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1.  Challenges in the Pathology of Non–Muscle-Invasive Bladder Cancer: a Dialogue Between the Urologic Surgeon and the Pathologist 
Urology  2013;81(6):1123-1130.
Approximately 70% to 80% of urothelial carcinomas are detected at the stage of non–muscle-invasive bladder cancer (NMIBC). Initial management is often successful, but recurrence is common and leads to a long, burdensome, costly disease course. The quality and efficiency of care depends in part on accurate, clearly communicated descriptions of tumor characteristics. This review identifies current best practices, unmet needs, and key issues in the pathology of NMIBC for the practicing urologist. Reasonable and objective recommendations are provided with the goal of improving urologist–pathologist communication, the efficiency of healthcare utilization, and outcomes for patients with NMIBC.
doi:10.1016/j.urology.2013.01.027
PMCID: PMC5224832  PMID: 23522296
2.  Use of Medical Therapy and Success of Laser Surgery and TURP for BPH 
Urology  2015;86(6):1115-1122.
Objective
To assess the impact of surgery for BPH on use of medication (5-ARIs, alpha blockers, antispasmodics), we assessed pre- and post-operative medication utilization among surgically treated men.
Materials and Methods
Using the Truven Health Analytics MarketScan® Commercial Claims Database, we defined a cohort of men < 65 years of age who had surgical therapy for BPH with either TURP or laser procedures from 2007 through 2009. Primary outcomes included freedom from medical or surgical intervention by 4 months after surgery (chi-square and multivariable logistic regression) and subsequent use of medical or surgical intervention in initial responders (Kaplan-Meier and multivariable Cox regression).
Results
We identified 6430 patients treated with either TURP (3096) or laser procedure (3334) for BPH. Pre-surgical antispasmodic use was associated with the highest risk of medication use at 4 months after surgery (OR 5.19; CI 3.16 to 8.53 versus no medication use prior to surgery). At three years after surgery, 6% (95% CI 4–8%) of laser and 4% (95% CI 2–5%) of TURP treated patients had repeat surgical intervention, and both laser and TURP treated patients had an estimated new use of medication rate of 22% (95% CI 18–25% laser and 20–25% TURP). The strongest predictor of intervention after surgery was pre-operative antispasmodic use (HR 2.49; 95% CI 1.41 to 4.43).
Conclusions
Our results show a need for effective patient counseling about continued or new use of medical therapy after laser and TURP procedures. However, most patients experience durable improvement after surgical intervention for BPH.
doi:10.1016/j.urology.2015.07.019
PMCID: PMC4698045  PMID: 26375848
Benign Prostatic Hyperplasia; Lower urinary tract symptoms; Transurethral Resection of the Prostate; Laser Vaporization; Laser Ablation; Medical Therapy for lower urinary tract symptoms
3.  Rapid Identification of Rectal Multi-Drug Resistant E. coli Prior to Transrectal Prostate Biopsy 
Urology  2015;86(6):1200-1205.
Objective
To develop and evaluated a rapid multiplex-qPCR to identify fecal carriers of multi-drug resistant extra-intestinal pathogenic E. coli clonal groups.
Methods
Men presenting for transrectal prostate biopsy (TPB) at the San Diego Veterans Affairs Medical Center underwent rectal culture immediately prior to TPB. Rectal swabs were streaked ciprofloxacin-supplemented (4 mg/L) MacConkey agar plates, identified, and susceptibility tested. The same swab was sent to the University of Washington for qPCR test (EST200) targeting two major MDR-ExPEC clonal groups – ST131 and ST69 that combined were expected to represent majority of fluoroquinolone as well as trimethoprim-sulfamethoxazole resistant E. coli. We calculate test characteristics including the area under the receiver operative curve (AUC).
Results
We enrolled 104 men from 11/5/2013 to 6/10/2014. Fluoroquinolone - resistant E. coli were cultured from 19.2% (20/104) of rectal swabs and 26% (27/104) of all swabs were positive for EST200 by PCR. The test characteristics comparing the EST200 to the culture-based detection of fluoroquinolone-resistance were 75%, 86%, 94%, and 56%, respectively. The AUC was 0.84 for the EST200 to detect fluoroquinolone resistance prior to TPB.
Conclusions
Compared to the reference standard rectal culture, EST200 was able to detect majority of fluoroquinolone resistant E. coli on rectal swabs prior to prostate biopsy.
doi:10.1016/j.urology.2015.07.008
PMCID: PMC4698053  PMID: 26299464
4.  Pre-Biopsy MRI and MRI-Ultrasound Fusion-Targeted Prostate Biopsy in Men with Previous Negative Biopsies: Impact on Repeat Biopsy Strategies 
Urology  2015;86(6):1192-1199.
OBJECTIVE
To report outcomes of MRI-ultrasound fusion (MRF-TB) and 12-core systematic biopsy (SB) over a 26-month period in men with prior negative prostate biopsy.
METHODS
Between 6/12 and 8/14, 210 men presenting to our institution for prostate biopsy with ≥1 prior negative biopsy underwent multiparametric MRI followed by MRF-TB and SB and were entered into a prospective database. Clinical characteristics, MRI suspicion scores (mSS), and biopsy results were queried from the database and the detection rates of Gleason ≥7 prostate cancer (PCa) and overall PCa were compared between biopsy techniques using McNemar’s test.
RESULTS
Fifty-three (31%) of 172 men meeting inclusion criteria (mean age 65±8 years; mean PSA 8.9±8.9) were found to have PCa. MRF-TB and SB had overall cancer detection rates (CDR) of 23.8% and 18.0% (p=0.12), respectively, and CDR for Gleason score (GS)≥7 disease of 16.3% and 9.3% (p=0.01), respectively. Of 31 men with GS≥7 disease, MRF-TB detected 28 (90.3%) while SB detected 16 (51.6%) (p<0.001). Using UCSF-CAPRA criteria, only one man was re-stratified from low-risk to higher risk based on SB results compared to MRF-TB alone. Among men with mSS<4, 80% of detected cancers were low-risk by UCSF-CAPRA criteria.
CONCLUSIONS
In men with previous negative biopsies and persistent suspicion for PCa, SB contributes little to the detection of GS≥7 disease by MRF-TB, and avoidance of SB bears consideration. Based on the low likelihood of detecting GS≥7 cancer and overall low-risk features of PCa in men with mSS<4, limiting biopsy to men with mSS≥4 warrants further investigation.
doi:10.1016/j.urology.2015.07.038
PMCID: PMC4726647  PMID: 26335497
prostate MRI; MRI-US fusion; prostate biopsy; prostate cancer; repeat biopsy
5.  New Chronic Kidney Disease and Overall Survival After Nephrectomy for Small Renal Cortical Tumors 
Urology  2015;86(6):1137-1143.
OBJECTIVE
To evaluate kidney functional and overall survival (OS) outcomes in a cohort of patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) for tumors ≤4 cm.
MATERIALS AND METHODS
We performed a retrospective study on 2110 patients who underwent PN or RN with normal contralateral kidneys and normal serum creatinine from 1989 through 2012. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Primary end points were baseline incidence of CKD, OS, and new onset of eGFR ≤60 and ≤45 mL/min/1.73 m2.
RESULTS
Preoperatively, 30% and 8% of the cohort had eGFR ≤60 and ≤45 mL/min/1.73 m2, respectively. Five-year freedom from eGFR ≤60 mL/min/1.73 m2 was 24% (95% confidence interval [CI], 19%-30%) and 76% (95% CI, 72%-78%) for RN and PN, respectively, and 5-year freedom from eGFR ≤45 mL/min/1.73 m2 was 51% (95% CI, 45%-56%) and 91% (95% CI, 89%-93%) for RN and PN, respectively. On multivariable analysis, hazard ratio for RN vs PN was 4.98 (95% CI, 4.11-6.04, P <.0001) for new onset of eGFR ≤60 mL/min/1.73 m2 and 9.28 (95% CI, 7.26-11.86, P <.0001) for new onset of eGFR ≤45 mL/min/1.73 m2. The RN group had a higher rate of death per year than the partial group (hazard ratio = 1.61, 95% CI, 1.24-2.08, P = .0003).
CONCLUSION
The present study confirms published works demonstrating that a significant proportion of patients have pre-existing CKD. In patients with normal kidney function, RN is associated with a significantly higher risk for developing CKD and worse OS than PN.
doi:10.1016/j.urology.2015.07.046
PMCID: PMC5017203  PMID: 26362947
6.  Temporal trends in conduit urinary diversion with concomitant cystectomy for benign indications: a population-based analysis 
Urology  2016;98:70-74.
Objectives
To describe national trends in cystectomy at the time of urinary diversion for benign indications. Multiple practice patterns exist regarding the necessity of concomitant cystectomy with urinary diversion for benign end-stage lower urinary tract dysfunction. Beyond single institution reports, limited data is available to describe how concurrent cystectomy is employed on a national level.
Methods
A representative sample of patients undergoing urinary diversion for benign indications with or without concurrent cystectomy was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998–2011. Using multivariate logistic regression models, we identified hospital and patient-level characteristics associated with concomitant cystectomy with urinary diversion.
Results
There was an increase in the proportion of concomitant cystectomy at the time of urinary diversion from 20% to 35% (p<0.001) between 1998 and 2011. The increase in simultaneous cystectomy over time occurred at teaching hospitals (vs. community hospitals), in older patients, in male patients, in the Medicare population (vs. private insurance and Medicaid), and in those with certain diagnoses.
Conclusions
There has been an overall increase in the use of cystectomy at the time of urinary diversion for benign indications on a national level, though the indications driving this clinical decision appear inconsistent.
doi:10.1016/j.urology.2016.06.035
PMCID: PMC5116247  PMID: 27374730
cystectomy; urinary diversion; ileal conduit; national trends; neurogenic bladder
7.  EDITORIAL COMMENT 
Urology  2014;84(5):1072.
doi:10.1016/j.urology.2014.06.068
PMCID: PMC5108527  PMID: 25443906
8.  EDITORIAL COMMENT 
Urology  2014;85(1):153-154.
doi:10.1016/j.urology.2014.06.088
PMCID: PMC5105592  PMID: 25530377
9.  Reduced Penile Size and Treatment Regret in Men With Recurrent Prostate Cancer After Surgery, Radiotherapy Plus Androgen Deprivation, or Radiotherapy Alone 
Urology  2013;81(1):130-134.
OBJECTIVE
To report the relative incidence of the perceived reduction in penile size across prostate cancer treatment modalities and to describe its effect on quality of life and treatment regret.
MATERIALS AND METHODS
The incidence of patient complaints about reduced penile size was calculated for 948 men in the Comprehensive, Observational, Multicenter, Prostate Adenocarcinoma (COMPARE) registry who experienced biochemical failure (per registry definition) and were assessed a median of 5.53 years after prostatectomy or radiotherapy (RT) consisting of either external beam RT or brachytherapy, with or without androgen deprivation therapy (ADT). Multivariate logistic regression analysis was used to determine the factors associated with treatment regret and interference with emotional relationships.
RESULTS
Of 948 men, 25 (2.63%) complained of a reduced penile size. The incidence of reduced penile size stratified by treatment was 3.73% for surgery (19 of 510), 2.67% for RT plus ADT (6 of 225), and 0% for RT without ADT (0 of 213). The surgery (P = .004) and RT plus ADT (P = .016) groups had significantly more shortened penis complaints than the RT alone group. The rate of a shortened penis after surgery and after RT plus ADT was similar (P = .47). On multivariate analysis adjusting for age, treatment type, and baseline comorbidity, a perceived reduction in penile size was associated with interference with close emotional relationships (odds ratio 2.36, 95% confidence interval 1.02–8.26; P = .04) and increased treatment regret (odds ratio 3.37, 95% confidence interval 1.37–8.26; P = .0079).
CONCLUSION
Complaints about a reduced penile size were more common with RT plus ADT or surgery than RT alone and were associated with greater interference with close emotional relationships and increased treatment regret. Physicians should discuss the possibility of this rarely mentioned side effect with their patients to help them make more informed treatment choices.
doi:10.1016/j.urology.2012.08.068
PMCID: PMC5105593  PMID: 23273077
10.  Urinary Stone Disease: Progress, Status, and Needs 
Urology  2015;86(4):651-653.
doi:10.1016/j.urology.2015.07.006
PMCID: PMC4592788  PMID: 26190090
11.  Effect of demographics on excretion of key urinary factors related to kidney stone risk 
Urology  2015;86(4):690-696.
Objective
To investigate the effect of demographics including age and sex on excretion of four key urinary factors (calcium (Ca), magnesium (Mg), oxalate (Ox) and uric acid (UA)) related to kidney stone risk.
Methods
Twenty-four hour urine samples were collected from non-Hispanic white sibships in Rochester, MN. Height, weight, blood pressure, serum creatinine and cystatin C (CC) were measured. Diet was assessed using the Viocare food frequency questionnaire. Effects of demographics and dietary elements on urinary excretions were evaluated in univariate, multivariate, and interaction models that included age, sex, and body mass index (BMI).
Results
Samples were available from 709 individuals. In multivariate models, sex was a significant predictor of all four urinary factors, age was significant for all but UA excretion, and serum creatinine was significant only for Ca and Mg excretion (p<0.05). BMI or weight positively correlated with Mg, Ox and UA excretion (p<0.05). Use of a thiazide diuretic (lower) and dietary protein (higher) were associated with Ca excretion, while dietary Ca was associated with higher Mg excretion. Urinary UA excretion increased with animal protein intake and CC estimated glomerular filtration rate (eGFR), and was lower with concurrent loop diuretic use. Significant interaction effects on urinary UA excretion were observed for loop diuretic use and sex, eGFR and sex, age and animal protein intake, and BMI and eGFR (p<0.05).
Conclusions
Age and sex influence excretion of key urinary factors related to kidney stone risk, and should be taken into account when evaluating kidney stone patients.
doi:10.1016/j.urology.2015.07.012
PMCID: PMC4592816  PMID: 26206452
Calcium; Diet; Nephrolithiasis; Oxalate; Uric acid
12.  Does Routine Pathology Analysis of Adult Circumcision Tissue Identify Penile Cancer? 
Urology  2015;85(6):1431-1434.
OBJECTIVE
To assess the utility of foreskin pathology analysis, we evaluated the outcomes and the costs of this practice in patients for whom penile cancer was not suspected. Adult circumcision specimens are routinely sent for pathologic analysis even when penile cancer is not suspected, increasing costs with little benefit.
MATERIALS AND METHODS
All adult patients who underwent circumcision between January 2000 and August 2013 at a single institution were evaluated by retrospective chart review. Cases of suspected penile cancer (n = 6) were excluded. We identified cases where foreskin specimens were sent for pathologic analysis and reviewed pathology reports. Our Department of Pathology estimated the cost for evaluation of specimens at $311 per case.
RESULTS
A total of 147 circumcisions were performed in patients with no suspicious findings. Pathologic analysis was obtained in 69% (101 of 147) of the cases. Inflammation (58%) was the most common finding. One unsuspected instance of squamous cell carcinoma (Tis) was identified in a patient with human immunodeficiency virus (1 of 147 = 0.7%). The overall cost of pathologic analysis in this study was $31,411.
CONCLUSION
In individuals without predisposing immunodeficiency and where cancer was not suspected, we found that pathologic analysis of circumcision specimens identified no additional malignancies. Our data suggest that in this normal risk population, pathologic analysis may not be required. Additionally, forgoing pathology on foreskin specimens in lower risk cases may reduce costs to the health care system.
doi:10.1016/j.urology.2014.12.065
PMCID: PMC5018204  PMID: 25872693
13.  TARGETED PROSTATE BIOPSY: LESSONS LEARNED MIDST THE EVOLUTION OF A DISRUPTIVE TECHNOLOGY 
Urology  2015;86(3):432-438.
Lessons learned during a 6-year experience with more than 1200 patients undergoing targeted prostate biopsy via MRI/US fusion are reported: (1) The procedure is safe and efficient, requiring some 15–20 minutes in an office setting; (2) MRI is best performed by a radiologist with specialized training, employing a trans-abdominal multi-parametric approach and preferably a 3T magnet; (3) Grade of MRI suspicion is the most powerful predictor of biopsy results, e.g., Grade 5 usually represents cancer; (4) Some potentially-important cancers (15%–30%) are MRI-invisible; (5) Targeted biopsies provide >80% concordance with whole-organ pathology. Early enthusiasm notwithstanding, cost-effectiveness is yet to be resolved, and the technologies remain in evolution.
doi:10.1016/j.urology.2015.07.001
PMCID: PMC4569505  PMID: 26166671
targeted prostate biopsy; MRI-ultrasound fusion; multiparametric MRI; direct in-bore biopsy; cognitive fusion biopsy
14.  Sarcomatoid Carcinoma of the Prostate: Retrospective Review of a Case Series from Johns Hopkins Hospital 
Urology  2015;86(3):539-543.
Objective
To identify survival differences in patients with sarcomatoid prostate cancer based on initial staging and treatment regimens.
Methods
We retrospectively reviewed the clinical outcomes of patients with a pathologically confirmed diagnosis of sarcomatoid prostate cancer. The primary statistical objective was to estimate overall survival and assess the survival of patients at different stages treated with either local and/or systemic approaches.
Results
We identified 70 transurethral resections, needle biopsies or prostatectomy specimens that were reviewed by the Department of Pathology at Johns Hopkins Hospital from 2002–2012 and given the diagnosis of sarcomatoid prostate cancer. Of the 45 patients with available survival data, complete medical histories were obtained on 27 patients who were stratified based on a modified staging system (local disease, local disease with bladder invasion, and metastatic disease). After a median follow-up of 106 months, the median overall survival (OS) of patients in the local disease group was not reached. Notably, five of the 9 patients diagnosed with local disease survived > 5 years and were treated with surgery and/or external beam radiation therapy. The OS hazard was significantly increased in patients with either clinical evidence of bladder invasion (HR: 20.46 [95% CI: 2.43,172]; p = < 0.0001) or metastatic disease (HR: 43.34 [95% CI: 4.39,427.4]; p = < 0.0001), which both demonstrated poor outcomes (median OS: local with bladder invasion – 9 months; metastatic disease – 7.1 months).
Conclusions
This retrospective analysis suggests that local sarcomatoid prostate cancer can be effectively treated with definitive therapy leading to favorable outcomes.
doi:10.1016/j.urology.2015.06.011
PMCID: PMC4569516  PMID: 26126695
Sarcomatoid; prostate cancer
15.  The International Prostate Symptom Score (IPSS) Is an Inadequate Tool to Screen for Urethral Stricture Recurrence After Anterior Urethroplasty 
Urology  2016;95:197-201.
OBJECTIVE
To validate the use of the International Prostate Symptom Score (IPSS) as a stand-alone tool to detect urethral stricture recurrence following urethroplasty.
MATERIALS AND METHODS
This study included 393 men who had undergone anterior urethroplasty and were enrolled in a multi-institutional outcomes study. Data analyzed included pre- and post-operative answers to the IPSS in addition to findings from a same- day cystoscopy. IPSS from men found to have cystoscopic recurrence were then compared to scores from those with successful repairs, and receiver operating characteristic curves were plotted to illustrate the predictive ability of these questions to screen for cystoscopic recurrence.
RESULTS
Mean postoperative scores were lower (fewer symptoms) in successful repairs; IPSS improved from preoperative values regardless of recurrence. Successful repairs had significantly better degree of improvement in question #5 (assessing weak stream) compared to recurrences. Receiver operating characteristic curves demonstrated the highest area under the curve for the IPSS quality of life question (0.66) that alone outperformed the complete IPSS questionnaire (0.56).
CONCLUSION
The IPSS had inadequate sensitivity and specificity to be used as a stand-alone screening tool for stricture recurrence in this large cohort of men, highlighting the need to continue development of a disease-specific, validated patient-reported outcome measure.
doi:10.1016/j.urology.2016.04.006
PMCID: PMC5002376  PMID: 27109599
16.  UROLOGICAL SURVEILLANCE AND MEDICAL COMPLICATIONS AFTER SPINAL CORD INJURY IN THE UNITED STATES 
Urology  2015;86(3):506-510.
Objectives
To evaluate national patterns of urologic follow up after SCI and the occurrence and predictors of urological complications.
Methods
This retrospective cohort study utilized a 5% sample of Medicare data 2007–2010. The minimum adequate urologic surveillance was defined as a: urologist visit; serum creatinine; and upper urinary tract imaging study within the two year period. Each patient was classified to their most severe complication in a multivariate linear regression model.
Results
Among the 7162 patients with SCI, the majority were functionally paraplegic (82.4%) and Caucasian (80.9%). 4.9% received no screening studies over the two year period, 70.5% received some, but not all screening and 24.6% received all three screening tests. Patients travelled a mean of 21.3 ±27.5 miles to receive care. A total of 35.7% of patients saw a urologist during the two year period, 48.6% had some form of upper tract evaluation, with the majority being CT scans and 90.7% had serum creatinine. Fully 35.8% of all patients had a minor complication during their two year follow up. 17.1% had a moderate complication and 8.0% had a severe complication. In our prediction model, patient factors that correlated with increased complications included male gender, African American race, paraplegia and receiving some or all of the NGB recommended screening. Patient distance of travel to their treating physician (urologist or physiatrist) did not affect the rate of complications.
Conclusions
Most patients with SCI are not receiving the recommended screening for urological complications which are common in this population.
doi:10.1016/j.urology.2015.06.005
PMCID: PMC4979001  PMID: 26123520
Spinal Cord injuries; neurogenic bladder; complications; screening
17.  Partial and Radical Nephrectomy for Unilateral Synchronous Multifocal Renal Cortical Tumors 
Urology  2015;85(6):1404-1410.
Objective
To evaluate clinicopathologic characteristics and treatment outcomes of patients undergoing partial (PN) or radical nephrectomy (RN) for unilateral synchronous multifocal renal tumors.
Methods
We retrospectively reviewed medical records for 128 patients with non-metastatic unilateral synchronous multifocal renal tumors who underwent surgical resection at our institution from 1995 to 2012. Five patients with hereditary renal cell carcinoma were excluded. Differences between patient and tumor characteristics from the two nephrectomy groups were evaluated. Outcomes in terms of recurrence-free survival, overall survival, and chronic kidney disease upstaging were estimated using Kaplan-Meier methods. The log-rank test was used for group comparisons.
Results
The study cohort included 78 PN patients (63%) and 45 RN patients (37%); 17/95 planned PN (18%) were converted to RN. Tumor diameter and R.E.N.A.L. nephrometry scores were greater in RN patients (p<0.0001 and p=0.0002, respectively). Pathological stage T3 was seen in 40% of RN patients and 10% of PN patients (p=0.0002). Histologic concordance was apparent in 60/123 patients (49%).
Median follow-up for patients alive without a recurrence was 4 years. Five-year recurrence-free survival was 98% for PN and 85% for RN. Five-year overall survival was 96% for PN and 86% for RN (p=0.5). Five-year freedom from chronic kidney disease upstaging was 74% for PN, and 55% for RN (p=0.11).
Conclusion
Partial nephrectomy for the treatment of unilateral synchronous multifocal renal tumors with favorable characteristics was associated with a low recurrence rate. These findings suggest PN is an appropriate management strategy for this group of carefully selected patients.
doi:10.1016/j.urology.2015.02.032
PMCID: PMC4972183  PMID: 25872696
Renal cell carcinoma; nephrectomy; prognosis; survival rate; multiple primaries
18.  Validation of a Visual Prostate Symptom Score in Men With Lower Urinary Tract Symptoms in a Health Safety Net Hospital 
Urology  2015;86(2):354-358.
OBJECTIVE
To evaluate the correlation between the International Prostate Symptom Score (IPSS) and the Visual Prostate Symptom Score (VPSS), a visual assessment of urinary stream, frequency, nocturia, and quality of life using pictograms, in a health safety net population.
METHODS
Men presenting to San Francisco General Hospital with lower urinary tract symptoms completed the IPSS and the VPSS without and then with assistance. Statistical analysis was performed using the chi-square test, the Wilcoxon signed rank test, and the Spearman rank correlation.
RESULTS
One hundred twenty-one patients were enrolled between December 2013 and May 2014 with a mean age of 54 years. There were statistically significant correlations between total VPSS and total IPSS (ρ = 0.71; P <.001) and for frequency (ρ = 0.47; P <.001), nocturia (ρ = 0.69; P <.001), force of stream (ρ = 0.65; P <.001), and quality of life (ρ = 0.69; P <.001). In addition, there were statistically significant correlations between total VPSS and both VPSS quality of life (ρ = 0.69; P <.001) and Qmax (ρ = −0.473; P = .006). The mean absolute disagreement for participants who took the IPSS independently vs with assistance was greater than for those who took the VPSS independently vs assistance for all symptoms: frequency (0.64 vs 0.3, respectively; P <.001), weak stream (0.82 vs 0.14, respectively; P <.001), nocturia (0.38 vs 0.23, respectively; P = .023), and quality of life (0.63 vs 0.32, respectively; P = .005).
CONCLUSION
Many men altered their IPSS responses when they received assistance. There was significantly less alteration in responses using the VPSS, suggesting that the VPSS is useful in determining lower urinary tract symptoms, particularly in patients with limited education and literacy.
doi:10.1016/j.urology.2015.05.012
PMCID: PMC4551494  PMID: 26169006
19.  ASSOCIATION BETWEEN TESTOSTERONE SUPPLEMENTATION THERAPY AND THROMBOTIC EVENTS IN ELDERLY MEN 
Urology  2015;86(2):283-286.
Objective
To determine the prevalence of thrombotic events and all-cause mortality in men older than 65 years with hypogonadism treated with testosterone therapy (TST).
Methods
We retrospectively reviewed the charts of 217 hypogonadal men >65 years. We compared men who received TST (n=153) to hypogonadal men (n=64) who did not receive TST. We evaluated all-cause mortality, prevalence of myocardial infarction (MI), transient ischemic attack (TIA), cerebrovascular accident (CVA, or ‘stroke’), and deep vein thrombosis / pulmonary embolism (DVT/PE). All events were verified by contacting patients. We excluded men with previous thrombotic events, men previously on androgen deprivation therapy and men who had used TST prior to age of 65.
Results
Median age and Charlson Comorbidity Index of men on TST (74y; 5.1) was similar between hypogonadal men not on TST (73y, p=0.48; 5.3, p=0.36). Median follow-up was 3.8 vs. 3.5 years (TST vs. no TST). No man on TST died, whereas 5 hypogonadal men who did not receive TST died (p=0.007). There were 4 thrombotic events (1 MI, 2 CVA/TIA, 1 PE) in men who received TST and 1 event (CVA/TIA) among men who did not receive TST (p = 0.8). All events (1 death, 6 months follow-up) occurred at least after 2 years of follow-up.
Conclusions
There was increased all-cause mortality in hypogonadal men not treated with testosterone compared to men who received testosterone therapy. There was no difference in prevalence of MI, TIA/CVA, or PE between patients treated with testosterone and hypogonadal men not treated with testosterone.
doi:10.1016/j.urology.2015.03.049
PMCID: PMC4548855  PMID: 26299630
20.  National Variation in Urethroplasty Cost and Predictors of Extreme Cost: A Cost Analysis with Policy Implications 
Urology  2016;94:246-254.
Objective
To determine which factors are associated with higher urethroplasty procedural costs and whether they have been increasing or decreasing over time. Identification of determinants of extreme costs may help reduce cost while maintaining quality.
Materials and Methods
We conducted a retrospective analysis using the 2001–2010 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS). The HCUP-NIS captures hospital charges which we converted to cost using the HCUP Cost-to-Charge Ratio. Log cost linear regression with sensitivity analysis was used to determine variables associated with increased costs. Extreme cost was defined as the top 20th percentile of expenditure, analyzed with logistic regression and expressed as Odds Ratios (OR).
Results
A total of 2298 urethroplasties were recorded in NIS over the study period. The median (interquartile range) calculated costs was $7321 ($5677–$10000). Patients with multiple comorbid conditions were associated with extreme costs (OR 1.56 95% CI 1.19–2.04, p=0.02) compared to patients with no comorbid disease. Inpatient complications raised the odds of extreme costs OR 3.2 CI 2.14–4.75, p<0.001). Graft urethroplasties were associated with extreme costs (OR 1.78 95% CI 1.2–2.64, p=0.005). Variation in patient age, race, hospital region, bed size, teaching status, payer type, and volume of urethroplasty cases were not associated with extremes of cost.
Conclusion
Cost variation for perioperative inpatient urethroplasty procedures is dependent on preoperative patient comorbidities, postoperative complications and surgical complexity related to graft usage. Procedural cost and cost variation are critical for understanding which aspects of care have the greatest impact on cost.
doi:10.1016/j.urology.2016.03.044
PMCID: PMC4969107  PMID: 27107626
surgical cost; cost effectiveness; urethroplasty; utilization
21.  Association of Free Testosterone with Hypogonadal Symptoms in Men with Near-Normal Total Testosterone Levels 
Urology  2015;86(2):287-290.
Objective
To investigate the association between hypogonadal symptoms and free testosterone levels in men with near-normal total testosterone levels (250–350ng/dL) and to determine whether a discriminatory threshold for free testosterone exists below which hypogonadal symptoms become more prevalent.
Methods
We reviewed the charts of 3,167 men who presented to an outpatient men's health clinic. 231 men had symptoms of “low testosterone” and serum testosterone levels between 250 and 350ng/dL. We evaluated hypogonadal symptoms using the ADAM and qADAM questionnaires. Serum levels of total testosterone and SHBG were collected on the same day that men completed their questionnaires. We used linear regression to determine whether or not a threshold of free testosterone exists for hypogonadal symptoms. We performed univariate and multivariable analyses to evaluate factors that predicted a low free testosterone level.
Results
The median age was 43.5 y, and the median testosterone and free testosterone levels were 303ng/dL, and 6.3ng/dL respectively. Prevalence and severity of hypogonadal symptoms (ADAM and qADAM) were similar between men with low (<6.4ng/mL) and normal free testosterone levels. There was an association between age and three of the 10 hypogonadal symptoms (decreased enjoyment in life, sadness, and deterioration of work performance) with a low free testosterone on a univariate analysis. Only younger age was positively associated with free testosterone on multivariable analysis.
Conclusions
We did not observe a relationship between hypogonadal symptoms and free testosterone in men with near-normal testosterone levels.
Symptom-specific free testosterone thresholds could not be defined, as age remains an important confounder.
doi:10.1016/j.urology.2015.05.007
PMCID: PMC4549166  PMID: 26199166
22.  EDITORIAL COMMENT 
Urology  2015;86(5):921.
doi:10.1016/j.urology.2015.07.045
PMCID: PMC4966653  PMID: 26590037
23.  Physician use of sacral neuromodulation among Medicare beneficiaries with overactive bladder and urinary retention 
Urology  2015;86(1):30-34.
Objective
To identify physician-level factors associated with high rates of SNM testing.
Materials and Methods
We performed a retrospective cohort study using a 20% sample of national Medicare claims to identify physicians who performed SNM procedures between 2005 and 2010. Physician-level rates of device testing were determined based on the number of patients seen for overactive bladder and urinary retention diagnoses in the office in each calendar year. These rates were then used to fit a Poisson model to examine factors associated with high rates of device testing.
Results
The number of physicians performing test procedures increased 4-fold from 2005-2010. Average rates of test procedures increased from 4.0 to 6.4 procedures per physician per year (p<0.001), while rates of device implantation remained stable (p=0.23). Physicians who had higher rates of device testing were associated with lower rates of device implantation (Estimate −1.76, p<0.01). Other predictors of physicians with higher test rates included more recent calendar year, testing done in any setting other than an ambulatory surgery center, gynecology subspecialty, and geographic location in the South and West (all p values <0.01).
Conclusions
Over time, physicians are testing more patients but are not implanting more devices. Additionally, there is an inverse relationship between rates of device testing and implantation, suggesting opportunities to improve efficiency and resource utilization.
doi:10.1016/j.urology.2015.04.003
PMCID: PMC4492875  PMID: 26026856
urology; practice patterns; InterStim; population
24.  Utilities of Split-Thickness Skin Grafting for Male Genital Reconstruction 
Urology  2015;86(4):835-839.
Objective
To report our successful outcomes of genital split-thickness skin graft (STSG) in covering major skin loss and providing good functional and cosmetic outcomes.
Materials and Methods
A retrospective chart review was performed for all adult urology patients who underwent STSG at our institution from 1998 to 2014. Patients had a wide range of disease etiologies, including tissue loss (eg post-Fournier's gangrene), lymphedema, buried penis, foreign body injection, and tumors.
Results
A total of 54 patients were identified with the following breakdown of etiology: 13 patients with tissue loss (eg post-Fournier's gangrene), 13 with lymphedema, 12 with buried penis, 8 with foreign body injection, 4 with hidradenitis suppurativa, and 4 with tumors. Fifty-two out of 54 patients had more than 90% graft take, with maintained or improved erection, normal voiding, good cosmetic outcome as judged by the patient and the examining surgeon, and normal mobility. One patient died at 3 months due to cardiovascular cause, and 1 patient had a poor take of the graft.
Conclusion
We show the wide variety of indications for STSG use, the ease of the technique, and its successful outcomes. We believe this procedure should be offered to patients as a first-line treatment and also as a last resort when other more conservative approaches fail.
doi:10.1016/j.urology.2015.07.005
PMCID: PMC4920551  PMID: 26190089
25.  Healing of Donor-site Buccal Mucosa Urethroplasty 
Urology  2015;86(3):e9-e10.
Buccal mucosal graft represents the gold standard graft material for urethroplasty because of its thick epithelium and a thin lamina propria for maximal graft uptake. There is an ongoing debate whether to close the buccal graft donor site. We show a unique look at buccal donor site healing through serial pictures over a 100-day period. In this patient, the anterior half of the buccal donor site was closed at the time of harvest, allowing real-time observation of wound healing from both the closed and open aspects of the wound.
doi:10.1016/j.urology.2015.06.032
PMCID: PMC4917202  PMID: 26151892

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