received 200 U BTX-A initially, with subsequent injections between 100 and 300 U, administered by a trigone-sparing flexible cystoscopic technique. Efficacy was measured using voiding diaries and quality of life (QoL) assessed with Incontinence Impact Questionnaire-7 and Urogenital Distress Inventory-6 questionnaires. Urodynamic data were obtained for injections 1-3. All measurements were performed before and 3 months after injections.Results: Twenty patients received a repeat injection and of these 9 subsequently received a third and fourth injection. Significant improvements in overactive bladder syndrome symptoms and QoL were observed after each injection as compared with baseline. Maximum cystometric capacity and bladder compliance increased with decrease in the maximum detrusor pressure during filling cystometry. When comparing overactive bladder symptoms, QoL, and urodynamic parameters 3 months after the first and last injections, no significant differences were found. Nine patients had their BTX-A dose altered, with better outcomes in 5. The commonest reported problems were difficulty in emptying the bladder and urinary tract infection.Conclusions: BTX-A appears to be effective and safe after repeated administration in patients with idiopathic detrusor overactivity. Certain patients will benefit from dose optimization to improve efficacy or prevent voiding dysfunction.

Reduction in the Risk of Prostate Cancer: Future Directions After the Prostate Cancer Prevention Trial - Corrected Proof

E. David Crawford, Gerald L. Andriole, Michael Marberger, Roger S. Rittmaster — 2009-12-25

The landmark Prostate Cancer Prevention Trial (PCPT) generated interest in the potential health benefits and cost of reducing prostate cancer risk—specifically, the potential role of 5α-reductase inhibitors. However, the PCPT raised several unanswered questions, including the cause and significance of the increased incidence of high-grade tumors associated with finasteride. In the present study, we review the PCPT findings and unanswered questions, next steps in this field, and ongoing prostate cancer prevention trials addressing these unanswered questions. Particular emphasis is placed on the design of the second large-scale trial of a 5α-reductase inhibitor, the REduction by DUtasteride of prostate Cancer Events (REDUCE) trial.

Economic Costs of Overactive Bladder in the United States - Corrected Proof

2009-12-25

Objectives: To calculate, from a societal perspective, current direct (medical and nonmedical) and indirect costs of overactive bladder (OAB) in the United States and project them to future years. Existing cost assessments of OAB in the United States are incomplete and outdated.Methods: A prevalence-based model was developed incorporating age- and sex-specific OAB prevalence rates, usage data, and productivity data. On the basis of the information gathered from the recent 5 years of the medical literature, practice guidelines, Medicare and managed care fee schedules, and expert panel input, the annual per capita and total US costs were calculated for 2007. US census population forecasts were used to project the costs of OAB to 2015 and 2020.Results: In 2007, average annual per capita costs of OAB were $1925 ($1433 in direct medical, $66 in direct nonmedical, and $426 in indirect costs). Applying these costs to the 34 million people in the United States with OAB results in total national costs of $65.9 billion (billion = 1000 million), ($49.1 billion direct medical, $2.3 billion direct nonmedical, and $14.6 billion indirect). Average annual per capita costs in 2015 and 2020 would be $1944 and $1969 and total national costs would be $76.2 billion and $82.6 billion, respectively.Conclusions: These data suggest that the economic burden of OAB is about 5-fold higher than older, noncomprehensive estimates. These costs are higher than previously published data for the United States and Europe because this analysis relies on more current data, real world age- and sex-specific treatment patterns and costs, and includes a more complete set of cost components.

Preliminary Results of Prostate Vaporization in the Treatment of Benign Prostatic Hyperplasia by Using a 200-W High-intensity Diode Laser - Corrected Proof

2009-12-25

Objectives: To evaluate the efficacy and safety of a 200-W high-intensity diode laser in the treatment of benign prostatic hyperplasia.Methods: The prostate was vaporized by using a side-firing laser fiber (diode laser: power, 150-200 W; wavelength, 980 nm; Limmer, Germany). The following parameters were assessed at baseline, and after a follow-up period of 1- and 6 months: International Prostate Symptom Score, maximum uroflow rate, postvoid residual urine volume, and quality of life score. Prostate volume and prostate-specific antigen levels were assessed at baseline and 6 months postoperatively.Results: This study included 55 patients diagnosed with lower urinary tract symptoms secondary to BPH, who were treated between December 2007 and July 2008. The recatheterization rate was 10.9%. None of these patients required a blood transfusion or had transurethral resection syndrome. Statistically significant improvements (P < .001) were observed in the values of International Prostate Symptom Score, Qmax, postvoid residual urine volume, and quality of life score at 1- and 6 months of follow-up as compared with the respective baseline values. Transient urge incontinence was noted in 8 patients (8/55, 14.5%).Sloughing of necrotic tissues was observed on cystoscopy in 8 patients within several weeks or months after the operation. The retreatment rate (secondary transurethral resection of the prostate) was 7.3%.Conclusions: From our preliminary data, it was evident that diode laser prostatectomy can achieve excellent hemostasis, and provide immediate relief from obstructive voiding symptoms. However, the postoperative irritative symptoms and sloughing of necrotic tissues remained to be an important issue that needed to be resolved.

Prostate-specific Antigen–based Risk-adapted Discontinuation of Prostate Cancer Screening in Elderly African American and Caucasian American Men - Corrected Proof

2009-12-25

Objectives: To evaluate the relationship between initial prostate-specific antigen (PSA) and prostate cancer (PCa) risk in elderly African American (AA) and Caucasian American (CA) men.Methods: A total of 408 AA and 1720 CA men whose initial PSA measurement was performed between 75 and 80 years of age were retrieved from Duke Prostate Center database. Patients were stratified by race and initial PSA value. The relative risk (RR) of PCa detection was estimated. The rates of high risk PCa, and death from PCa stratified by initial PSA groups were compared using the chi-square test.Results: The age-adjusted RR of PCa detection in CA men with PSA 3.0-5.9 ng/mL was 1.9-fold higher when compared with that of men with PSA 0.0-2.9 ng/mL (P <.001), but it did not change significantly in AA men (P = .270). PSA 6.0-9.9 ng/mL was associated with age-adjusted RR of PCa 9.3-fold in AA men and 4.1-fold in CA men (both P values <.001). A low rate of high-risk PCa and death from PCa was indicated with PSA <6.0 ng/mL and <3.0 ng/mL and follow-up of a maximum of 19.2 years and 17.6 years, respectively, in AA and CA men.Conclusions: AA men with initial PSA <6.0 ng/mL and CA men with initial PSA <3.0 ng/mL between 75 and 80 years of age are unlikely to be diagnosed with high risk PCa or death from PCa. It may be safe to discontinue PSA screening in these men.

Osteoblast-specific Factor 2 Expression in Prostate Cancer-associated Stroma: Identification Through Microarray Technology - Corrected Proof

2009-12-25

Objectives: To better understand the gene expression patterns in tumor-associated stroma, laser-capture-microdissections from clinical specimens were analyzed by genome-wide-expression microarray technology. The epithelial–stromal interaction plays a critical role in prostate development, reactive changes, and tumorigenesis. Diverse microarray technologies have been used to characterize the molecular changes in prostate cancer. Even though these gene expression studies are compromised by the heterogeneity of the tumor, as well as by the difficulty associated with collecting appropriate counterparts to represent normal prostate cells, the gene array data from tumors have shown promising results. Currently, little is known about the tumor-associated stromal gene expression profile in prostate cancer.Methods: Matching benign and malignant epithelial cell–related stroma cells were subjected to microarray platforms.Results: The prostatatic stroma expressed several osteogenic molecules. In particular, one of the genes, OSF2, was upregulated in tumor-associated stroma compared with benign epithelial cell associated stroma, which was further validated by immunohistochemical examination.Conclusions: These data show that the combination of laser capture dissection with computational enhancement of epithelial and stromal microarray data is a useful tool to assess gene expression changes in prostate cancer stroma.

Transperitoneal Laparoscopic Radical Nephrectomy for Patients With Dialysis-dependent End-stage Renal Disease: An Analysis and Comparison of Perioperative Outcome - Corrected Proof

2009-12-25

Objectives: To evaluate LRN as treatment for high risk patients. Laparoscopic radical nephrectomy (LRN) is performed for renal tumors not amenable to nephron-sparing treatments. Indications are increasing to include higher risk patients including those with end-stage renal disease (ESRD) necessitating dialysis.Methods: We performed a retrospective analysis of a patient cohort with clinical stage T1 renal tumors undergoing transperitoneal LRN. Parameters examined included patient demographics, medical comorbidities, tumor characteristics, operative outcomes, and complications.Results: One hundred eighty-nine patients underwent 195 LRN. Sixteen patients (8.5%) had preexistent ESRD requiring dialysis. A higher American Society of Anesthiologists score (P <.05), higher age-adjusted Charlson comorbidity index (P = .003), higher incidence of previous abdominal surgery (P = .012), and higher incidence of hypertension (P = .025) were found for the ESRD group. Mean blood loss was 153.0 and 132.0 mL (P = .71) in the ESRD patients and non-ESRD patients, respectively. A longer stay (P = .02) was noted for ESRD patients. Mean tumor size in the ESRD patients and non-ESRD patients was 2.6 and 4.2 cm (P <.05), respectively. Renal cell carcinoma was the most common pathology in 14 of 20 (70.0%) ESRD patient renal units and 167 of 175 (95.4%) non-ESRD patient renal units (P = .001). Intraoperative and postoperative complication rates were 6.3% and 31.3% respectively for ESRD patients (P = .05), and 8.7% and 21.4% respectively for non-ESRD patients (P = .35). Most postoperative complications were minor.Conclusions: LRN, for the treatment of renal tumors in ESRD patients requiring dialysis, is feasible and safe with acceptable intraoperative and postoperative complication rates. Patients with ESRD may require longer hospital stay after LRN.

2,8-Dihydroxyadenine Nephrolithiasis Induces Developmental Stage-specific Alterations in Gene Expression in Mouse Kidney - Corrected Proof

2009-12-25

Objectives: To identify factors that may be crucial for the initiation and progression of stone-induced injury in the developing mouse kidney by a prospective observational study using microarray analysis. Kidney stone diseases are common in premature infants, but the underlying molecular and cellular mechanisms are not fully defined.Methods: Mice with adenine phosphoribosyltransferase deficiency develop 2,8-dihydroxyadenine (DHA) nephrolithiasis. The gene expression changes between Aprt−/− and Aprt+/+ kidneys from newborn and adult mice were compared using Affymetrix gene chips. Targets of interest were further analyzed by quantitative real-time polymerase chain reaction and immunohistochemistry.Results: We identified a set of genes that were differentially expressed in the developing kidney in response to DHA-induced injury. In 1-week-old Aprt−/− mice, the expression of Sprr2f and Clu was highly augmented and that of Egf was significantly decreased. We also observed that maturation-related gene expression changes were delayed in developing Aprt−/− kidneys, and immature Aprt−/− kidneys contained large numbers of intercalated cells that were blocked from terminal differentiation.Conclusions: This study presents a comprehensive picture of the transcriptional changes induced by DHA stone injury in the developing mouse kidney. Our findings help explain growth impairment in kidneys subject to injury during the early stages of development.

Identification of a MicroRNA Panel for Clear-cell Kidney Cancer - Corrected Proof

2009-12-25

Objectives: To identify a robust panel of microRNA signatures that can classify tumor from normal kidney using microRNA expression levels. Mounting evidence suggests that microRNAs are key players in essential cellular processes and that their expression pattern can serve as diagnostic biomarkers for cancerous tissues.Methods: We selected 28 clear-cell type human renal cell carcinoma (ccRCC), samples from patient-matched specimens to perform high-throughput, quantitative real-time polymerase chain reaction analysis of microRNA expression levels. The data were subjected to rigorous statistical analyses and hierarchical clustering to produce a discrete set of microRNAs that can robustly distinguish ccRCC from their patient-matched normal kidney tissue samples with high confidence.Results: Thirty-five microRNAs were found that can robustly distinguish ccRCC from their patient-matched normal kidney tissue samples with high confidence. Among this set of 35 signature microRNAs, 26 were found to be consistently downregulated and 9 consistently upregulated in ccRCC relative to normal kidney samples. Two microRNAs, namely, MiR-155 and miR-21, commonly found to be upregulated in other cancers, and miR-210, induced by hypoxia, were also identified as overexpressed in ccRCC in our study. MicroRNAs identified as downregulated in our study can be correlated to common chromosome deletions in ccRCC.Conclusions: Our analysis is a comprehensive, statistically relevant study that identifies the microRNAs dysregulated in ccRCC, which can serve as the basis of molecular markers for diagnosis.

Treatment of Pediatric Vesicoureteral Reflux Using Endoscopic Injection of Hyaluronic Acid/Dextranomer Gel: Intermediate-term Experience by a Single Surgeon - Corrected Proof

Michael H. Hsieh, Ramiro J. Madden-Fuentes, Nicholas E. Lindsay, David R. Roth — 2009-12-25

Objectives: Endoscopic injection of non–animal-stabilized hyaluronic acid/dextranomer gel is an increasingly recognized treatment option for vesicoureteral reflux. The procedure is minor compared with open surgery and, when successful, avoids the need for long-term antibiotic prophylaxis. We present data from 3 years of using non–animal-stabilized hyaluronic acid/dextranomer gel to treat children with vesicoureteral reflux.Methods: Pediatric patients aged 16 years with uncomplicated primary vesicoureteral reflux were recruited for endoscopic treatment with non–animal-stabilized hyaluronic acid/dextranomer gel. A follow-up voiding cystourethrogram was scheduled at 2 weeks after treatment, and vesicoureteral reflux resolution was defined as grade 0. Repeat non–animal-stabilized hyaluronic acid/dextranomer gel treatment was offered to patients with persistent vesicoureteral reflux.Results: Of 178 patients treated, 12 were lost to follow-up or yet to undergo post-treatment voiding cystourethrogram. The 166 remaining patients (efficacy population) had a mean age of 4.21 years (range: 0-16), and the median reflux grade was 3 (range: 1-5). Vesicoureteral reflux was resolved in 81.9% of patients and 86.4% of ureters after initial endoscopic treatment with non–animal-stabilized hyaluronic acid/dextranomer gel. The overall reflux resolution rate for patients increased to 89.6% after a second treatment in 19 patients, and 90.2% after a third treatment in 1 patient. No adverse events were reported. Five patients underwent open ureteral reimplantation after failed endoscopic injections.Conclusions: Endoscopic treatment with non–animal-stabilized hyaluronic acid/dextranomer gel is effective in a high proportion of children with vesicoureteral reflux and, in our opinion, should be considered as a first-line treatment option.

Identification of Spermatozoa in Archived Testicular Cancer Specimens: Implications for Bench Side Sperm Retrieval at Orchiectomy - Corrected Proof

2009-12-25

Objectives: To evaluate the patterns of spermatogenesis in the normal testicular parenchyma of primary testicular cancers and estimate the feasibility of sperm retrieval at the time of radical orchiectomy.Methods: We reviewed the archived histologic sections of 39 consecutive patients who had undergone radical orchiectomy for primary testicular cancer at 3 university-affiliated hospitals. We examined all areas of normal (noncancerous) testicular parenchyma to evaluate the level of spermatogenesis and presence of mature spermatozoa in these sections. A minimum of 100 seminiferous tubules were scored per case. We also evaluated the epididymal tubules for the presence of mature spermatozoa. A review of the clinical chart was performed to evaluate the relationship between clinical data and histologic findings.Results: In nearly 40% of the cases evaluated (15/38), the predominant histologic pattern was full spermatogenesis. Mature spermatozoa were identified in nearly 80% (30/38) of the testicular histologic sections and in 50% (14/28) of the evaluable epididymal sections. Clinical stage (presence of extranodal disease) and tumor marker levels were related to the probability of identifying mature spermatozoa in the testis.Conclusions: The data suggest that sperm retrieval at the time of radical orchiectomy is a feasible fertility option, with a 40% probability of recovering spermatozoa by random biopsy of the noncancerous testicular parenchyma and an 80% probability of recovering spermatozoa with a more extensive dissection. In 50% men, spermatozoa may be recovered by epididymal aspiration alone.