Ureteral reimplantation (UR) is the gold standard for the surgical treatment of vesicoureteral reflux (VUR) but few studies have documented its long-term results. We reviewed late cystography (LC) results following successful UR.
We performed a retrospective chart review of all children with primary VUR who underwent successful open UR (grade 0 VUR into the reimplanted ureter(s) on initial cystogram) at our institution from January 1990 – December 2002. We identified successful UR patients who underwent LC ≥ 1 year after UR and reviewed the results for the presence of recurrent VUR into the reimplanted ureter(s).
794 patients underwent successful open UR for primary VUR, of whom 60 (7.6%) had a subsequent LC. Preoperative VUR grade was ≤II in 20 (34.5%), ≥III in 38 (65.5%). Median age at UR was 3.5 years (IQR: 1.3–6.2 years); 51 (85%) were female. UR was intravesical in 45 (75%) and bilateral in 19 (32%). LC was performed at a median of 38.7 months after UR (IQR: 19.6–66.1 months). Indication for LC was febrile UTI in 16 (27%), non-febrile UTI’s in 15 (25%), follow-up of contralateral VUR in 16 (27%) and other clinical indications in 13 (21%). The recurrence rate was 0%; of the 79 reimplanted ureters, 100% (95% CI: 95.4–100) had no VUR (grade 0).
Among children who underwent successful open UR for primary VUR, there was no VUR recurrence on extended follow-up. This suggests that the late durability of open anti-reflux surgery is excellent.
Vesico-ureteral reflux; Surgical Procedures; Operative; Follow-up Studies; Urinary Tract Infections
Tosystematically evaluate ERG alterations in the multifocal tumor context by using whole-mount prostatectomy specimens of African American and Caucasian American patients matched for age, pathologic grade and stage. Oncogenic activation of the ETS-Related Gene (ERG) is the most common early genomic alteration in prostate cancer patients in Western countries. However, ERG alterations have not been systematically examined in African American patients with known higher risk of prostate cancer incidence and mortality.
ERG oncoprotein expression was analyzed in 91 Caucasian American and 91 African American prostate cancer patients matched for age, Gleason score and pathologic stage. A unique aspect of this study was the evaluation of ERG in whole-mount prostatectomy sections, minimizing sampling bias and allowing the careful assessment of ERG in the multifocal tumor context of prostate cancer.
The frequency of ERG positive prostate tumors was significantly greater among Caucasian Americans vs. African Americans when assessed in all tumor foci (41.9% vs. 23.9%, p<0.0001). Markedly higher frequency of the ERG oncoprotein expression was noted between the index tumors of Caucasian Americans (63.3%) and African Americans (28.6%). Of note, in African American patients the higher grade index tumors were predominantly ERG negative.
ERG typing of prostate tumors establishes a major difference between the index tumors of Caucasian and African American patients. ERG negative index tumors may indicate less favorable outcome in African American patients. This study underscores that typing of prostate tumors for ERG may enhance our understanding of biological differences between the examined ethnic groups.
Although racial differences in quality of life have been examined between African American and white prostate cancer patients, it is not known if differences exist while adjusting for psychological and cultural factors. Therefore, we evaluated the effects of race on quality of life while adjusting for subjective stress and religiosity among African American and white prostate cancer patients. We predicted that African American men would report poorer emotional and physical functioning after adjusting for these factors and that greater subjective stress and lower levels of religiosity would be associated with poorer well-being.
We conducted an observational study of QOL among 194 African American and white men who were recruited from February 2003 through March 2008.
Race had a significant effect on emotional functioning after adjusting for perceptions of stress and religiosity. Compared to white men, African American men (p=0.03) reported significantly greater emotional well-being. Greater subjective stress was associated significantly with poorer emotional functioning (p=0.0001) and physical well-being (p=0.0001). There were no racial differences in physical functioning (p=0.76).
The results of this study highlight the importance of developing a better understanding of the context within which racial differences in QOL occur and translating this information into support programs for prostate cancer survivors.
Race; disparities; prostate cancer; quality of life; stress
RhoA and its main downstream effector, Rho-kinase (ROCK) are important in maintaining the penis in the flaccid state. The pathophysiology of Sickle cell disease-associated priapism is not well defined. We hypothesize that RhoA/ROCK vasoconstrictive pathways may be involved in the development of priapism. Therefore, the objective of this study was to evaluate molecular changes in RhoA and ROCK in an established transgenic sickle cell mouse model of priapism.
Two groups of mice were utilized: 1) wild type (WT; C57BL/6), and 2) transgenic Sickle cell mice (Sickle). We evaluated RhoA GTPase and total ROCK activities as well as ROCK1 and ROCK2 protein expression in WT and Sickle mice penes. We also evaluated in vivo erectile responses to cavernous nerve stimulation (CNS) and the frequency and duration of spontaneous erections both pre- and post-CNS.
Sickle mice demonstrated significantly (p<0.05) enhanced erectile responses to CNS and frequency of spontaneous erections both pre- and post-CNS when compared to WT. Sickle mice penes had a significant decline in RhoA GTPase (p<0.01) and total ROCK activities (p<0.05) when compared to WT mice. There was a significant (p<0.05) reduction in ROCK2 protein expression in Sickle mice penes when compared to WT mice protein expression. No change in ROCK1 protein expression was observed in both cohort’s of mice penes.
These data suggest that Sickle cell disease associated-priapism may be contributed by a lack of RhoA/ROCK mediated vasoconstriction and highlight a novel molecular mechanism in the pathophysiology of priapism.
RhoA; priapism; sickle cell disease; vasoconstriction
Angiomyolipoma is a rare benign tumor most commonly found in the kidney and, infrequently, extrarenally. We report a case of pelvic angiomyolipoma in a male patient without stigmata of tuberous sclerosis. The patient presented with right retroperitoneal bleeding and was found to have bilateral renal angiomyolipomas as well as a pelvic mass with similar appearance as the other lesions. He underwent urgent embolization of the large right angiomyolipoma and subsequent robot-assisted left laparoscopic partial nephrectomy with simultaneous resection of the pelvic mass, which was well-tolerated. Pathology confirmed what is, to our knowledge, the only reported case of pelvic angiomyolipoma.
To examine the association of laser technology adoption in a market with surgery rates for benign prostatic hyperplasia (BPH).
Using the Florida files from the State Ambulatory and Inpatient Surgery Databases (2001 to 2009), we identified all patients who underwent transurethral surgery for BPH. We calculated rates of BPH surgery for all markets within the state (defined by Hospital Service Area) over time. Markets were split into 3 categories: 1) always offering, 2) never offering, or 3) initially not offering but adopting laser prostatectomy after 2001. We used multivariable regression models to estimate surgery rates, adjusted for other market characteristics. Interaction terms were included in the models to examine differences in time trends between market categories.
After adjusting for market characteristics, time trends differed by market category (p<0.001). Surgery rates decreased from 318 to 248 procedures per 100,000 men in markets always offering laser prostatectomy (p<0.001). Markets never offering laser surgery had much lower rates that remained stable (180 to 187 procedures per 100,000 men, p=0.805). In markets adopting laser technology, rates increased from 268 to 296 procedures per 100,000 men after adoption (p=0.044), such that four years after adoption these markets had the highest rates among the three categories.
Adoption of laser technology is associated with rising rates of surgical intervention for BPH. This trend appears to be induced by the introduction of laser surgery.
laser prostatectomy; benign prostatic hyperplasia; surgical trends; utilization of health services
To evaluate the feasibility and healing response to urethral sparing prostate histotripsy a canine model of benign prostatic hypertrophy.
Histotripsy was performed on 10 canines using a 750 kHz piezoelectric ultrasound transducer targeting the prostatic parenchyma while avoiding the urethra. Periprocedure prostatic urethral integrity was evaluated with serial cystourethroscopy. Evolution of histotripsy treatment effect and subjects’ response to urethral sparing was evaluated with serial ultrasound and laboratory evaluation, respectively. Subjects were euthanized acutely or chronically and findings were confirmed histologically.
Bilateral treatment was possible in 8/10 subjects while unilateral treatment was performed in 2/10. Failure to spare the urethra was observed in 2/18 treatments; one acutely and one chronically despite normal cystourethroscopy for the first week. Modest prostatic volume reduction was seen in subjects survived to 8 weeks post-histotripsy. Laboratory studies revealed transient perioperative increases in mean white-blood cell count, C-reactive protein, and lactate dehydrogenase. On histology, 80% of successful urethral sparing treatment cavities were completely epithelialized, containing simple fluid with minimal cellular debris at 8 weeks despite no communication with the urethra.
Urethral sparing histotripsy of the prostate is feasible and well tolerated in a canine model, resulting in modest volume reduction and prompt resorption of homogenized tissue debris. Human studies to evaluate the clinical utility and symptomatic response of urethral sparing are needed.
Histotripsy; Benign Prostatic Hypertrophy; Prostate; Ultrasound; TURP
To compare the effects of tumor volume (TV), tumor percentage involvement (TPI) and prostate volume (PV) on PSA recurrence (PSAR) following radical prostatectomy (RP).
A cohort of 3528 patients receiving RP between 1988 and 2008 was retrieved from the Duke Prostate Center. Patients were stratified by TV (<3cc, 3-6cc, >6cc), TPI (<10%, 10-20%, >20%) and PV (<35cc, 35-45cc, >45cc) and their effects on PSAR evaluated using Kaplan-Meier (KM) analysis. Clinico-pathological variables included in univariate analysis were age at surgery, race, year of surgery, PSA, pathological Gleason score, pathological tumor stage, margin status, extra capsular extension (ECE) and seminal vesicle invasion (SVI). The effects of TV, TPI and PV (as continuous and categorical variables) on PSAR were compared using Cox analysis.
TPI, TV and PV were predictive of PSAR (p <0.05) in KM. In multivariate analysis as continuous variables, TPI and PV were predictive of PSAR (Odds ratio (OR) = 1.16 and OR = 0.65, p <0.05). As categorical variables, TPI > 20% and PV 10-35cc were predictive of PSAR (OR = 1.45 and OR = 1.25, p <0.05). TV was not predictive of PSAR in either analysis. Pathological Gleason score ≥ 7, PSA, positive margins, SVI and tumor stage T3/4 were found to be predictors of PSAR (p <0.05).
TV, TPI and PV were predictive of PSAR in univariate analysis, but only TPI and PV were predictive in multivariate analysis. TPI and PV should be considered when evaluating, assessing and counseling patients about PSAR risk.
Prostate cancer; Tumor volume; Tumor percentage involvement; Prostate volume; PSA recurrence
Interstitial cystitis (IC) is a painful bladder syndrome associated with urinary frequency and urgency. Elusive etiology of IC makes its diagnosis only possible by exclusion in many cases. In the present study, we used proteomics for identifying disease-associated proteins in rat model of chronic bladder irritation.
Materials & Methods
Chronic irritation of rat bladder was caused by a brief (90 secs) intravesical instillation of 0.2ml of 0.4N HCl. Whole bladders were collected at different time points after treatment, snap frozen and nuclear and cytosolic protein extracts were obtained. Samples were resolved in standard 2D-gels stained with an improved Coomasie Stain or by Differential Gel Electrophoresis (DIGE). Differentially expressed spots were excised and identified by MALDI-TOF MS/MS. Histological and Western blot analysis were also performed.
Bladder morphology and histologic appearance of bladder sections following HCl treatment reflected hemorrhage, edema, epithelial denudation, detrusor mastocytosis and eosinophilia. Proteomic analysis of irritated rat bladder revealed marked overexpression of four nuclear proteins and marked underexpression of one nuclear protein compared to normal rat bladders. Among these proteins, inflammation-associated Calgranulin A (over) and smooth muscle protein-22/transgelin (under) showed opposed expression patterns following bladder irritation.
Presence of mast cells and eosinophils and overexpression of calgranulin A confirm the inflammatory component of HCl-irritated bladder. Altered expression of nuclear proteins is of particular interest because of their possible role as a prognostic marker in inflammatory bladder disorders. However, more studies are needed before clinical application of these findings can be established.
Interstitial Cystitis; Proteomics; Biomarkers; 2-D Gel
Accurate staging is critical for determining treatment for prostate cancer. Our objective was to examine whether race or age disparities affected the odds of being staged among prostate cancer patients.
Multivariable logistic regression models examined race and age disparities with respect to the odds of being staged among prostate cancer patients using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Similar analyses were performed to estimate the adjusted odds of being staged with distant metastatic versus in situ or local/regional disease.
The proportion of patients without staging ranged between 3% – 16% by age and 6% – 8% by race. Adjusted results demonstrated statistically significant lower odds (p < 0.05) for 70–74, 75–79, and 80+ year olds of 0.76, 0.52, and 0.23, respectively, relative to prostate cancer patients ages 65–69. The odds of being staged for African Americans are 0.78 times that of non-Hispanic Whites (95% CI = 0.72 – 0.86). The adjusted probability of distant metastatic disease at initial diagnosis is higher for African Americans (OR = 1.61; 95% CI = 1.47 – 1.76) and older men with ORs of 1.25, 1.85 and 4.33 for ages 70–74, 75–79 and 80+, respectively, compared to 65–69 year olds (all p < 0.05).
Even though the overall odds of being staged increased over time, race and age disparities persisted. When staging did occur, the probability of distant metastatic disease was high for African-Americans and there were increasing odds of metastatic disease for all men with advanced age.
Prostate cancer; staging; SEER-Medicare; health disparities; African American
To identify the effect of controlled metabolic diet on reducing urinary calcium oxalate supersaturation in subjects with hyperoxaluric nephrolithiasis after potentially malabsorptive forms of bariatric surgery.
Materials and Methods
Subjects with a history of CaOx kidney stones and mild hyperoxaluria after bariatric surgery (n=9) collected baseline 24-hour urine samples while on a free choice diet. They were then placed on a controlled diet low in oxalate (70 – 80 mg/day), normal in calcium (1000 mg/day), and moderate in protein prior to 2 final 24-hour urine collections.
Overall urinary CaOx supersaturation fell from 1.97 ± 0.49 delta Gibbs (DG) on the free choice diet to 1.13 ± 0.75 DG on the controlled diet (P<0.01). This happened in the absence of a significant change in urinary oxalate excretion, (0.69 ± 0.29 mmol/day) on the free choice diet compared to (0.66 ± 0.38 mmol/day) on the controlled diet. Urinary volume, citrate and pH all increased, although not significantly (p>0.05), contributing to the significant CaOx supersaturation change.
A controlled metabolic diet normal in calcium, moderate in protein and reduced in oxalate can positively impact urinary CaOx supersaturation after bariatric surgery. However, this diet did not appear to decrease urinary oxalate excretion. Therefore, restriction of dietary oxalate alone may not be enough to reduce urinary oxalate excretion to normal levels in this group of known enteric hyperoxaluric patients. Additional strategies may be necessary, such as use of oral calcium supplements as oxalate binders and a lower fat diet.
Bariatric surgery; calcium oxalate; diet therapy; enteric hyperoxaluria; nephrolithiasis; urolithiasis
To report our initial experience with robot-assisted laparoscopic partial nephrectomy compared to traditional laparoscopic partial nephrectomy.
A retrospective review of the Johns Hopkins Minimally Invasive Urological Surgery Database identified 207 consecutive patients undergoing laparoscopic or robotic-assisted laparoscopic partial nephrectomy between 2007 and 2011 by a single surgeon. Patient demographics, pathologic, operative, and peri-operative outcomes were compared between surgical techniques. Early oncologic outcomes are reported for the entire cohort.
102 and 105 patients underwent LPN and RALPN, respectively. Demographic data was comparable between groups. Clinical and pathologic tumor characteristics were similar between groups, and a significant proportion (≥48%) of patients in each group had moderate to high complexity tumors. Patients undergoing RALPN had decreased warm ischemia time, estimated blood loss, and operative times on univariate and multivariate analysis. There was no difference in total peri-operative or significant Urologic complications between groups. Review of early oncologic outcomes revealed no local recurrences and 1 case of metastatic RCC.
Minimally invasive partial nephrectomy is associated with favorable peri-operative outcomes and low morbidity. RALPN appears to be associated with favorable warm ischemia times when compared to LPN.
Renal Neoplasms; nephrectomy; robotics
To assess the impact of laparoscopy on utilization of partial nephrectomy (PN) by comparing national utilization trends in patients undergoing surgery for localized renal tumors.
Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we retrospectively examined trends in procedure utilization from 1995–2007 for patients undergoing surgery for localized (stage I/II) renal masses. Procedures were classified as open radical nephrectomy (ORN), laparoscopic radical nephrectomy (LRN), open partial nephrectomy (OPN), and laparoscopic partial nephrectomy (LPN). Patients were further stratified by tumor size (≤4cm, >4 to ≤7cm, >7cm). Data were primarily analyzed using logistic regressions.
11,689 patients (mean age 74.4±5.7 years, 56% male) with a mean tumor size of 4.7±3.3cm met inclusion criteria. From 1995–2007, ORN rates decreased while for each year successive year, patients were more likely to be treated with OPN (OR 1.17, CI 1.14–1.19), LRN (OR 1.44, CI 1.41–1.47) and LPN (OR 1.75, CI 1.68–1.83). While the increased utilization of OPN (7.5% vs. 13.6%, p<0.001) and LPN (0% vs. 14.2%, p<0.001) reached statistical significance, this was offset by a marked increase in LRN over the same time period (3.0% vs. 43.0%, p<0.001).
Despite increasing emphasis on nephron preservation, PN utilization rates remain low. Compared to a 40% increase in LRN, utilization of PN increased by only 20% from 1995–2007. As a result, 72% of identified Medicare beneficiaries with localized tumors were managed with RN in 2007. The trade-off of minimally invasive surgery for nephron preservation may have adverse long term consequences.
kidney; carcinoma; nephrectomy; nephron sparing; partial nephrectomy; laparoscopy
To evaluate erectile function following high dose radiotherapy for prostate cancer using the international index of erectile function (IIEF), expanded prostate cancer index composite (EPIC), and stamp test.
Men with favorable and intermediate risk prostate cancer were assigned to receive prostate intensity modulated radiotherapy (IMRT) vs. an erectile tissue-sparing IMRT technique on a phase III randomized prospective study. The stamp test, IIEF, and EPIC questionnaires were completed at baseline, 6 months, one year, and two years after IMRT. Sexual Health Inventory for Men (SHIM) scores were abstracted from IIEF questionnaires. A partner questionnaire, designated IIEF-P, modeled after the IIEF but from the perspective of the partner, was collected.
Ninety four men enrolled on the trial who completed at least one questionnaire or one stamp test were analyzed. The median age of the patient population was 62.5 years. The median RT dose was 76 Gy (range: 74–80 Gy). At 6-months and one year after high-dose IMRT, a positive stamp result significantly correlated with median EPIC sexual summary, sexual function (EF), and bother subscale scores. Additionally, 6-months after IMRT the stamp test correlated with median IIEF, IIEF EF domain, and SHIM scores. Robust concordance for the IIEF and SHIM results was appreciated between responding patients: partner pairs.
Nocturnal tumescence indicated by a positive stamp test correlates well with established quality of life questionnaires after IMRT. The stamp test should strongly be considered as an objective measure of erectile function in future studies of ED in prostate cancer patients.
prostate cancer; intensity modulated radiotherapy; erectile dysfunction
Enuresis and nocturia are common among children with sickle cell anemia (SCA). The objectives of this study were to describe the prevalence of enuresis and nocturia among children and young adults with SCA and determine the relationship, if any, between these symptoms and SCA-related morbidity.
A prospective infant cohort of African-American children with SCA was previously established from the Cooperative Study for Sickle Cell Disease. Included in this cohort were children with SCA enrolled before 6 months of age for whom questions about enuresis and nocturia had been completed.
A total of 213 participants were included in this analysis. Sixty-nine individuals (33%) experienced enuresis over the course of the study. No children under 6 years of age were asked about enuresis. Thereafter, enuresis was most prevalent between the ages of 6 and 8 years (42%) and continued to be common in young adults ages 18 to 20 years (9%). Seventy-nine percent of individuals reported a history of nocturia. There was no association between enuresis or nocturia and an increased rate of pain or acute chest syndrome (ACS) episodes.
Enuresis and nocturia are common in children with SCA. Among adults with SCA, enuresis and nocturia are more persistent compared with adults in the general population. Enuresis and nocturia are not associated with an increased rate of pain or ACS.
To identify parameters that predict insignificant prostate cancer in 67 radical prostatectomies after biopsy reclassification to worse disease on active surveillance.
Parameters evaluated at diagnosis and at biopsy reclassification included serum prostate-specific antigen, prostate-specific antigen density, number of positive cores, maximum percent involvement of cancer per core, and any interval negative biopsies. Gleason upgrading at biopsy reclassification was also assessed to predict insignificant cancer.
Mean time between diagnosis and radical prostatectomies was 30.3 months with a median of 3 biopsies (range 2–9). Nineteen of 67 (28.4%) had clinically insignificant cancer at radical prostatectomy. In the entire group, there were no variables significantly associated with insignificant cancer at radical prostatectomy. In a subgroup analysis of 37 patients without Gleason pattern 4/5 at biopsy reclassification, 16/37 (43.2%) showed insignificant cancer at radical prostatectomy. In this subgroup, prostate-specific antigen at diagnosis was significantly lower in men with insignificant cancer (3.7 ng/mL) vs significant cancer (5.4 ng/mL) (P = .0005). With prostate-specific antigen <4 ng/mL at diagnosis or at biopsy reclassification, 12/13 (92.3%) men showed insignificant cancer, whereas only 4/24 (16.7%) men with prostate-specific antigen >4 ng/mL both at diagnosis and at biopsy reclassification showed insignificant cancer.
Most men with biopsy reclassification while on active surveillance have significant disease at radical prostatectomy, justifying their treatment. Low prostate-specific antigen at diagnosis or at biopsy reclassification can predict a high probability of insignificant cancer in the absence of Gleason pattern 4/5 on biopsy. These men may be candidates for continuing active surveillance.
Racial disparities in bladder cancer outcomes have been documented with poorer survival observed among blacks. Bladder cancer outcomes in other ethnic minority groups are less well described. We examined trends in bladder cancer survival among whites, blacks, Hispanics, and Asian/Pacific Islanders in the US over a 30-year period.
From the Surveillance, Epidemiology and End Results cancer registry data, we identified patients diagnosed with transitional cell carcinoma of the bladder between 1975 and 2005. This cohort included 163,973 white, 7,731 black, 7,364 Hispanic and 5,934 Asian/Pacific Islander patients. We assessed the relationship between ethnicity and patient characteristics. Disease-specific 5-year survival was estimated for each ethnic group and for subgroups of stage and grade.
Blacks presented with higher stage disease than whites, Hispanics and Asian/Pacific Islanders, although a trend toward earlier stage presentation was observed in all groups over time. Five-year disease-specific survival was consistently worse for blacks than for other ethnic groups, even when stratified by stage and grade. Five-year disease-specific survival was 82.8% in whites compared with 70.2% in blacks, 80.7% in Hispanics and 81.9% in Asian/Pacific Islanders. There was a persistent disease-specific survival disadvantage in black patients over time which was not seen in the other ethnic groups.
Ethnic disparities in bladder cancer survival persist between whites and blacks, while survival in other ethnic minority groups appears similar to that of whites. Further study of access to care, quality of care and treatment decision making among black patients is needed to better understand these disparities.
ethnic groups; healthcare disparities; survival; urinary bladder; urinary bladder neoplasms
partial nephrectomy; renal scintigraphy; renal function; renal tumor
To determine the impact of evaluative care guideline compliance on surgical intervention for BPH.
From Medicare claims data, we developed a cohort of men new to a urologist with a diagnosis of BPH. We determined urologists’ compliance with guideline recommended care (3 months) and their time- and geography-standardized average monthly Medicare expenditures (1 year). At the level of the urologist, we assessed the impact of these measures on the use of surgical therapy within 1 year of the new patient visit.
Of 10,248 patients in the cohort, 675 received surgical intervention (6.7%). Guideline compliance (2% received surgery in highest quintile; 11% lowest quintile) was associated with surgical intervention. The results were robust to adjustment for patient and surgeon factors (Guideline Compliance - OR 0.09; 95% CI 0.06 to 0.15 highest to lowest adherence).
Urologists who tend to follow the AUA best practice guidelines for BPH evaluation perform surgical interventions on their BPH patients less frequently than urologists who do not follow these guidelines.
Previous studies have confirmed lower prostate-specific antigen (PSA) levels among men with higher body mass index (BMI). This report investigated whether annual changes in BMI are associated with the opposite changes in PSA.
Normal linear mixed models were used to characterize annual PSA, BMI and the ratio of PSA to BMI profiles for 2,641 men undergoing prostate cancer screening for up to eight years as part of a San Antonio screening study.
Among the 1898 participants (71.9%) who never received a prostate biopsy during the study and the 585 participants (22.1%) who had one or more biopsies, all negative for prostate cancer, BMI was higher for Hispanics than other racial groups, lower for older men at study entry and increased every year during the study, and PSA and PSA/BMI ratios were higher for older men at study entry and increased each year on study (all p-values < .05). Among the 158 men (6.0%) eventually diagnosed with prostate cancer no trends in BMI were statistically significant but PSA and PSA/BMI ratios were higher on average for older men at study entry and increased each year on study (both p-values < .05). Correlations between BMI and PSA changes per year were negative but not statistically significantly different from zero.
The individual man scrutinizing his PSA and weight year-to-year can expect a slight annual increase in both, but changes in PSA from one year to the next cannot be attributed to weight gain or loss.
body mass index; prostate-specific antigen; correlation; prostate cancer
To determine whether concomitant surgeries affected outcomes in a randomized trial comparing retropubic (RMUS) versus transobturator midurethral slings (TOMUS).
Subjects (n=597) were stratified into 4 groups based on type of concomitant surgeries: Group I had anterior/apical with or without posterior repairs (n=79, 13%), Group II had posterior repairs or perineorrhaphy only (n=38, 6%), Group III had non-prolapse procedures (n=34, 6%) and Group IV had no concomitant surgeries (n=446, 75%). Complication rates, voiding dysfunction, objective and subjective surgical failure rates and changes in urodynamic (UDS) values (post-op minus pre-op) were assessed and compared in these 4 groups.
There were no differences in complications, voiding dysfunction and subjective failure outcomes between these 4 groups. Group I had lower odds ratio (OR) of objective surgical failure compared to Group IV (OR 0.38, 95% CI 0.18–0.81, p=0.05). The OR of failure of all undergoing concomitant surgeries (Groups I–III) was lower than Group IV (OR 0.57, 95% CI 0.35–0.95, p=0.03). The change in Pdet@Qmax (from pressure-flow) was significantly higher in Group III versus IV (p=0.01). The change in Qmax (from uroflowmetry) was significantly less in Group I and II versus Group IV (p=0.046 and 0.04, respectively).
Concomitant surgeries did not increase complications. Subjects who underwent certain concomitant surgeries had lower failure rates than those undergoing slings only. These data support safety and efficacy of performing concomitant surgery at the time of mid-urethral slings.
midurethral slings; stress urinary incontinence; outcomes; concomitant surgery; complications; urodynamics
To assess the feasibility of two patient-reported health related quality of life (HRQOL) instruments, CARE and SF-12, as tools for evaluating HRQOL outcome consequences following renal surgery, and to determine which domains of these HRQOL instruments are most sensitive to HRQOL outcome effects of renal surgery.
Patients completed CARE and SF-12 preoperatively (baseline) and at 2, 4, 12 and 24 weeks after surgery. Clinical data, patient response rate, HRQOL changes over time, and likelihood of patient return to baseline HRQOL were evaluated.
Seventy-one patients were enrolled. Sixty patients completed the baseline and at least one follow-up set of questionnaires. The CARE pain, gastrointestinal (GI) and activity domain scores and the SF-12 physical composite score (PCS) were sensitive to changes in HRQOL (all p<0.05), whereas other domain subscores of these instruments did not change from pre-surgical baseline to post-surgical follow-up. Postsurgical HRQOL effects detected by the CARE pain, GI, and activity domains, and SF-12 PCS were most evident at 2 weeks (all p<0.001). The CARE composite score demonstrated 74% and 50% of patients returned to within 90% of baseline 4 weeks after radical and partial nephrectomy respectively.
Evaluation of patient-reported HRQOL outcomes after renal surgery is feasible, our findings suggest that the activity, pain, and GI domains of CARE and PCS subscore of the SF-12 are sensitive measures of HRQOL outcome consequences of renal surgery and represent appropriate measures of either care quality or comparative effectiveness analyses of robotic, laparoscopic, and open renal surgery.
renal cell carcinoma; nephrectomy; quality of life; outcomes
To determine the sensitivity of 4 strains of Oxalobacter formigenes (OxF) found in humans, HC1, Va3, CC13, and OxK, to varying concentrations of commonly-prescribed antibiotics. OxF gut colonization has been associated with a decreased risk of forming recurrent calcium oxalate kidney stones.
For each strain and each antibiotic concentration, 100 μL of an overnight culture and 100 μL of the appropriate antibiotic were added to a 7 mL vial of oxalate culture media containing 20 mM oxalate. On the fourth day, vials were visually examined for growth, and a calcium oxalate precipitation test was performed to determine whether OxF grew in the presence of the antibiotic.
All 4 OxF strains were resistant to amoxicillin, amoxicillin/clavulanate, ceftriaxone, cephalexin, and vancomycin while they were all sensitive to azithromycin, ciprofloxacin, clarithromycin, clindamycin, doxycycline, gentamicin, levofloxacin, metronidazole, and tetracycline. One strain, CC13, was resistant to nitrofurantoin while the others were sensitive. Differences in minimum inhibitory concentration between strains were demonstrated.
Four human strains of OxF are sensitive to a number of antibiotics commonly utilized in clinical practice; however, minimum inhibitory concentrations differ between strains.
Oxalobacter formigenes; Calcium; Oxalate; Kidney stone; Antibiotics
We evaluated clinical parameters associated with recovery of ejaculation following nerve-sparing post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) for non-seminomatous germ cell tumor.
We queried our institutional database for all patients who underwent nerve-sparing PC-RPLND between 1995 and 2005 using a bilateral template. Nerve-sparing was carried out whenever technically feasible and oncologically prudent. Antegrade ejaculation was defined as any seminal fluid expulsion and was determined by patient report. We evaluated recovery of antegrade ejaculation based on clinical and pathologic parameters and fit a logistic regression model to determine which pre-operative variables are associated with antegrade ejaculation.
A total of 341 patients had PC-RPLND during the study period, 136 (40%) with nerve sparing techniques. Post-operative antegrade ejaculation was reported by 107/136 (79%) of patients with information available. On the multivariable analysis, a right-sided primary testicular tumor (OR 0.4, 95% CI: 0.1, 1.0, p=0.044) and residual masses ≥5 cm (OR 0.1, 95% CI: 0.0, 0.7, p=0.020) were associated with retrograde ejaculation. However, 40/54 (74%) with right-sided primary tumors and 4/9 (44%) with mass ≥5 cm reported antegrade ejaculation. The 5-year relapse free survival was 98% with a median follow up of 39 months (IQR 19, 66).
Nerve-sparing PC-RPLND is associated with excellent functional return of antegrade ejaculation, is feasible in select patients with bulky disease, and has excellent oncologic outcomes.
Testicular Cancer; Chemotherapy; Surgery; Ejaculation; Retroperitoneal Lymph Node Dissection