Urology - Articles in Press

Comparison of 12-Core Versus 8-Core Prostate Biopsy: Multivariate Analysis of Large Series of US Veterans - Corrected Proof

2010-09-02

Objectives: To investigate the impact of additional biopsy cores on prostate cancer diagnosis among US veterans. The reported rate of positive biopsy results varies from 20% to 40%.Methods: We analyzed 1546 consecutive initial prostate biopsy procedures (8-core and 12-core biopsy protocols) at the Atlanta VA Medical Center. Both biopsy protocols targeted the peripheral zone. Cancer detection rates were compared between the 2 protocols in univariate and multivariate analyses with results expressed as odds ratios and corresponding 95% confidence intervals. Characteristics of cancer detected were also compared. Sensitivity analyses were performed for different population subgroups.Results: The overall positive biopsy rate was 49.9%, 51.2% in the 8-core group and 49.2% in the 12-core group. There was no difference between the 2 biopsy groups (adjusted odds ratio = 0.97, 95% confidence interval = 0.76-1.25). Advanced age and high body mass index were significantly associated with higher likelihood of prostate cancer, whereas larger prostate volumes were associated with lower risk.Conclusions: In this large series of prostate biopsy procedures, in which the peripheral zone was well targeted, there was no evidence that 12-core biopsy improved the likelihood of prostate cancer diagnosis compared with 8-core biopsy. As such, the results of this cohort from a US veteran population suggest that targeting the peripheral zone is more important than the absolute number of biopsy cores. However, in certain subgroups of patients with specific clinical characteristics, such as those with very large prostates, more cores may be required. Further studies are needed to identify such characteristics.

The Acute Effects of Increased Intra-abdominal Pressure on Testicular Tissue: An Experimental Study in Pigs - Corrected Proof

2010-09-02

Objectives: To evaluate the acute effects of increased intra-abdominal pressure (IAP) on testicular germ cell apoptosis and the expressions of endothelial nitric oxide synthase (eNOS), inducible nitric-oxide synthase (iNOS), and Johnson's scores in testicular tissue.Materials and methods: Twelve male pigs weighing 52 to 55 kg were divided into 2 groups as group 1 (n = 6; gasless [control]) and group 2 (n = 6; 20 mm Hg IAP with CO2 pneumoperitoneum for 4 hours). In the second group, left laparoscopic nephrectomy was performed during the CO2 insufflation period. The right testes of pigs were removed. Testicular germ cell apoptosis, expressions of eNOS and iNOS, and Johnson's scores were evaluated for each group.Results: The control group (group 1) exhibited low apoptotic cell level and low iNOS and eNOS level in testes. IAP (group 2) resulted in marked increases in germ cell apoptosis, eNOS, and iNOS compared with the control group (group 1) (P .05). Moreover, Leydig cell hyperplasia, congestion, and necrosis, which were not documented in the control group, were seen in the study group.Conclusions: The purpose of the present study was to evaluate whether IAP could affect germ cell apoptosis and NOS concentrations in the testes after laparoscopic procedures in an animal model. In such an animal model simulating laparoscopic procedures, we demonstrated that high-pressure and long-lasting CO2 insufflation cause testicular changes in the acute period.

Long-term Prostate Cancer Survivors With Low Socioeconomic Status Reported Worse Mental Health–related Quality of Life in a Population-based Study - Corrected Proof

2010-09-02

Objective: To explore whether socioeconomic status (SES) was associated with health-related quality of life (HRQL) and health care use among long-term prostate cancer survivors.Patients and methods: Through urologists in the Comprehensive Cancer Center South, all 5- to 10-year prostate cancer survivors known in the Eindhoven Cancer Registry without disease progression were invited to complete the 36-item Short Form Health Survey (SF-36), the Expanded Prostate Cancer Index, and the Dutch sexual activities module. Multivariate linear regression assessed the effect of SES (based on home value and household income) on HRQL and health care use.Results: Five-hundred eighty-four patients (response rate 81%) were included. Survivors with a low SES exhibited lower mental SF-36 scores (6–16 points on a 0–100 scale), independent of sociodemographic and clinical characteristics (P <.05), and hardly any differences in physical SF-36 subscales, sexual function, and urinary and bowel function and bother. Presence of serious comorbidity had a stronger predictive value for HRQL than SES. Health care use did not seem to be associated with SES.Conclusions: Prostate cancer survivors with a low SES exhibited a worse mental but not physical HRQL than those with a higher SES. Long-term health outcomes of patients with low SES may be maximized by paying extra attention to comorbid conditions.

Bone-anchored Sling for Male Stress Urinary Incontinence: Assessment of Complications - Corrected Proof

Nicholas R. Styn, Edward J. McGuire, Jerilyn M. Latini — 2010-09-02

Objectives: To evaluate the complications associated with the male bone-anchored sling (BAS) to determine the appropriate preoperative counseling for men considering surgery. The BAS is a surgical option for the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency.Methods: We retrospectively reviewed 119 men who had undergone 140 BAS procedures for SUI from May 2000 to May 2009 at our institution. All complications were recorded during the follow-up visits. Pad test and questionnaire results were recorded, as available.Results: BAS was performed in 140 cases for 119 men with SUI. Mean patient age was 65.8 years (range 23-89). Main etiologies for SUI included previous treatment of prostate cancer (82.4%), neurologic dysfunction (12.6%), and previous transurethral resection of the prostate (3.6%). Recurrent SUI, de novo urge incontinence, and wound infection were the most frequent complications encountered (25.2%, 17.6%, and 16%, respectively). The 3 most common reasons for reoperation included bulking agent injection for recurrent SUI (5.9%), sling revision for bone screw dislodgement (5.9%), and sling revision for recurrent SUI (5.0%). Overall complication and reoperation rate for the index cases was 58.8% and 26.9%, respectively.Conclusions: The incidence of complications after male BAS placement might be greater than previously reported. Patient counseling before surgery regarding the potential complications is important. Men treated for prostate cancer should be informed of the risk of recurrent SUI. In appropriately selected patients, we believe the BAS is a reasonable surgical option; however, the risk of postoperative complication is not equivocal.

Reassessment of Renal Cell Carcinoma Lymph Node Staging: Analysis of Patterns of Progression - Corrected Proof

Taekmin Kwon, Cheryn Song, Jun Hyuk Hong, Choung-Soo Kim, Hanjong Ahn — 2010-09-02

Objectives: To evaluate the prognostic value of lymph node (LN) metastasis and the therapeutic role of LN dissection (LND) in patients with renal cell carcinoma.Methods: We reviewed the medical records of 1503 patients who had undergone nephrectomy from 1990 to 2007. The patients were stratified according to the number, location, and size of LN metastases. The disease-free survival, cancer-specific survival, and survival relative to the preoperative suspicion of LN metastasis were analyzed.Results: Of the 1503 patients, 726 (48.3%) had Stage pN0, 37 (2.5%) had Stage pN+, including 16 with pN1 and 21 with pN2, and 740 (49.2%) had Stage pNx. The average number of LNs removed was 5 (range 1-33), and the average size of the metastasized LNs was 2.4 cm (range 0.8-6). Of the patients without preoperative clinical evidence of LN metastasis, 203 underwent LND; all had Stage pN0. The LN stage was a significant predictor of distant metastasis-free survival (P = .002) and cancer-specific survival (P = .001) between the pNx/pN0 and pN+ groups but not between the pN1 and pN2 groups. Metastasized LN size (<3 vs ≥3 cm) also significantly predicted for distant metastasis-free survival (P = .003) and cancer-specific survival (P = .001). In LN-positive patients, LND improved local recurrence-free survival but not distant metastasis-free survival or cancer-specific survival.Conclusions: The current LN staging system, which is dependent on the number of metastatic LNs, did not significantly correlate with the prognosis in patients with renal cell carcinoma. In contrast, LN size (<3 vs ≥3 cm) better reflected the effect of this disease on survival. The therapeutic role of LND might be limited.

Transverse Testicular Ectopia Associated With Persistent Müllerian Duct Syndrome: Another Entity in Which Magnetic Resonance Imaging Is Unreliable - Corrected Proof

Mehmet İlker Gökce, Berk Burgu, Özgü Aydoğdu, Suat Fitöz, Tarkan Soygür — 2010-09-01

In this case report we describe a case of persistant Müllerian duct syndrome together with transverse testicular ectopia. These 2 entities are discussed to assess the relationship between them and the lack of necessity for magnetic resonance imaging in cases of undescended testes, and relevant literature is reviewed.

The History of Urology in Cleveland, Ohio - Corrected Proof

Kamran P. Sajadi, Howard B. Goldman — 2010-09-01

Introduction: Urology in Cleveland, as in the rest of the country, has evolved greatly over the past century. The recent passing of Resnick and Novick warrants a review of Cleveland's rich urological history.Materials and Methods: We reviewed historical and scientific literature and interviewed Cleveland urologists.Results: Lower joined his cousin Crile as professor at Case Western Reserve University (CWRU) before they cofounded the Cleveland Clinic (CC) in 1921. Goldblatt at CWRU discovered renovascular hypertension, leading Poutasse at CC to develop renovascular arteriography and bypass surgery. Kolff brought his greatest invention, dialysis, to the United States when he joined CC. Straffon put CC's renal transplant program on the map through his success with deceased donor transplants. Persky, renowned at radical prostatectomies, chaired urology at CWRU for nearly 30 years and trained 6 future university department chairpersons. Resnick succeeded him and became one of the eminent figures in urology; an authority on numerous subjects, president of the American Urological Association and American Board of Urology (ABU) and Editor of the Journal of Urology. Novick, who became chairman at CC in 1985, was the consummate renal surgeon; he was adept at renal revascularization and transplantation, but his greatest surgical innovation was the partial nephrectomy. He likewise held many positions, including president of the ABU.Conclusions: Cleveland has been a driving force in the evolution of urology in the last century. Resnick and Novick led a golden age of urology for several decades until their recent untimely passings.

Squamous Cell Carcinoma Within a Horseshoe Kidney With Associated Renal Stones Detected by Computed Tomograpy and Magnetic Resonance Imaging - Corrected Proof

2010-08-31

We describe a 69-year-old man who came to our observation with a history of persistent left flank abdominal pain, fever for several weeks, and a previous history of passing renal stones. Radiological examinations with computed tomography and magnetic resonance imaging revealed a solid mass within the left side of a horseshoe kidney, with associated large renal stones. The patient subsequently underwent partial left nephrectomy. The final diagnosis was consistent with squamous cell carcinoma arising in a horseshoe kidney, with associated renal stones.

Robot-assisted Tapered Ureteral Reimplantation for Congenital Megaureter - Corrected Proof

Alvin C. Goh, Richard E. Link — 2010-08-31

OBJECTIVE: To discuss the clinical implications of primary obstructed congenital megaureter in the adult and illustrate a minimally-invasive approach for surgical intervention.Methods: We present the case of a 51-year-old man with a longstanding history of symptomatic congenital megaureter, illustrating an approach for robot-assisted tapered ureteral reimplantation. Ureteral dissection, tapering, and nonrefluxing ureteroneocystostomy were all completed using a robot-assisted laparoscopic technique.Results: The total operative time was 262 minutes, with an estimated blood loss of 150 mL. The patient's hospital course was uneventful, with discharge on postoperative day 4 without a Foley catheter or drain. A diuretic renal scan was performed at 5 months that showed good preservation of renal function with rapid clearance of tracer on the reconstructed side. The patient was pain free at his last follow-up visit without any symptoms.Conclusions: We have demonstrated a technique for robot-assisted tapered nonrefluxing ureteral reimplantation for congenital megaureter. Robotic assistance provided a safe and effective approach for complex ureteral reconstruction while minimizing morbidity.

Urachal Catheter Provides New Choice for Long-term Urinary Diversion in Prune Belly Syndrome - Corrected Proof

2010-08-27

Abstract: Prune belly syndrome has been identified as a clinical triad of abdominal muscle deficiency, bilateral cryptorchidism, and urologic abnormalities. We present the case of a discordant monozygotic twin with prune belly syndrome and voiding dysfunction that was relieved by long-term urinary catheterization by way of the urachus. To the best of our knowledge, this alternative method has not been previously reported. We suggest that for newborn infants with long-term voiding dysfunction, if the urachus retains patency, urinary catheterization through the urachus could be a choice for urine drainage instead of cystostomy, providing a better cosmetic appearance and quality of life.

Experience of Retroperitoneal Laparoscopic Treatment on Pheochromocytoma - Corrected Proof

2010-08-27

Objectives: To evaluate the safety and efficacy of retroperitoneal laparoscopic resection for pheochromocytoma.Methods: The clinical data of 131 cases of pheochromocytoma were analyzed retrospectively. There were 69 males and 62 females with an age range of 8 to 77 years, including 120 cases of adrenal pheochromocytoma and 11 extraadrenal pheochromocytomas. Retroperitoneal laparoscopic resection was performed in all cases. We divided our practical experience into three stages: (1) the tentative and exploratory stage, (2) the accumulative stage, and (3) the mature stage.Results: During the tentative and exploratory stage, 10 patients underwent retroperitoneal laparoscopic surgery. The mean diameter of the tumor was 4.2 cm. The mean operation time was 105 minutes, and the median volume of blood loss during surgery was 450 mL. During the accumulative stage, the mean tumor diameter of the 72 cases was 5.6 cm. The mean operation time was 85 minutes and median volume of blood loss was 140 mL. During the mature stage, the mean tumor diameter of the 49 cases (including 11 extra-adrenal pheochromocytoma patients) was 6.7 cm. The mean operation time was 75 minutes and median volume of blood loss was 70 mL. Follow-ups ranging from 1 to 70 months were conducted, with three cases recurring. There were no cases of distant metastases or death.Conclusions: Retroperitoneal laparoscopic surgery for pheochromocytoma is feasible and safe. This procedure will be increasingly performed as medical personnel continue to develop their skills and accumulate experience.

Long-term Outcomes of Dismembered Pyeloplasty for Midline-crossing Giant Hydronephrosis Caused by Ureteropelvic Junction Obstruction in Children - Corrected Proof

Minki Baek, Kwanjin Park, Hwang Choi — 2010-08-27

Objectives: To assess the long-term surgical outcomes of dismembered pyeloplasty for congenital midline-crossing giant hydronephrosis (GH) caused by ureteropelvic junction obstruction (UPJO).Methods: From June 1986 to September 2005, 167 unilateral UPJO pediatric patients who underwent dismembered pyeloplasty performed by a single surgeon were retrospectively analyzed. The patients were followed up for more than 5 years. Differential renal function (DRF) assessed by DTPA renal scan more than 3 years postoperatively was compared between GH and non-GH children. Improvement in renal parenchymal thickness (RPT) on ultrasonography at 5 years postsurgery was also compared. In GH children, surgical outcomes were compared based on the age at operation and whether preoperative nephrostomy was performed.Results: DRF measured more than 3 years postoperatively was 33 ± 14% versus 48 ± 12% (P < .05), and the improvement of RPT was 4 ± 2 mm (181%) versus 5 ± 4 mm (168%) in GH (n = 25) and non-GH (n = 142) children, respectively (P = .305). GH patients who underwent pyeloplasty before 12 months of age (n = 13) experienced more improvement in RPT (192% vs 102%) compared with GH patients who underwent surgery after 12 months of age (n = 12) (P < .05). The surgical outcomes for RPT improvement or long-term DRF were not different based on whether preoperative nephrostomy was performed. No children developed hypertension or elevated serum creatinine.Conclusions: Long-term surgical outcomes after dismembered pyeloplasty for GH were satisfactory. In children with GH caused by UPJO, early relief of obstruction allows comparable nephron sparing.

Estimation of Prostate Size in Community-dwelling Men - Corrected Proof

2010-08-27

Objectives: To use two population-based samples of prostate cancer–free men todevelop and validate a novel multivariable equation for estimating prostate volume (PV). Previous investigators have demonstrated the ability to use serum prostate-specific antigen (PSA) levels to estimate PV in men without prostate cancer; however, the ability of additional clinical variables to further enhance PV estimation in these men remains unclear.Methods: We applied linear regression modeling to data from an 80% random sample (n = 366) of the baseline cohort from the Olmsted County Study of Urinary Symptoms and Health Status among Men (OCS) to develop an equation for estimating PV in men without prostate cancer. We then evaluated the predictive ability of this equation by comparing estimated and measured PV values in 3 additional validation sets of men.Results: The final linear regression model included PSA, age, and weight as independent predictors of PV. For prediction in baseline OCS men, the multiple correlation coefficients increased from 0.62PSAalone to 0.71fullmodel. In addition, the area under the curve estimates from the receiver operating characteristic curves increased from 0.79PSAalone to 0.85fullmodel for predicting PV >30 mL.Conclusions: Our data suggest that PV can be estimated with easily obtained clinical variables. Moreover, we demonstrate that age and weight can be added to PSA level to achieve greater accuracy in predicting PV. This methodology may prove useful for estimating PV in men in settings where costs and practicality preclude the use of imaging techniques.

Intravesical Electromotive Botulinum Toxin Type A Administration—Part II: Clinical Application - Corrected Proof

2010-08-27

Objectives: To assess the effect of electromotive botulinum toxin type A administration on urodynamic variables, urinary/fecal incontinence, and vesicoureteral reflux (VUR) due to refractory neurogenic detrusor overactivity in children with myelomeningocele.Methods: A total of 15 children (mean age 7.8 years) were included. Using a specially designed catheter, 10 IU/kg of electromotive botulinum toxin type A was inserted into the distended bladder. While connected to the indwelling catheter and 2 dispersive pads, a pulsed current generator delivered 10 mA for 15 minutes. The urodynamic parameters, including reflex volume, maximal bladder capacity, maximal detrusor pressure, and end-fill pressure, and the urinary/fecal incontinence status and VUR grade were evaluated before and at 1, 4, and 9 months after treatment.Results: The mean reflex volume and maximal bladder capacity had increased considerably (99 ± 35 mL versus 216 ± 35 mL and 121 ± 39 mL versus 262 ± 41 mL, respectively; P < .001). In contrast, the mean maximal detrusor pressure and end-fill pressure had significantly decreased (75 ± 16 cm H2O versus 39 ± 10 cm H2O and 22 ± 7 cm H2O versus 13 ± 2 cm H2O) after treatment. The difference was statistically significant (P < .001). Urinary incontinence improved in 12 patients (80%). The VUR grade substantially decreased in 7 of the 12 children (mean VUR grade 2.25 ± 1.3 versus 1.37 ± 0.7; P = .001), and none of the children required surgical intervention. Fecal incontinence was alleviated in 10 (83.3%) of the 12 children. Skin erythema and burning sensation were observed in 6 children.Conclusions: The results of our study have shown that electromotive botulinum toxin type A administration is a feasible and safe method with no need for anesthesia. This novel delivery system resulted in considerable improvement in the urodynamic parameters, urinary/fecal incontinence, and VUR in patients with refractory neurogenic detrusor overactivity.

Concordance Between One-hour Pad Test and Subjective Assessment of Stress Incontinence - Corrected Proof

2010-08-27

Objectives: To examine the concordance among the 1-hour pad test results, subjective questions regarding incontinence, and a quality-of-life questionnaire to assess the role of the pad test as a noninvasive measurement tool in clinical trials. The 1-hour nonstandard pad test is one of several quantitative tools used to measure urinary incontinence; however, its utility has been questioned.Methods: The study subjects were women participating in 2 clinical trials evaluating noninvasive interventions: circular muscle exercises versus pelvic floor muscle training for urinary incontinence. The quantity of urinary leakage according to the pad test and questions regarding subjective urinary leakage from the quality-of-life questionnaire were evaluated for all study subjects combined and in subgroups.Results: A total of 731 clinical pad tests were evaluated from the 2 trials. Significant associations were found between several questions regarding subjective leakage and the pad test results in the study subgroups. A significant correlation was seen between the pad test results and the quality-of-life questionnaire scores (r = 0.14 before intervention and r = 0.42 after intervention in the combined studies; P < .05).Conclusions: The 1-hour pad test demonstrated concordance with subjective assessment tools for urinary incontinence and should be considered a part of the armamentarium for assessing the severity of this condition.

Cholesterol Embolization to Bladder in Setting of Transient Ischemic Attack and Hematochezia: An Unusual Presentation of Cholesterol Embolization Syndrome - Corrected Proof

Carrie E. Black, Christopher J. Cold, Darius J. Unwala — 2010-08-27

A 74-year-old woman presented to the emergency department with a history of acute ataxia, right-sided facial numbness, dysarthria, dysphagia, hematochezia, and gross hematuria. The patient awoke with the need to void and, on ambulating, developed this constellation of symptoms. Within a few hours, her symptoms had resolved, and, by the time, she was examined, her neurologic examination findings were normal. Her medical history was significant for multiple cerebrovascular accidents, myocardial infarction, hypertension, dyslipidemia, unstable angina, diabetes, obesity, and nephrolithiasis. Given her medical history, the patient was prescribed long-term anticoagulation with warfarin. A previous evaluation using carotid ultrasonography and echocardiography did not show any significant lesions. The patient's only residual deficit from her previous cerebrovascular accidents was mild right-sided weakness and dysgraphia. The review of her systems was positive for intermittent hematochezia and hematuria for 1 year and irritative voiding symptoms, including dysuria, frequency, and nocturia (voiding 4-5 times nightly). The physical examination findings were within normal limits for the cardiothoracic, abdominal, and neurologic systems. No deficits were found in her cranial nerves, and no perceived lateralizing motor or sensory deficits were seen. Her hemoccult fecal occult blood test was positive.

Surgically Corrected Urethral Diverticula: Long-term Voiding Dysfunction and Reoperation Rates - Corrected Proof

2010-08-27

Objectives: To present the largest reported cohort of women with urethral diverticula and to evaluate the surgical outcomes and long-term voiding symptoms after urethral diverticulectomy. Studies evaluating the outcomes after urethral diverticulectomy have been limited by small patient numbers and short-term follow-up.Methods: Women who had undergone diverticulectomy at our institution from 1996 to 2008 were mailed surveys. Urinary bother was assessed using the Urogenital Distress Inventory 6-item questionnaire, and patients were asked to report subsequent urethral or vaginal surgery and the number of urinary tract infections within the previous year. To determine the rate of surgical recurrence, the charts of women not responding to the survey were reviewed.Results: A total of 122 women were identified as having undergone urethral diverticulectomy during the study period. Of these, 13 (10.7%) had an eventual recurrence that required repeat surgical excision. Patients with a proximal diverticulum, multiple diverticula, or previous pelvic or vaginal surgery (excluding previous diverticulectomy) were more likely to develop recurrence (P = .01, P = .03, and P < .001, respectively). For the 61 women (50%) responding to our survey, the mean follow-up was 50.4 months. Of these 61 women, 24 (39.3%) had had a urinary tract infection within the previous year, with 14 (23%) women having had ≥3 within the previous year. Also, 16 (26.2%) had persistent pain or discomfort with urination. The mean ± SD total Urogenital Distress Inventory-6 score was 31.1 ± 25.5 for the survey responders.Conclusions: To our knowledge, our study represents the largest study with the longest follow-up after urethral diverticulectomy. Patients with proximal or multiple diverticula and those with previous pelvic surgery should be counseled appropriately regarding the risks of recurrence and persistent voiding dysfunction.

Multiple Circumferential Urethrocutaneous Fistulae as a Rare Complication of Circumcision and Review of Literature - Corrected Proof

2010-08-27

Circumcision remains the most common surgical procedure performed in boys worldwide. Although circumcision can be associated with numerous major and minor complications, urethrocutaneous fistula is extremely rare and serious. An 18-years-old boy presented with urine passage from 4 fistula orifices. He had been circumcised by nonmedical personnel when he was 2 years old. During the surgery, after degloving the penis, it was observed that the fistulae tracts were combining. There were only 2 fistulae orifices on the urethra. The fistulae were repaired with simple closure. This is the second case reported in the literature describing multiple urethrocutaneous fistulae.

TMPRSS2-ERG Gene Fusion and Clinicopathologic Characteristics of Korean Prostate Cancer Patients - Corrected Proof

Kyoungbun Lee, Ji Youn Chae, Cheol Kwak, Ja Hyeon Ku, Kyung Chul Moon — 2010-08-27

Objectives: To survey the status of TMPRSS2-ERG fusion in Korean prostate cancer patients, we assessed the differences in clinicopathologic characteristics and biochemical recurrence according to TMPRSS2-ERG fusion status.Methods: The incidence of the TMPRSS2-ERG fusion gene was evaluated via fluorescence in situ hybridization (FISH) using ERG break-apart probes in 254 prostate cancer tissues resected by radical prostatectomy, and analyses of clinicopathologic parameters and biochemical recurrence were conducted.Results: The fusion rate of the TMPRSS2-ERG gene was 20.9% (53/254). TMPRSS2-ERG gene fusion was identified more frequently in patients with low Gleason grade (primary Gleason pattern ≤3 or sum of Gleason score ≤7, P = .015 and .027). Patients with large cribriform glands in Gleason pattern 4 harbored a rare TMPRSS2-ERG fusion gene compared with patients without large cribriform glands (P = .027). The incidence of biochemical recurrence did not differ according to TMPRSS2-ERG fusion gene status (P = .598).Conclusions: ERG gene aberration did not correlate with biochemical recurrence of prostate cancers in Korean patients. Lower Gleason grade demonstrated higher rates of TMPRSS2-ERG fusion compared with high-grade tumors, including those demonstrating a large cribriform glands pattern. Prostate cancer with large cribriform glands revealed rare TMPRSS2-ERG gene fusion.

Urinary Prostaglandin E2 Was Increased in Patients With Suprapontine Brain Diseases, and Associated With Overactive Bladder Syndrome - Corrected Proof

2010-08-27

Objective: To investigate the association between the urinary levels of prostaglandins (PGE2 and PGF2α), nerve growth factor (NGF) and substance P, and overactive bladder (OAB) symptoms in patients with suprapontine brain diseases.Materials and Methods: The subjects were 114 patients in the chronic phase of a brain disease and 27 healthy controls with no brain disease or lower urinary tract symptoms (LUTS). The OAB symptoms were assessed with the OAB symptom score and the subjects were then classified into 5 groups: healthy control, patients without LUTS, increased bladder sensation (IBS), OAB dry, and OAB wet. Urinary mediator concentrations were measured using enzyme-linked immunosorbent assay and normalized to the urinary creatinine concentration, and then compared among the 5 groups.Results: The urinary PGE2 level was significantly higher in patients with brain diseases than in healthy controls, even in the patients without any OAB symptoms, and compared with patients without LUTS, a significant increase in the urinary PGE2 was observed in patients with OAB dry or wet (P = .004 or .015, respectively). The PGF2α level showed a significant increase in OAB wet compared with patients without LUTS (P = .001). The urinary levels of NGF and substance P were not significantly associated with OAB as a result of this type of brain disease.Conclusion: The urinary PGE2 level was putatively elevated in patients with suprapontine brain diseases and associated with the presence of OAB. The PGF2α level may also be associated with OAB.

Use of the NMP22 BladderChek Test in the Diagnosis and Follow-Up of Urothelial Cancer: A Cross-sectional Study - Corrected Proof

2010-08-26

Objectives: To investigate the efficacy of the nuclear matrix protein (NMP) 22 BladderChek test (NMP22BC) in the detection and follow-up of urothelial carcinoma.Material and Methods: A total of 1021 patients who underwent the NMP22BC, cytology, and cystoscopy, were studied. We divided the patients into 2 groups: group I consisted of 597 patients who were being followed up for previous urothelial carcinoma, and group II consisted of 424 patients with hematuria. The sensitivity and specificity of the NMP22BC, cytology, and the combination (NMP22BC + cytology) were compared.Results: Of the 1021 patients, 131 were diagnosed with urothelial cancer. The overall sensitivities for the NMP22BC, cytology, and the combination were 32.1%, 38.2%, and 52.7%, respectively. In group I, the sensitivity of the NMP22BC was lower than the sensitivity of cytology (22.58% vs 35.5%); there was no difference between the sensitivity of the NMP22BC and that of cytology in group II (40.58% vs 40.58%). For the combination, the sensitivity was greater than that of either test alone in both groups (46.77% and 57.97% in groups I and II, respectively). The sensitivity of the NMP22BC was greater than that of cytology (22.6% vs 13.2%) for low-grade bladder cancer.Conclusions: The NMP22BC has lower sensitivity than cytology. However, the sensitivity of NMP22BC in low-grade tumors was higher than that of cytology. Therefore, when the NMP22BC is combined with cytology, the sensitivity for detecting urothelial carcinoma is increased, which implies that this combination may be useful in the screening and follow-up of urothelial carcinoma.

Pyeloureterostomy in the Management of the Lower Pole Pelvi-ureteric Junction Obstruction in Incomplete Duplicated Systems - Corrected Proof

Dinçer Avlan, Gökhan Gündoğdu, Ali Delibaş, Ali Nayci — 2010-08-26

Objectives: To report our experience with the pyeloureterostomy (PU) for the treatment of the lower pole PUJO in incomplete duplex systems. The combination of the duplicated collecting system and pelviureteric junction obstruction (PUJO) is a rare association and infrequently reported. Surgical treatment can be challenging in such cases.Methods: We retrospectively reviewed the medical data of the patients who had surgery from 2001 to 2009, with a diagnosis of PUJO of the lower pole moiety in incomplete duplex system. Demographic, diagnostic, and procedural data were recorded.Results: Seven patients were identified with the lower pole PUJO associated with incomplete duplex systems. Their median age was 49 months (range 2-108 months). Prenatal hydronephrosis was detected in 3 patients, and 4 had a febrile urinary tract infection. PU was performed in 6 patients because od short ureteral length between the ureteropelvic junction and junction of lower and upper pole ureters. One patient was treated with the dismembered pyeloplasty because of sufficient ureteral length of the lower pole. No complications were detected during 14 months of follow-up.Conclusions: The management of the lower pole PUJO in incomplete duplex systems should be individualized for every patient. PU is a good surgical option in the management of the lower pole PUJO associated with incomplete ureteral duplication.

Body Mass Index Adjusted Prostate-specific Antigen and Its Application for Prostate Cancer Screening - Corrected Proof

2010-08-26

Objectives: The prostate cancer prevention trial (PCPT) prostate cancer risk calculator was developed to aid physicians in counseling men for consideration of prostate biopsy based on prostate-specific antigen (PSA) and other clinical risk factors. This study investigated the role of body mass index (BMI) in this assessment.Materials and Methods: BMI category was defined as <25 (under/normal weight), 25.0-29.9 (overweight), 30.0-34.9 (obese [OB] I), 35.0-39.9 (OB II), and ≥40 (OB III). BMI-adjusted PSA for a man was determined by multiplying his PSA to the ratio of the geometrical mean of PSA for BMI <25 to the geometrical mean of PSA for his BMI category. Operating characteristics of PSA and BMI-adjusted PSA were compared with PCPT risks using area underneath the receiver operating characteristic curve (AUC). Statistical tests of differences between AUCs for different diagnostic tests were performed with the nonparametric U-statistic method.Results: BMI-adjusted PSA equaled to unadjusted PSA multiplying 1.09, 1.20, 1.50, and 1.71 for men in overweight, OBI, OBII, and OBIII categories, respectively. The AUC for BMI-adjusted PSA values (0.84) did not differ from PSA; that of the PCPT calculator with BMI-adjusted PSA (0.87) did not differ from the calculator with PSA. Of 2816 men with a PSA less than or equal to 2.5 ng/mL who did not undergo biopsy, 126 (4.5%) would have a BMI-adjusted PSA exceeding 2.5 ng/mL.Conclusions: Because of lower levels of PSA, overweight and obese men may have diminished cancer detection opportunities when undergoing PSA-based screening.

The Role of Preoperative Endo-rectal Coil Magnetic Resonance Imaging in Predicting Surgical Difficulty for Robotic Prostatectomy - Corrected Proof

2010-08-26

Objectives: To determine whether pelvimetry on endo-rectal coil magnetic resonance imaging (eMRI) predicts surgical difficulty of robot-assisted laparoscopic prostatectomy (RALP).Methods: Patients' records with preoperative eMRI in our RALP database from April 2008 thru May 2009 were reviewed. Demographic, preoperative clinical data, and eMRI anatomic measurements, including calculated prostate volume (PV) and the pelvic cavity index (PCI), were recorded. PCI is the pelvic inlet multiplied by the interspinous distance and divided by the pelvic depth; PCI estimates the robotic working space. Correlative and multiple regression analyses of clinical and pelvimetric data were performed for prediction of estimated blood loss (EBL), operative time (OT), positive surgical margin (PSM), and transfusion rate as surrogates of surgical difficulty.Results: Prostatic transverse diameter, PV, and the PV-to-PCI ratio were significantly correlated with both OT and EBL (P <.05). Body mass index also correlated with EBL (P <.05). Multiple linear regression analysis demonstrated that the PV-to-PCI ratio significantly predicts OT and EBL. No factor significantly predicted PSM status or transfusion rate on regression analysis. Analysis within the PSM group revealed that those with an apical PSM had statistically narrower and deeper pelvises.Conclusions: Patients with larger prostates and with narrow, deep pelvises are predicted to have a more difficult RALP. The PV-to-PCI ratio statistically predicts lengthier and bloodier procedures. However, that ratio does not predict PSM or transfusion risk on regression analysis. The eMRI predicts the level of surgical difficulty and is a valuable adjunctive study to obtain before RALP.

Incidence of Perioperative Urinary Tract Infection After Single-dose Antibiotic Therapy for Midurethal Slings - Corrected Proof

Michael S. Ingber, Sandip P. Vasavada, Farzeen Firoozi, Howard B. Goldman — 2010-08-26

Objectives: A recent Best Practice Statement published by the American Urological Association (AUA) recommends that antibiotic therapy in patients undergoing midurethral synthetic slings (MUS) should be 24 hours or less. Subjects at our institution are routinely administered a single dose of intravenous antibiotics before MUS surgery. We prospectively evaluated urinary tract infection (UTI) rates and risk factors for UTI in subjects undergoing MUS who receive single-dose antibiotic therapy.Methods: Adult female patients who were undergoing MUS for stress or mixed urinary incontinence were prospectively included and received a single-dose of an intravenous antibiotic in accordance with the AUA Best Practice Statement. Subjects requiring additional procedures for prolapse were excluded. Baseline characteristics and preoperative and postoperative postvoid residual (PVR) were documented. Subjects were contacted within 1 week of surgery, and seen in the office at 1 month, when a urinalysis was performed, and urine culture sent if subjects were symptomatic.Results: A total of 101 subjects underwent solitary MUS and received a single dose of intravenous antibiotics. Overall, 6 (5.9%) subjects developed a UTI within 1 month of surgery. Patients who developed a UTI were more likely to have elevated PVRs at the preoperative office visit (62.2 vs 26.8 mL, P = .004).Conclusions: Our study has demonstrated that the rate of perioperative UTI after MUS with one perioperative dose of intravenous antibiotics is low. Patients with an elevated preoperative PVR may be at an increased risk of developing a UTI. Single-dose antibiotic administration is safe and effective at preventing perioperative UTI in subjects undergoing solitary MUS.

Large Symptomatic Periurethral Cystic Lesion in a Male - Corrected Proof

2010-08-23

Abstract: We report an unusual case of a periurethral cystic mass in a 43-year-old man who presented with perineal pain, dysuria, painful ejaculation, and post-ejaculatory lower urinary tract symptoms. Computed tomography and magnetic resonance imaging demonstrated a multiocular periurethral cystic structure. On surgical exploration of the urethra, a cystic lesion was identified and removed. The mass was classified as a complex periurethral cyst from the histopathologic findings.

Gleason Score Correlation Between Biopsy and Prostatectomy Specimens and Prediction of High-grade Gleason Patterns: Significance of Central Pathologic Review - Corrected Proof

2010-08-23

Objectives: To investigate the significance of dedicated central pathologic review for Gleason score (GS) correlation between the biopsy and radical prostatectomy (RP) specimens and the prediction of high-grade Gleason patterns. A discrepancy in the GS between the biopsy and RP specimens has been reported.Methods: The Clinicopathological Research Group for Localized Prostate Cancer disease registry collated the data from 1629 patients who had undergone RP from 1997 to 2005. All biopsy and RP specimens were retrospectively re-evaluated by 2 central uropathologists according to the International Society of Urological Pathology consensus. The GS correlation between the biopsy and RP specimens and the presence of high-grade Gleason patterns (4 or 5) were recorded. The GS was categorized into 5 groups (2-4, 5-6, 3 + 4, 4 + 3, and 8-10).Results: Central review significantly increased the exact concordance rate and decreased the undergrading and overgrading rates between the biopsy and RP specimens compared with local review (P < .05 for all). In each GS or prostate-specific antigen group, the central review biopsy GS had a significantly greater exact concordance rate with the RP specimen GS compared with the local review biopsy GS (P < .05 for all). Regarding high-grade Gleason patterns in the RP specimens, central review showed significantly greater sensitivity, positive predictive value, and negative predictive value than local review (P < .05 for all).Conclusions: We have demonstrated that central review using the International Society of Urological Pathology consensus improves the GS correlation and better predicts high-grade Gleason patterns compared with local review. We recommend central pathologic review by dedicated uropathologists for multi-institutional studies using data from prostate biopsy and RP specimens.

Loss of Muscarinic and Purinergic Receptors in Urinary Bladder of Rats With Hydrochloric Acid-induced Cystitis - Corrected Proof

Akira Yoshida, Aiko Kageyama, Tomomi Fujino, Yoshihisa Nozawa, Shizuo Yamada — 2010-08-17

Objectives: To clarify the basic mechanism involved in the pathophysiology of cystitis by characterizing the urodynamic parameters, pharmacologically relevant (muscarinic and purinergic) receptors, and the in vivo release of adenosine triphosphate (ATP) in the bladder of hydrochloric acid (HCl)-treated rats.Methods: The muscarinic and purinergic receptors in rat tissue were measured by radioreceptor assays using (N-methyl-3H) scopolamine methyl chloride ([3H]NMS) and αβ-methylene-ATP (2,8-3H) tetrasodium salt ([3H]αβ-MeATP), respectively. The urodynamic parameters and ATP levels were measured using a cystometric method and the luciferin-luciferase assay, respectively.Results: In the HCl-treated rats, the micturition interval and micturition volume were significantly (48% and 55%, respectively, P <.05) decreased and the number of micturitions was significantly (3.2-fold, P <.05) increased compared with those of the control rats. The maximal number of binding sites for [3H]NMS and [3H]αβ-MeATP was significantly (55% and 72%, respectively, P <.001) decreased in the bladder of HCl-treated rats, suggesting downregulation of both muscarinic and purinergic receptors. In the HCl-treated rats, the inhibition constant, Ki, values for oxybutynin, solifenacin, and darifenacin were significantly (1.3-1.4-fold, P <.05) increased, but those for tolterodine and AF-DX116 were unchanged. Similarly, the inhibition constant for A-317491, pyridoxal-phosphate-6-azophenyl-2′,4′-disulfonic acid tetrasodium, and MRS2273 was significantly (5.5, 11, and 7.6-fold, respectively, P <.001) increased. Furthermore, the in vivo release of ATP was significantly (P <.05) enhanced in the HCl-treated rat bladder.Conclusions: Both muscarinic and purinergic mechanisms might be, at least in part, associated with the urinary dysfunction due to cystitis.

Determinants of Performing Radical Prostatectomy Pelvic Lymph Node Dissection and the Number of Lymph Nodes Removed in Elderly Men - Corrected Proof

2010-08-17

Objective: Controversy persists regarding the adequacy of pelvic lymph node dissection (PLND) and cancer control when comparing minimally invasive radical prostatectomy (MIRP) and open radical prostatectomy (RRP). We characterized determinants of performance and extent of PLND during radical prostatectomy in elderly men.Methods: A population-based study was conducted comprised of 5448 men ≥65 years undergoing RRP and MIRP during 2004 to 2006 from Surveillance, Epidemiology, and End Results (SEER)–Medicare-linked data. Multivariable logistic regression was used to assess the effect of demographic and tumor characteristics, surgical approach, and surgeon volume on the likelihood of performing PLND.Results: PLND was performed for 87.6% vs. 38.3% of men undergoing RRP vs. MIRP (P <.001). Among RRP, 82.6% vs. 4.6% underwent extended vs. limited PLND, with a median yield of 4 vs. 3 lymph nodes (P <.001). Median MIRP PLND yield was 3 lymph nodes. In adjusted analyses, men undergoing RRP vs. MIRP (odds ratio [OR] 16.7; 95% confidence interval [CI], 11.1-25.0), those with few vs. multiple comorbidities (OR 1.4, 95% CI 1.02-1.91), intermediate (OR 1.87; 95% CI 1.48-2.37), and high (OR 2.77; 95% CI 2.02-3.78) vs. low-risk features, and men treated by high-volume surgeons (OR 1.008; 95% CI 1.004-1.011) were more likely to undergo PLND. Conversely, Hispanic (OR 0.68, 95% CI 0.49-0.96) vs. white men were less likely to undergo PLND.Conclusions: Independent of tumor characteristics, men undergoing RRP vs. MIRP were more likely to undergo PLND with greater lymph node yield and racial variation observed. Further studies are needed to determine the appropriate use of PLND.

Three-Dimensional Anatomy of the Pelvic Bone in Bladder Exstrophy: Comparison Between Patients Managed With Osteotomy and Pubic Symphysis Internal Fixation Using Metal Plates - Corrected Proof

2010-08-17

Objectives: To compare intrapelvic osseous dimensions in classic bladder exstrophy patients who underwent pelvic osteotomy and pubic symphysis internal fixation, using metal plates without osteotomy by defining intrapelvic angles and distances using three-dimensional computed tomography scan (3D-CT).Methods: Fourteen exstrophy patients who were operated with osteotomy (OST) and 19 patients who had undergone pubic approximation using metal plates (PLT) were enrolled in this study. 3D-CT was performed to measure 8 intrapelvic angles and 9 distances. In addition, a 3D-CT image of control group of 14 age- and sex-matched patients and the preoperative data of 12 cases (6 patients in each group) were considered to compare the bony aspects of exstrophy patients before and 6 months after surgery.Results: Sacroiliac joint angle, pubococcygeal angle, ischiopubic angle, pubic diastasis, and inter-triradiate distance were different from controls in both techniques. Iliac wing angle, however, was at near normal values in PLT group. The result of before-after comparison revealed significant changes in iliac wing angle, sacroiliac joint angle, and pubic diastasis in both groups.Conclusions: Our study suggests that internal fixation of pubic arch using metal plates in bladder exstrophy may be as effective as the currently accepted osteotomy-containing techniques from the standpoint of intrapelvic osseous dimensions and angles. Modification of our new pubic approximation technique is essential to better recapitulate the anatomy of the normal bony pelvis.

A Mild and Rare Form of Klippel-Trenaunay Syndrome Presenting With Urethral Bleeding Due To Penile Hemangioma - Corrected Proof

Abdulkadir Tepeler, Yavuz Yeşilolva, Ali Kılınç, Tevfik Aktoz, Abdurrrahman Önen — 2010-08-17

Abstract: Klippel-Trenaunay syndrome (KTS) is characterized by a triad of cutaneous port-wine capillary malformations, hemihypertrophy, and varicose veins. Intermittent gross painless hematuria is usually the first clinical sign. An 8-year-old boy with multiple hemangiomas, including glans penis, and associated with KTS presented with urethral bleeding. Radiologic and endoscopic evaluation revealed neither intra-abdominal nor intravesical hemangioma. Urethral bleeding was thought to be related to glanular hemangioma extending to the anterior penile urethra. Although we were able to manage the case conservatively, many patients require endoscopic or surgical interventions. Radiologic and endoscopic evaluations and careful follow-up is essential for diagnosis and prompt treatment.

Multidetector Computed Tomography: Role in Determination of Urinary Stones Composition and Disintegration With Extracorporeal Shock Wave Lithotripsy—an in Vitro Study - Corrected Proof

2010-08-17

Objectives: To evaluate the ability of noncontrast computed tomography (NCCT) to predict stone composition and fragility for treatment with extracorporeal shock wave lithotripsy (SWL).Methods: A total of 103 stones from patients who had undergone different open surgical procedures were scanned with a 64 detector row helical computed tomography (CT) scanner using 1-mm collimation at 2 energy levels of 80 and 120 kV. The chemical compositions of the urinary stones were assessed on the basis of the differences in the densities measured in Hounsfield units (HU). Stones were then broken in an electromagnetic lithotripter until complete fragmentation, and number of shock waves was counted.Results: After exclusion of the groups with few calculi, 46 pure stones (18 uric acid, 22 calcium oxalate monohydrate, 6 struvite) and 48 mixed stones were included in the statistical analysis. For measurements at 120-kV, 80-kV, and dual-energy CT values, the overall difference between the densities of the stones was statistically significant; however there was a cross-over in densities between all stone groups. There were significant positive correlations at 120-kV, 80-kV, and dual-energy CT values between stone density and number of shock waves required for complete fragmentation. Stones with HU >1000 required statistically significant higher number of shock waves.Conclusions: Multidetector CT is not an accurate method for detection of human stone compositions; however a high stone CT attenuation value is s significant predictor of failure to fragment renal stones by SWL.

Enhanced Transrectal Ultrasound Modalities in the Diagnosis of Prostate Cancer - Corrected Proof

Edouard J. Trabulsi, Daniel Sackett, Leonard G. Gomella, Ethan J. Halpern — 2010-08-17

Standard grayscale transrectal ultrasound has a poor sensitivity for detection of prostate cancer. Saturation biopsy schemes have improved prostate cancer detection rates over standard template biopsy schemes, but carry additional morbidity and cost. Enhanced ultrasound modalities (EUM), including color and power Doppler, contrast-enhancement, harmonic and flash replenishment imaging, and elastography have demonstrated improved prostate cancer detection. EUM targeting areas with increased or abnormal vascularity or firmness for biopsy offer improved prostate cancer detection. EUM, detect prostate cancer more efficiently than standard ultrasound guided biopsies. These emerging technologies may potentially augment standard prostate biopsy in clinical practice.

Treatment of Recurrent Urinary Incontinence After Artificial Urinary Sphincter Placement Using the AdVance Male Sling - Corrected Proof

Brian Christine, L. Dean Knoll — 2010-08-16

Objectives: We report on the use of the AdVance male sling to treat men who had an artificial urinary sphincter placed and subsequently developed recurrent urinary incontinence.Methods: Nineteen men who had undergone placement of an artificial urinary sphincter for post prostatectomy urinary incontinence, and who had developed recurrent incontinence, were treated by placing an AdVance sling. Self-reported pad use preoperatively was 2-5 pads per day.Results: All 19 patients (100%) reported improvement in their incontinence as documented by decreased pad use. Of these men, 15 (79%) became dry, using no further pads, and four (21%) decreased pad use to 1 pad per day. Of the 15 dry patients, 8 remained dry without reactivation of the artificial sphincter (53%); the other 7 maintained complete continence with a combination of the sling and an activated artificial sphincter.Conclusions: Men who suffer from recurrent urinary incontinence secondary to cuff compression atrophy can be made continent by the placement of a male sling. The technique of sling placement requires no special modification in these patients. By not revising the artificial urinary sphincter the capsule surrounding the device is not violated, which may decrease the risk of postoperative infection. In addition, the patient may not need to rely upon the use of his artificial sphincter to maintain continence.

MRI-guided Transurethral Ultrasound Therapy of the Prostate Gland Using Real-time Thermal Mapping: Initial Studies - Corrected Proof

2010-08-16

Objective: To confirm the correlation between planning and thermal injury of the prostate as determined by magnetic resonance imaging (MRI) and histology in canine and humans treated with transurethral ultrasound.Material and methods: Canine studies: 2 sets of in vivo studies were performed under general anesthesia in 1.5 T clinical MRI. Nine dogs were treated using single transducer; 8 dogs were treated using urethral applicator with multiple transducers. Rectal cooling was maintained. After initial imaging, a target boundary was selected and high-intensity ultrasound energy delivered. The spatial temperature distribution was measured continuously every 5 seconds with MR thermometry using the proton-resonant frequency shift method. The goal was to achieve 55 °C at the target boundary. After treatment, the prostate was harvested and fixed with adjoining tissue, including rectum. Temperature maps, anatomical images, and histologic sections were registered to each other and compared.Human studies: To date, 5 patients with localized prostate cancer have been treated immediately before radical prostatectomy. Approximately 30% of the gland volume was targeted.Results: A continuous pattern of thermal coagulation was successfully achieved within the target region, with an average spatial precision of 1-2 mm. Radical prostatectomy was routine, with an uncomplicated postoperative course in all patients. The correlation between anatomical, thermal, and histologic images was ≤3 mm. Treatment time was <30 minutes. No thermal damage to rectal tissue was observed.Conclusions: Thermal ablation within the prescribed target of the prostate has been successfully demonstrated in canine studies. The treatment is also feasible in humans.

Adjuvant Radiotherapy Use and Patterns of Care Analysis for Margin-positive Prostate Adenocarcinoma with Extracapsular Extension: Postprostatectomy Adjuvant Radiotherapy: A SEER Analysis - Corrected Proof

Amol J. Ghia, Dennis C. Shrieve, Jonathan D. Tward — 2010-08-16

Objectives: To perform a patterns of care analysis for patients with prostate cancer and high-risk pathologic factors following radical prostatectomy with regards to adjuvant radiation.Methods: A retrospective analysis was conducted using the Surveillance, Epidemiology and End Results (SEER) Program. We identified men from 2004 to 2005 with prostate adenocarcinoma (PA) who had undergone radical prostatectomy (RP) and were found to have extracapsular extension (ECE) with positive margins.Results: We identified 1427 PA patients with ECE and positive margins after an RP. Most were clinically staged as T1 or T2 before surgery (95.8%). Using the D'Amico Risk Stratification, 52.0% were high-risk, 39.7% were intermediate-risk, and 8.3% were low-risk. Of these, 18.2% (260) received ART, whereas 81.8% (1167) did not. Those who received ART had worse prognostic factors, such as Gleason scores >7 (38.5% vs 24.8%; P 10 (44.6% vs 35.2%; P = .0045), pathologically positive lymph nodes (11.5% vs 6.4%; P = .006), and D'Amico high-risk disease (66.8% vs 48.7%; P < .0001). The use of ART based on geographic region ranged from 8.3%-34.2%.Conclusions: Less than 20% of patients with pT3 disease and positive margins received ART in the study period just before the publication of randomized data demonstrating an improvement in biochemical failure with ART in this SEER retrospective analysis. This is the largest patterns of care analysis to date of ART in patients with margin-positive pT3 prostate adenocarcinoma.

Microscopic Invasion of Perivesical Fat by Urothelial Carcinoma: Implications for Prognosis and Pathology Practice - Corrected Proof

Emil Scosyrev, Jorge Yao, Edward Messing — 2010-08-16

Objective: To determine whether microscopic invasion of perivesical fat by urothelial carcinoma (stage pT3a) confers a different prognosis relative to deep muscle invasion (pT2b) and/or gross extravesical extension (pT3b) among patients with a given nodal status treated by cystectomy.Methods: Cancer records for patients diagnosed with stage pT2b-pT3b bladder cancer from 1998-2006 were obtained from the SEER database (n = 2388). Pathologic substage (pT3a vs pT2b vs pT3b) was the primary covariate of interest. Other covariates included age, sex, race, grade, number of nodes examined, number of positive nodes, nodal stages, and radiotherapy. Cox regression model was used to estimate the covariate-adjusted effect of tumor substages on all-cause mortality.Results: The risk of nodal metastases increased with increasing substage (pT2b = 20%, pT3a = 36%, pT3b = 48%, trend P <.001). Among patients with node-negative tumors, the adjusted hazard ratios for all-cause mortality were 1.68 (P <.001) for pT3a vs pT2b and 1.03 (P = .78) for pT3b vs pT3a tumors, whereas for node-positive disease, they were 1.42 (P = .009) for pT3a vs pT2b and 1.44 (P = .001) for pT3b vs pT3a tumors.Conclusions: Microscopic invasion of perivesical fat was associated with significantly inferior survival relative to pT2b disease of the same nodal status. For node-positive pT3 tumors, more advanced pathologic substage (pT3b vs pT3a) was also associated with decreased survival. Our findings support the current practice of pathologic distinction between pT2b and pT3a disease and substaging of extravesical tumors based on microscopic versus gross extravesical extension.

A Novel Technique for the Repair of Urostomal Hernias Using Human Acellular Dermal Matrix - Corrected Proof

Christopher R. Mitchell, Robert R. Cima — 2010-08-16

Objective: To report a new technique to reconstruct the abdominal wall at the site of the hernia with 2 separate layers of human acellular dermal matrix (hADM). Parastomal hernia is the most commonly encountered complication of ileal conduit urinary diversion, occurring at a rate of 5%-25%.1-3 Multiple methods of parastomal hernia repair, including primary fascial repair, mesh repair, and stoma resiting have been reported, with a wide variety of approaches and materials being used.Methods: Between 2008 and 2009, 4 patients underwent surgical repair of urostomal hernias using hADM (LifeCell, Branchburg, NJ). All were operated on by a single surgeon using a standard technique of open repair whereby the posterior and anterior rectus fascia at the stoma site were reconstructed with hADM. Demographic data, preoperative and intraoperative risk factors, immediate postoperative complications, and hernia recurrence were collected and analyzed.Results: Four patients underwent urostomal hernia repair with Alloderm without intraoperative complications. Mean operative time was 261.25 ± 80.8 minutes. Mean hospital stay was 9 ± 3 days. With an average of 270 ± 104-days' follow-up, there were no recurrent hernias detected.Conclusions: In patients with urostomal hernia, reconstruction of the stoma site and abdominal wall with hADM appears to be a safe and effective management solution and avoids the difficulty with relocating the urostomy or placing prosthetic material in the site.

Proteome of Human Calcium Kidney Stones - Corrected Proof

2010-08-16

Objectives: Idiopathic calcium oxalate (CaOx) stones are believed to develop attached to papillary subepithelial deposits called Randall's plaques. Calcium phosphate (CaP) stones, conversely, are thought to arise within the inner medullary collecting ducts, enlarging and damaging surround tubular structures as they expand. If this is true, we theorize that differences will be seen within the organic portion (matrix) of CaOx stones compared with CaP stones using a mass spectroscopy (MS) approach.Methods: From a cohort of 47 powdered stones, 25 calculi (13 CaOx, 12 CaP) were confirmed to contain a dominant mineral content of >80% by powder x-ray diffraction. Matrix proteins were then extracted, purified, and digested. Peptide tandem MS data were acquired, and spectra were searched against a large human protein database to identify protein matches.Results: No significant differences were seen between pattern profiles of CaOx and CaP stones. However, variations in protein expression patterns were seen within individual CaOx (monohydrate and dihydrate) and CaP (apatite and brushite) mineral subtypes, suggesting a relationship between crystal-surface binding properties and matrix composition. Both groups contain a large number of inflammatory proteins and a catalog of common proteins is included.Conclusions: Calcium kidney stone matrix contains hundreds of proteins and is predominated by proteins associated with inflammatory response. Many of the same proteins were identified in both CaOx and CaP stones, suggesting inflammation as a unifying origin or a common secondary role in calcium stone pathogenesis.

Huge Adrenal Ganglioneuroma - Corrected Proof

Ming-Chih Lai, Chung-Chieh Wang, Wei-Chou Lin, Kao-Lang Liu, Kuo-How Huang — 2010-08-16

Abstract: We describe a 53-year-old man who presented with epigastralgia for 1 month. He had 3-year history of increased stool frequency and hypertension. An incidental adrenal mass 19 cm in largest diameter was discovered by computed tomography. Open tumor excision was performed. His symptoms of epigastralgia, hypertension, and chronic diarrhea had subsided after operation. He was tumor-free at 2-year follow-up.

Lymphovascular Invasion and the Presence of More Than Three Tumors Are Associated With Poor Outcomes of Muscle-invasive Bladder Cancer After Bladder-conserving Therapies - Corrected Proof

Minguang Zhang, Ran Tao, Cunming Zhang, Zhoujun Shen — 2010-08-16

Objectives: To identify the predictive factors for survival and recurrence of patients with muscle-invasive bladder cancer (MIBC) (urothelial carcinoma) after bladder-conserving therapies and to determine the efficacy of partial cystectomy plus chemotherapy and radiotherapy in the treatment of MIBC.Methods: From 2002 through 2007, 100 patients with MIBC (pT2 74%, pT3-4 26%) underwent partial cystectomy (PC). Subjects who had stage pT3-4 disease received adjuvant chemotherapy and radiotherapy. Univariate and multivariate analyses were performed to determine the predictive factors.Results: At median follow-up of 31.5 months (range 6-66 months), 46% patients experienced superficial local recurrence and 14% developed muscle-invasive local recurrence. At the end of follow-up, 24 patients died of bladder cancer, and 71 patients (71%) survived with intact bladders. The 5-year bladder-intact survival rate was 63%. The 5-year cancer-specific survival (CSS) rate was 68%.By multivariate analysis, the presence of more than 3 tumors (P = .002, RR 2.718, 95% CI 1.455-5.079) and nonpapillary growth patterns (P = .005, RR 4.537, 95% CI 1.573-13.081) were predictive factors for local cancer recurrence; the presence of more than 3 tumors (P = .002, RR 4.109, 95% CI 1.676-10.072), lymphovascular invasion (P = .001, RR 6.098, 95% CI 2.038-18.246), and partial cystectomy plus ureteral reimplantation (PC plus UR) (P = .011, RR 0.129, 95% CI .027-0.627) were significantly associated with 5-year CSS, and PC plus UR promoted survival.Conclusions: PC plus chemotherapy and radiotherapy is a rational alternative to radical cystectomy for the treatment of MIBC. Lymphovascular invasion and the presence of more than 3 tumors predict poor outcomes in MIBC after bladder-sparing therapy.

Baseline Renal Function Status Limits Patient Eligibility to Receive Perioperative Chemotherapy for Invasive Bladder Cancer and Is Minimally Affected by Radical Cystectomy - Corrected Proof

2010-08-16

Objectives: To evaluate the proportion of patients with muscle-invasive urothelial carcinoma (UC) who would be eligible to receive cisplatin-based chemotherapy before and after radical cystectomy based on renal function.Methods: We identified 194 consecutive patients who underwent cystectomy for cT2-T4 UC. Serum creatinine (SCr) immediately before and nadir SCr 1-3 months after surgery were used to calculate creatinine clearance (CrCl) and glomerular filtration rate (GFR). A cut-off CrCl ≥ 60 mL/min or GFR ≥ 60 mL/min/1.73 m2 was used to determine eligibility for chemotherapy.Results: Median patient age was 70.5 years (IQR 63.77) and median preoperative SCr was 1.05 mg/dL (0.9, 1.3). In total, 80/194 (41%) and 64/194 (33%) patients had inadequate renal function to receive chemotherapy before cystectomy based on CrCl and GFR, respectively. The frequency of inadequate baseline renal function increased significantly with patient age, from 12% of patients < 65 to 54% of patients >65 years of age (P < 0.0001). Surgery did not adversely affect the proportion of patients eligible to receive chemotherapy based on renal function, regardless of age. In fact, after controlling for gender, race, preoperative renal function, hydronephrosis, and choice of diversion, patients <65 years of age were found to have a 14% increase in CrCl (P = .01) and an 11% increase in GFR (P = .04) after cystectomy.Conclusions: Approximately 40% of patients who would be candidates for neoadjuvant chemotherapy could not receive cisplatin because of poor renal function. Surgery did not affect patients' eligibility to receive chemotherapy based on renal function status. Development of effective non–cisplatin-based regimens is therefore necessary to optimize survival.

Which Patients With Undetectable PSA Levels 5 Years After Radical Prostatectomy Are Still at Risk of Recurrence?—Implications for a Risk-adapted Follow-up Strategy - Corrected Proof

2010-08-16

Objectives: To determine the predictors of late prostate-specific antigen (PSA) failure among men with an undetectable PSA level 5 years after radical prostatectomy (RP).Methods: A total of 505 men who had undergone RP for prostate cancer from 1985 to 2000 at Brigham and Women's Hospital and who had ≥5 years of recurrence-free survival (ie, all PSA levels <0.2 ng/mL) constituted the study cohort. Cox multivariate regression analysis was used to determine the factors associated with PSA failure after 5 years. Kaplan-Meier analysis was used to estimate the PSA failure-free survival rate.Results: The median follow-up was 10.7 years after RP (interquartile range 7.8-13.3). No patient had PSA failure at year 5, but the PSA failure-free survival rate for this cohort at year 10 was 88% (95% confidence interval 84.4%-91.0%) and, at year 13, was 82% (95% confidence interval 77.0%-86.0%). On multivariable regression analysis, the factors associated with failure after year 5 were Gleason score 7 (adjusted hazard ratio [AHR] 1.88, P = .036), Gleason score 8-10 (AHR 4.81, P ≤ .002), extracapsular extension (AHR 2.37, P = .003), and seminal vesicle invasion (AHR 1.52, P = .062).Conclusions: Among men with an undetectable PSA level 5 years after RP, Gleason score 7, Gleason score 8-10, extracapsular extension, and seminal vesicle invasion were significant predictors of subsequent late PSA failure. Patients with these factors (particularly Gleason score 8-10 or seminal vesicle invasion) should have continued close monitoring of their PSA level and consideration of early salvage, as appropriate. However, patients with Gleason score 6 disease were very unlikely to develop late recurrence and might be candidates for less-intense follow-up once they have passed the 5-year mark.

Efficacy of Epididymectomy in Treatment of Chronic Epididymal Pain: A Comparison of Patients With and Without a History of Vasectomy - Corrected Proof

2010-08-16

Objectives: To evaluate the surgical outcome in, and satisfaction with treatment of, patients undergoing epididymectomy for postvasectomy pain syndrome.Methods: A total of 49 patients were included. All participants had undergone epididymectomy for chronic epididymal pain from January 2000 to June 2009. Of the 49 patients, 4 had undergone bilateral epididymectomy, and the total number of procedures was 53: 18 in patients with postvasectomy pain syndrome (group 1, n = 16), 21 in patients with chronic epididymitis and no history of vasectomy (group 2, n = 19), and 14 in patients with an epididymal cyst and no history of vasectomy (group 3, n = 14). The preoperative and postoperative pain scale scores and surgical outcome were analyzed.Results: For the total patient sample, the mean age was 52.91 ± 13.51 years, and the mean body mass index was 24.10 ± 3.22 kg/m2. The mean duration of pain was 1.3 years (range 0.25-20), and the mean duration of postoperative follow-up was 4.2 years (range 0.05-10.25). The mean preoperative pain score was 6.91 ± 0.97. The mean postoperative pain scale score was 1.92 ± 1.54 (P < .01). Statistically significant differences in the preoperative and postoperative pain scores were found for each group: group 1, 5.38 ± 1.47 (range 3-8); group 2, 4.10 ± 1.41 (range 2-6), and group 3, 5.21 ± 1.88 (range 2-8; P = .004). In group 1, excellent surgical outcomes and high patient satisfaction were reported for 94.5% (17 of 18) of the procedures performed.Conclusions: The results of our study have shown that epididymectomy is more effective in patients with a history of vasectomy than in those without.

Does Previous Robot-assisted Radical Prostatectomy Experience Affect Outcomes at Robot-assisted Radical Cystectomy? Results from the International Robotic Cystectomy Consortium - Corrected Proof

2010-08-16

Objectives: To evaluate the effect of previous robot-assisted radical prostatectomy (RARP) case volume on the outcomes of robot-assisted radical cystectomy. Little is known regarding the effect of previous robotic surgical experience on the implementation and execution of robot-assisted radical cystectomy.Methods: Using the International Robotic Cystectomy Consortium database, 496 patients were identified who had undergone robot-assisted radical cystectomy by 21 surgeons at 14 institutions from 2003 to 2009. The surgeons were divided into 4 groups according to their previous RARP experience (≤50, 51-100, 101-150, and >150 cases). The overall operative time, blood loss, lymph node yield, pathologic stage, and surgical margin status were compared among the 4 groups using chi-square analysis.Results: The mean operative time was 386 minutes (range 178-827). The mean estimated blood loss was 408 mL (range 25-3500). The operative time and blood loss were both significantly associated with previous RARP experience (P < .001). The mean lymph node count was 17.8 nodes (range 0-68). Lymph node yield and increased pathologic stage were significantly associated with previous RARP experience (P < .001). Finally, 34 (7.0%) of the 482 patients had a positive surgical margin. Margin status was not significantly associated with previous RARP experience (P = .089).Conclusions: Previous RARP case volume might affect the operative time, blood loss, and lymph node yield at robot-assisted radical cystectomy. In addition, surgeons with increased RARP experience operated on patients with more advanced tumors. Previous RARP experience, however, did not appear to affect the surgical margin status.

Nondismembered Ureteroplasty for Congenital Midureteral Stenosis: A New Application of an Old Technique - Corrected Proof

Apul Goel, Dharamveer Singh, Vengetesh K. Sengottayan, Satyanarayan Sankhwar — 2010-08-16

Objectives: To share our experience with nondismembered ureteroplasty (NDU), a novel application of an old technique in congenital midureteral stenosis (CMS).Methods: A 35-year-old man was diagnosed as a case of CMS, a rare benign condition on the basis of extensive evaluation, including ultrasonography, intravenous urography, ethylenedicystine renal scan, antegrade and retrograde contrast study of the left kidney and ureter, and a 64-slice computed tomographic angiography of the abdomen with 3-dimensional reconstruction. He was managed by open NDU, where a longitudinal incision over the narrowed segment was closed transversely using the Heineke–Mikulicz principle, thereby preserving the midureteral blood supply, which is considered tenuous.Results: The patient had a successful outcome and is asymptomatic at 1-year follow-up, with significant resolution of hydroureteronephrosis on ultrasonography, and a nonobstructed left kidney with 37% differential renal function on renal scan.Conclusions: Nondismembered ureteroplasty is a meticulous surgical technique emphasizing blood supply preservation; it can be a useful option in relatively long-segment CMS and adds another method in the surgeon's armamentarium for repairing this rare condition. This technique can be especially useful during laparoscopic or robotic repair of such stenosis.

Association of DNA Polymorphisms Within the CYP11B2/CYP11B1 Locus and Postoperative Hypertension Risk in the Patients With Aldosterone-producing Adenomas - Corrected Proof

2010-08-13

Objectives: Hypertension often persists after adrenalectomy for primary aldosteronism. Traditional factors associated with postoperative hypertension were evaluated, but whether genetic determinants were involved remains poorly understood. The aim of this study was to investigate the association of DNA polymorphisms within steroid synthesis genes (CYP11B2, CYP11B1) and the postoperative resolution of hypertension in Chinese patients undergoing adrenalectomy for aldosterone-producing adenomas (APA).Methods: Ninety-three patients with APA were assessed for postoperative resolution of hypertension. All patients were genotyped for rs1799998 (C-344 T), intron 2 conversion, rs4539 (A2718G) within CYP11B2 and rs6410 (G22 5A), rs6387 (A2803G) within CYP11B1. The associations between CYPB11B2/CYP11B1 polymorphisms and persistent postoperative hypertension were assessed by multivariate analysis.Results: CYP11B2-CYP11B1 haplotype was associated with persistent postoperative hypertension in Chinese patients undergoing adrenalectomy with APA (P = .006). Specifically, the rs4539 (AA) polymorphism was associated with persistent postoperative hypertension (P = .002). Multivariate logistic regression revealed the common haplotypes H1 (AGACT), H2 (AGAWT), and H3 (AGAWC) were associated with the persistent postoperative hypertension (P = .01, 0.03, 0.005 after Bonferroni correction). Additional predictors of persistent postoperative hypertension included duration of hypertension (P <.0005), family history of hypertension (P = .001), and elevated systolic blood pressure (P = .015).Conclusions: The rs4539 (AA), H1, H2, and H3 are genetic predictors for postoperative persistence of hypertension for Chinese patients treated by adrenalectomy with APA. DNA polymorphisms at CYP11B2/B1 locus may confer susceptibility to postoperative hypertension of patients with APA.

Simplified Laparoscopic Partial Nephrectomy Using a Single-layer Closure and No Bolsters for Renal Tumors - Corrected Proof

Matthew H. Hayn, Khurshid A. Guru, Hyung L. Kim — 2010-08-13

Objectives: Surgical outcomes for a simplified LPN technique using a single-layer closure were reviewed for central and peripheral renal tumors.Methods: A total of 159 consecutive patients who underwent LPN were identified using a single-institution database. Renal tumors abutting the collecting system or renal sinus were considered central. After tumor excision, the tumor bed was repaired using a single layer closure by passing partially straightened CPX needles beneath the entire cut surface. Pathologic and postoperative outcomes were compared between the central tumor group (CTG) and the peripheral tumor group (PTG).Results: There were 83 and 76 patients in the CTG and PTG, respectively. When compared with the PTG, the CTG had a larger mean tumor size (3.4 vs 2.3 cm, P <.0001) and greater depth of tumor invasion (2.3 vs 1.1 cm, P <.0001). In the CTG, 66 tumors were malignant, and 2 patients had a positive margin. In the PTG, 50 tumors were malignant, and 1 patient had a positive margin. There was no statistically significant difference between the groups in operative times, estimated blood loss, transfusion rates, complications, positive margins, and length of hospital stays. The CTG had a longer warm ischemia time (24 vs 18 minutes, P = .0002), but this did not result in a significant difference in postoperative creatinine clearance (86 vs 87, P = .842).Conclusions: During LPN, a single-layer closure without bolsters is safe and effective, and early surgical outcomes are similar for central and peripheral tumors.

Does Prior Abdominal Surgery Influence Outcomes or Complications of Robotic-assisted Laparoscopic Radical Prostatectomy? - Corrected Proof

2010-08-13

Objectives: To determine whether robotic-assisted laparoscopic radical prostatectomy (RALP) in patients with prior abdominal surgery is associated with increased operating times, positive surgical margins, or complications.Methods: An institutional review board–approved retrospective review of a prospective, prostatectomy database was performed. Patients undergoing surgery between January 1, 2004, and February 29, 2008 were included. Transition from open retropubic prostatectomy to RALP took place through 2004, at which point all surgical candidates were offered RALP, regardless of prior surgical history. Learning curves from all surgeons were included. Patients with prior abdominal surgery were compared with those patients without prior surgery with respect to total operating time, robotic-assist time, surgical margin positivity, and rate of complications.Results: A total of 1083 patients underwent RALP between January 1, 2004, and February 29, 2008, at our institution; of these, 839 had sufficient data available for analysis. In all, 251 (29.9%) patients had prior abdominal surgery, whereas 588 (70.1%) had no prior abdominal surgery. Total operating times were 209 and 204 minutes (P = .20), robotic console times were 165 and 163 minutes (P = .59), and surgical margin positivity was 21.1% and 27.2% (P = .08) for patients with and without prior abdominal surgery, respectively. The incidence of complications was 14.3% and 17.3% for patients with and without prior abdominal surgery (P = .33).Conclusions: Prior abdominal surgery was not associated with a statistically significant increase in overall operating time, robotic assist time, margin positivity, or incidence of complications in patients undergoing RALP. Robotic prostatectomy can be safely and satisfactorily performed in patients who have had a wide variety of prior abdominal surgery types.

Bilateral Wilms' Tumors: Single-center Experience With 22 Cases and Literature Review - Corrected Proof

2010-08-13

Objectives: Bilateral Wilms' tumors represent a therapeutic challenge. The primary aim of management is eradication of the neoplasm and preservation of renal function. We present our experience in the management of such cases in a single-center experience.Methods: This was a retrospective study of 22 patients with histologically proven bilateral nephroblastoma who were treated from 1993 to 2008 at our center. Of the 22 patients, 12 were girls and 10 were boys, with a median age of 3 years (range 1-9); 19 had a synchronous presentation and 3 a metachronous presentation. Of the 22 patients, 6 underwent initial surgical resection followed by chemotherapy and 16 underwent initial biopsy and preoperative chemotherapy. The final oncologic and renal outcomes were assessed.Results: The median follow-up period was 3 years (range 1-11). Of the 22 patients, 8 died, for an overall survival rate of 63.5%. The survival for the initial chemotherapy and initial surgery groups was essentially similar. Of all the variables studied, unfavorable histologic findings had a significant negative effect on survival. Of the 5 patients with unfavorable histologic findings, 4 died during the follow-up period. The median volume of preserved renal parenchyma was 40%. All patients had good renal function during follow-up, except for 1 patient who had undergone bilateral nephrectomy.Conclusions: Bilateral Wilms' tumors impose 2 conflicting issues: elimination of the pathology and preservation of the renal function. Currently, treatment regimens involving initial chemotherapy followed by conservative surgery can achieve these goals in an important proportion of patients.