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1.  The Utility of an Extensive Postchemotherapy Staging Evaluation in Patients Receiving Neoadjuvant Chemotherapy for Bladder Cancer 
Urology  2014;84(2):358-363.
OBJECTIVE
To assess the utility of an extensive restaging examination performed after the completion of neoadjuvant chemotherapy (NAC) but before radical cystectomy (RC) in the management of patients with advanced bladder cancer.
METHODS
We studied 62 patients who underwent NAC with the intent of proceeding to consolidative RC. A restaging examination, including endoscopic and bimanual examination, as well as cross-sectional imaging of the abdomen and pelvis, was performed after chemotherapy. The impact of restaging on clinical management was determined. In patients proceeding to RC, the degree of correlation between clinical stage (at diagnosis vs on restaging) and pathologic stage was determined.
RESULTS
Restaging altered the treatment course in 6 patients (9.7%) in whom RC was not performed because of restaging findings. An additional 56 patients (90.3%) proceeded to RC. In these patients, compared with clinical stage at diagnosis, the postchemotherapy clinical stage correlated more strongly with pathologic stage (κ = 0.02 vs 0.17). On multivariate analysis, diagnostic clinical stage was not associated with pathologic stage (P = .85), whereas postchemotherapy clinical stage was strongly predictive of pathologic stage (P <.01).
CONCLUSION
An extensive restaging examination altered treatment strategy in a small, but clinically significant subset of patients treated with NAC for bladder cancer. Furthermore, restaging allowed for more accurate prediction of pathologic stage after RC, thereby improving assessment of patient prognosis. Consideration should be given to incorporating a restaging evaluation into the standard management paradigm for bladder cancer.
doi:10.1016/j.urology.2014.03.040
PMCID: PMC4332781  PMID: 25065987
2.  Maximal Testosterone Suppression in Prostate Cancer—Free vs Total Testosterone 
Urology  2014;83(6):1217-1222.
Testosterone remains a key target in the treatment of advanced prostate cancer. The relationship of free testosterone to prostate cancer treatment and outcomes remains largely unexplored. A consensus of prostate cancer experts was convened in 2013 to review current knowledge surrounding relationship of total and free testosterone to prostate cancer, discuss the free hormone hypothesis, and highlight future avenues for therapeutics. Free testosterone may better reflect prostate cancer tissue androgen levels than serum total testosterone concentration. Free testosterone deserves more research regarding its relation to clinical outcomes.
doi:10.1016/j.urology.2014.02.001
PMCID: PMC4332796  PMID: 24713136
3.  [No title available] 
PMCID: PMC3905625  PMID: 24468524
4.  [No title available] 
PMCID: PMC3906681  PMID: 24360063
5.  [No title available] 
PMCID: PMC3922632  PMID: 24468511
6.  Multi-institutional 1-Year Bulbar Urethroplasty Outcomes Using a Standardized Prospective Cystoscopic Follow-up Protocol 
Urology  2014;84(1):213-216.
OBJECTIVE
To evaluate multi-institutional outcomes of bulbar urethroplasty utilizing a standardized cystoscopic follow-up protocol.
METHODS
Eight reconstructive surgeons prospectively enrolled urethral stricture patients in a multi-institutional study and performed postoperative cystoscopy at 3 and 12 months. Anatomic failure was defined as the inability to pass a flexible cystoscope without force. Functional failure was defined as the need for a secondary procedure. Men not compliant with the 12-month cystoscopy were called and asked if any interval secondary procedures had been performed. Patients with bothersome voiding complaints at cystoscopy were considered symptomatic.
RESULTS
Of 213 men in study, 136 underwent excisional urethroplasty (excision and primary anastomosis [EPA]) and 77 underwent repair with buccal grafts. Cystoscopy compliance was 79.8% at 3 months and 54.4% at 12 months. Anatomic success rates were higher at 3 vs 12 months for EPA repairs (97.2% [106 of 109] vs 85.5% [65 of 76; P = .003] but not buccal repairs (85.5% [53 of 62] vs 77.5% [31 of 40]; P = .30). Functional success rates at a year were higher but statistically similar to anatomical success rates (EPA—90.3% [93 of 103]; P = .33; buccal—87% [47 of 54]; P = .22). Of the 20 anatomic recurrences, only 13 (65%) were symptomatic at the time of cystoscopic diagnosis.
CONCLUSION
Rates of success are lower when using the anatomic vs traditional definition. Of recurrences found by cystoscopy, only 65% were symptomatic. One-year patient cystoscopy compliance was poor and its ability to be used as the gold standard screening methodology for recurrence is questionable.
doi:10.1016/j.urology.2014.01.054
PMCID: PMC4307391  PMID: 24837453
7.  Risk Factors for Erosion of Artificial Urinary Sphincters: A Multicenter Prospective Study 
Urology  2014;84(4):934-938.
OBJECTIVE
To evaluate the short- to medium-term outcomes after artificial urinary sphincter (AUS) placement from a large, multi-institutional, prospective, follow-up study. We hypothesize that along with radiation, patients with any history of a direct surgery to the urethra will have higher rates of eventual AUS explantation for erosion and/or infection.
MATERIALS AND METHODS
A prospective outcome analysis was performed on 386 patients treated with AUS placement from April 2009 to December 2012 at 8 institutions with at least 3 months of follow-up. Charts were analyzed for preoperative risk factors and postoperative complications requiring explantation.
RESULTS
Approximately 50% of patients were considered high risk. High risk was defined as patients having undergone radiation therapy, urethroplasty, multiple treatments for bladder neck contracture or urethral stricture, urethral stent placement, or a history of erosion or infection in a previous AUS. A total of 31 explantations (8.03%) were performed during the follow-up period. Overall explantation rates were higher in those with prior radiation and prior UroLume. Men with prior AUS infection or erosion also had a trend for higher rates of subsequent explantation. Men receiving 3.5-cm cuffs had significantly higher explantation rates than those receiving larger cuffs.
CONCLUSION
This outcomes study confirms that urethral risk factors, including radiation history, prior AUS erosion, and a history of urethral stent placement, increase the risk of AUS explantation in short-term follow-up.
doi:10.1016/j.urology.2014.05.043
PMCID: PMC4307589  PMID: 25109562
8.  Urinary Concentrations of Aquaporin-1 and Perilipin-2 in Patients with Renal Cell Carcinoma Correlate with Tumor Size and Stage but Not Grade 
Urology  2013;83(1):10.1016/j.urology.2013.09.026.
OBJECTIVE
To evaluate trends in urine aquaporin-1 (AQP1) and perilipin 2 (PLIN2) concentrations in patients with clear cell and papillary renal cell carcinoma (RCC) this investigation determined the relationship between the urine concentration of these biomarkers and tumor size, grade and stage.
MATERIALS and METHODS
Biomarker concentrations were determined by sensitive and specific Western blot procedures normalized to urine creatinine excretion. Analysis included 61 patients undergoing a partial or a radical nephrectomy for clear cell or papillary renal cancer and 43 age- and sex-matched control patients. Relationships between urine biomarker concentrations and tumor size, stage, and grade were assessed.
RESULTS
Patients with renal cell carcinoma had 35-fold and 9-fold higher median urinary AQP1 and PLIN2 concentrations, respectively, compared to controls (p values). Both tumor markers decreased following tumor resection, to concentrations equivalent to those of controls. The sensitivity and specificity were both 100% for AQP1, and 92% and 100% for PLIN2. There was a significant linear correlation between tumor size and prenephrectomy AQP1 (Spearman coefficient 0.78, P<0.001) and PLIN2 (Spearman coefficient 0.69, P<0.001) concentrations. There was a correlation of both markers with tumor stage (overall P=0.030), when stage was dependent primarily on tumor size (stages T1 and T2), but not with stage T3 which reflected extra-renal spread. Neither marker showed a significant correlation with tumor grade.
CONCLUSIONS
AQP1 and PLIN2 are significantly increased in patients with clear cell and papillary renal cell carcinoma compared to controls. Preoperative urinary concentrations of these markers reflect tumor size and stage.
doi:10.1016/j.urology.2013.09.026
PMCID: PMC3872509  PMID: 24239027
Kidney Cancer; Urine Biomarkers; Aquaporin-1; Perilipin 2
9.  Survival Following Diagnosis of Localized T1a Kidney Cancer: Current Population-based Practice of Surgery and Nonsurgical Management 
Urology  2013;83(1):126-133.
doi:10.1016/j.urology.2013.08.088
PMCID: PMC3892770  PMID: 24246317
kidney cancer; renal cell carcinoma; active surveillance; nephrectomy; survival; SEER-Medicare; nonsurgical management
10.  Racial Differences in Longitudinal Changes in Serum Prostate-Specific Antigen Levels: The Olmsted County Study and The Flint Men’s Health Study 
Urology  2013;83(1):88-93.
Objective
To determine the distribution of and racial differences in changes in PSA from a population-based sample of men.
Materials and Methods
Data from two prospective cohort studies of a random sample of Caucasian men, ages 40–79 in 1990, followed biennially through 2007 and African-American men, ages 40–79 in 1996, followed through 2000 were examined to assess longitudinal changes in PSA concentrations. Serum PSA levels were determined at each examination for both cohorts and observations after a diagnosis of prostate cancer or treatment for benign prostatic hyperplasia (BPH) were censored. Observed and estimated annual percentage change in serum PSA levels were examined by race.
Results
At baseline, the median PSA level in Caucasian men did not differ from the median level observed in African-American men (Caucasian men: 0.9 ng/mL; African-American men: 0.9 ng/mL; P value=0.48). However, African-American men had a much more rapid increase in PSA level over time compared to Caucasian men (median annual percent change in PSA Caucasian men: 3.6%/year; African-American men: 7.9%/year; P value<0.001).
Conclusion
These data suggest that African-American men have more rapid rates of change in PSA levels over time. If the difference in rate of changes between African-American and Caucasian men is an early indicator of future prostate cancer diagnosis, earlier detection in African-American men could help to alleviate the racial disparities in prostate cancer diagnosis and mortality.
doi:10.1016/j.urology.2013.08.025
PMCID: PMC3896508  PMID: 24139354
Prostate cancer; PSA; racial differences; epidemiology
11.  Ambulatory surgery centers and outpatient urologic surgery among Medicare beneficiaries 
Urology  2014;84(1):57-61.
Objectives
To determine the effect of an ambulatory surgery center (ASC) opening in a healthcare market on utilization and quality of outpatient urologic surgery.
Methods
Retrospective cohort study of Medicare beneficiaries undergoing outpatient urologic surgery from 2001 to 2010. Markets were classified into three groups based on ASC status (i.e., those with ASCs, those without ASCs, and those where ASCs were introduced). Multiple propensity score methods adjusted for differences between markets and general linear mixed models determined the effect of ASC opening on utilization and quality, defined by mortality and hospital admission within 30 days of the index procedure.
Results
During the study period, 195 ASCs opened in markets previously without one. Rates of hospital based urologic surgery in markets where ASCs were introduced declined from 221 to 214 procedures per 10,000 beneficiaries in the 4 years after baseline. In contrast, rates in the other two market types increased over the same period (p < 0.001). Rates of outpatient urologic surgery overall (i.e., in the hospital and ASC) demonstrated similar growth across market types during same period (p = 0.56). The introduction of an ASC into a market was not associated with increases in hospital admission or mortality (p’s > 0.5).
Conclusions
The introduction of an ASC into a healthcare market lowered rates of outpatient urologic surgery performed in the more expensive hospital setting. This redistribution was not associated with declines in quality or with greater growth in overall outpatient surgery use.
doi:10.1016/j.urology.2014.04.008
PMCID: PMC4077194  PMID: 24976220
population; propensity score; administrative claims; healthcare market; hospital service area; mortality; hospital admission
12.  OPPOSING ROLES OF FOLATE IN PROSTATE CANCER 
Urology  2013;82(6):10.1016/j.urology.2013.07.012.
doi:10.1016/j.urology.2013.07.012
PMCID: PMC3852144  PMID: 23992971
Centers for Disease Control and Prevention; CDC; National Health and Nutrition Examination Survey; NHANES; folate; folic acid; prostate cancer; prostate specific membrane antigen; PSMA
13.  National Trends in the Utilization of Partial Nephrectomy Before and After the Establishment of AUA guidelines for the Management of Renal Masses 
Urology  2013;82(6):10.1016/j.urology.2013.07.068.
Objective
To assess the impact of the American Urological Association guidelines advocating partial nephrectomy for T1 tumors guidelines on the likelihood of undergoing partial nephrectomy.
Materials and Methods
We analyzed the Nationwide Inpatient Sample, a dataset encompassing 20% of all United States inpatient hospitalizations, from 2007 through 2010. Our dependent variable was receipt of radical vs. partial nephrectomy (55.50, 55.51, 55.52, and 55.54 vs. 55.4) for a renal mass (ICD-9 code 189.0). The independent variable of interest was time of surgery (before or after the establishment of AUA guidelines); covariates included a diagnosis of chronic kidney disease (CKD), overall comorbidity, age, race, gender, geographic region, income, and hospital characteristics. Bivariate and multivariable adjusted logistic regression was used to determine the association between receipt of partial nephrectomy and time of guideline establishment.
Results
We identified 26,165 patients with renal tumors who underwent surgery. Prior to the guidelines, 4031 (27%) patients underwent partial nephrectomy compared to 3559 (32%) after. On multivariable analysis, undergoing surgery after the establishment of guidelines (OR 1.20 [95% Cl 1.08-1.32], p<0.01) was an independent predictor of partial nephrectomy. Other factors associated with partial nephrectomy were urban location, surgery at a teaching hospital, large hospital bed size, Northeast location, and Black race. Female gender and CKD were not associated with partial nephrectomy.
Conclusions
Although adoption of partial nephrectomy increased after establishment of new guidelines on renal masses, partial nephrectomy remains an underutilized procedure. Future research must focus on barriers to adoption of partial nephrectomy and how to overcome them.
doi:10.1016/j.urology.2013.07.068
PMCID: PMC3852430  PMID: 24295245
American Urological Association guideline; renal mass; partial nephrectomy
14.  Dietary Management of Idiopathic Hyperoxaluria and the Influence of Patient Characteristics and Compliance 
Urology  2013;82(6):10.1016/j.urology.2013.08.002.
Objectives
To assess the efficacy of dietary management for the treatment of idiopathic hyperoxaluria in a large tertiary care center. Additionally, this study examines the influence of patient factors, compliance, and follow-up on oxalate reduction which has not been previously investigated.
Methods
Retrospectively, 149 kidney stone patients with idiopathic hyperoxaluria who received dietary management at our stone clinic were evaluated. Changes in urinary parameters on 24-hour urine collections were calculated for all patients and those with abnormal values in the overall, short (30–240 days), and long-term (>240 days) time period. Changes in urinary oxalate were evaluated with respect to patient characteristics and compliance measures.
Results
Urine oxalate and supersaturation of calcium oxalate were significantly (P<0.001) reduced by 8.9±19.2 mg/d and 1.7±4.3, respectively. 48.3% reduced their urinary oxalate to normal. Urine oxalate reductions were similar in the short- and long-term periods. Women lowered urine oxalate nearly twice as much as men (12.7±2.0 mg/d vs 6.7±2.2 mg/d, P=0.022) and BMI negatively correlated with oxalate reduction (Pearson’s r= −0.213). Reported noncompliance and keeping follow-up appointments did not affect oxalate, however, there was a significant correlation between increasing urine volume and reducing oxalate (Pearson’s r= −0.21).
Conclusions
This study confirms that meaningful reductions of urine oxalate and supersaturation of calcium oxalate can be achieved with dietary management of hyperoxaluria on a larger clinical scale. Furthermore, we identified that females and patients with low BMIs had greater urine oxalate reductions and also urine volume may be used by clinicians as a measure of dietary compliance.
doi:10.1016/j.urology.2013.08.002
PMCID: PMC3864764  PMID: 24054440
hyperoxaluria; diet therapy; nephrolithiasis; compliance
15.  Neoadjuvant androgen deprivation therapy (NADT) Leads to Immediate Impairment of Vitality/ Hormonal and Sexual Quality of Life: Results of a Multi-Center, Prospective Study 
Urology  2013;82(6):1363-1368.
Objectives
To evaluate the immediate effects of neoadjuvant androgen depravation therapy (NADT) on health-related quality of life (HRQOL) among patients undergoing RT for newly diagnosed prostate cancer.
Methods
The Prostate Cancer Outcomes and Satisfaction with Treatment Quality Assessment (PROST-QA) Consortium is a prospective, multi-institutional study. HRQOL is measured with the EPIC-26 questionnaire. Differences in patient reported HRQOL were observed between pre-treatment and 2 months after NADT start (and before definitive RT) with significant differences evaluated by paired t-test.
Results
From among 450 subjects who completed the EPIC-26 before and 2-months after NADT start, 71 received NADT prior to proceeding with definitive RT. Patients receiving NADT experienced significant impairment in vitality/hormonal (p<0.0001) and sexual (p<0.0001) HRQOL after NADT initiation. The mean ± standard deviation vitality/hormonal score fell from an average of 94.1 ± 9.7 before NADT to 78.7 ± 16.3 two months after NADT initiation; and sexual HRQOL fell from a mean of 51.7 ± 31.1 pre-treatment to 32.3 ± 26.1 after NADT initiation. Both of these HRQOL domain changes exceeded the thresholds for clinical significance. Patients receiving NADT also experienced a significant impairment in urinary continence (p=0.024), although this difference did not meet criteria for clinical significance.
Conclusions
In this analysis, patients receiving NADT experience significant impairment in sexual and vitality/hormonal HRQOL even before starting definitive radiation therapy. The significant impact of this therapy on HRQOL needs to be considered before initiating NADT in men where there is no clear evidence of clinical benefit.
doi:10.1016/j.urology.2013.06.062
PMCID: PMC3904352  PMID: 24139340
PROST-QA; neoadjuvant androgen deprivation therapy; quality of life; radiotherapy; prostate cancer
16.  Trends in Medical Management of Men with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia 
Urology  2013;82(6):1386-1392.
Objective
To examine trends in medical management of men with BPH/LUTS in relation to sentinel events specific to particular medication regimens.
Methods
Using the National Ambulatory Medical Care Survey (1993–2010), we identified outpatient visits by men with BPH/LUTS. We ascertained prescriptions for medical therapy and distinguished between treatment with α-blocker (AB) monotherapy, 5-α reductase inhibitor monotherapy, combination therapy, and anticholinergic therapy. We evaluated temporal trends in prescription patterns, and assessed for changes after sentinel events related to each regimen (e.g., FDA approval for tamsulosin and AB monotherapy). Finally, we used multivariable logistic regression to determine factors associated with each treatment strategy.
Results
From 1993–2010, there were over 101 million outpatient visits for men with a diagnosis of BPH/LUTS. Among these visits, use of BPH medication increased from 14% of visits in 1993–1995 to over 40% of visits in 2008–2010 (p<0.001). After tamsulosin was FDA approved, providers were twice as likely to prescribe ABs (OR 2.35, 95% CI 1.60 – 3.43). Providers were five times as likely to prescribe combination therapy after level 1 evidence supported its use (OR 5.13, 95% CI 3.35 – 7.86).
Conclusions
Over the past 15 years, there has been a steady increase in use of medications to manage men with BPH. Providers seem to have readily adopted novel medications and treatment regimens in response to FDA approval and supportive level 1 evidence.
doi:10.1016/j.urology.2013.07.062
PMCID: PMC3962766  PMID: 24269224
prostatic hyperplasia; drug therapy; cross-sectional studies; ambulatory care
17.  Statin use and the risk of recurrence after radical prostatectomy in a cohort of men with inherited and/or early-onset forms of prostate cancer 
Urology  2014;83(6):1356-1361.
doi:10.1016/j.urology.2014.02.015
PMCID: PMC4230295  PMID: 24745796
Prostate cancer recurrence; statin medications; biochemical recurrence; prostate cancer epidemiology; inherited prostate cancer; early-onset prostate cancer
18.  Recent Time Trends in the Epidemiology of Stage IV Prostate Cancer in the United States: Analysis of Data From the Surveillance, Epidemiology, and End Results Program* 
Urology  2009;75(6):1396-1404.
OBJECTIVES
To describe recent epidemiologic trends in stage IV prostate cancer. Although advances in screening and diagnostic techniques have led to earlier detection of prostate cancer, a portion of patients still present with late-stage disease.
METHODS
Population-based cancer registry data from the Surveillance, Epidemiology, and End Results Program (cases from 1988 to 2003, follow-up through 2005) were used to calculate annual age-adjusted incidence rates of stage IV prostate cancer (overall and for the subset presenting with distant metastases) and to assess time trends in patient, tumor, and treatment characteristics and survival.
RESULTS
From 1988 to 2003, the age-adjusted incidence of stage IV prostate cancer significantly declined by 6.4% each year. The proportion of men diagnosed at younger ages, with poorly differentiated tumors, or who underwent a radical prostatectomy significantly increased over time. Five-year relative survival improved across the study period (from 41.6% to 62.3%), particularly in those diagnosed at younger ages or with moderately to well-differentiated tumors. Later years of diagnosis were independently associated with a decreased risk of death (from all causes and from prostate cancer specifically) after controlling for important patient, tumor, and treatment characteristics. Tumor grade and receipt of radical prostatectomy appeared to be the strongest independent prognostic indicators. Temporal trends were similar in the subset presenting with distant metastases, except that no significant improvement in survival was observed.
CONCLUSIONS
As younger men may expect to live longer with advanced prostate cancer, there remains a need to widen the range of therapeutic and supportive care options.
doi:10.1016/j.urology.2009.07.1360
PMCID: PMC4249683  PMID: 19969335
19.  Retroperitoneal Histology of Patients with Elevated Serum Alpha-Fetoprotein and Pure Seminoma at Orchiectomy 
Urology  2011;78(4):844-847.
Objectives
A histologic diagnosis of seminoma at orchiectomy with an elevation in serum alpha-fetoprotein (AFP) indicates the likelihood of unrecognized NSGCT elements. We report the retroperitoneal histology of a contemporary series of patients with pure seminoma at orchiectomy with an elevation in serum AFP that were managed as NSGCT.
Methods
We identified 22 patients between 1989 and 2009 with pure seminoma diagnosed at orchiectomy with an elevated serum AFP (> 15 ng/ml) either pre- or post-orchiectomy. Retroperitoneal histology and relapse data are reported.
Results
Median pre-orchiectomy and pre-chemotherapy serum AFP levels were 248 ng/ml (IQR 48, 4693) and 279 ng/ml (IQR 66, 5311), respectively. Percentage of patients with clinical stage I, II, and III was 5%, 50%, and 45%, respectively. Percentage of patients with IGCCCG good, intermediate, and poor risk status was 32%, 32%, and 36%, respectively. Twenty-one patients had induction chemotherapy followed by PC-RPLND. Overall, 67% of patients had NSGCT elements in the retroperitoneum. Histologic findings were pure teratoma in 38%, malignant transformation in 14%, and viable NSGCT in 14%. Fifty-nine percent had some component of teratoma in the RP. One patient (5%) had any seminoma in the RP, but this patient also had RP teratoma. Seven patients relapsed and received salvage chemotherapy. Actuarial relapse free survival at 5 and 10 years was 76% and 61% reflecting a high percentage of patients with stage II/III disease.
Conclusions
Pure seminoma at orchiectomy with an elevated serum AFP portends a high likelihood of harboring NSGCT elements in the RP.
doi:10.1016/j.urology.2011.02.002
PMCID: PMC4237276  PMID: 21782217
testicular cancer; seminoma; AFP; RPLND
20.  Transverse Versus Vertical Camera Port Incision in Robotic Radical Prostatectomy: Effect on Incisional Hernias and Cosmesis 
Urology  2011;78(3):586-590.
OBJECTIVE
To examine the incidence of incisional hernias (IHs) and propose a simple modification to reduce the incidence of IHs. Robot-assisted radical prostatectomy (RARP) historically uses a vertical midline camera port incision to extract the prostate.
METHODS
Of 900 consecutive RARPs, the initial 735 had a vertical and subsequent 165 transverse incisions. Two methods were used to identify IHs: clinic visits noted in the prospective database and screening using electronic mail. We compared the baseline factors between the vertical IH and IH-free cohorts. The maximal scar width was recorded in 178 consecutive men presenting to our clinic: vertical (n = 107) and transverse (n = 71).
RESULTS
IHs occurred significantly more often after a vertical incision (5.3% vs 0.6%, P = .005). The IH rates after a vertical incision could be estimated to be as great as 16.7% (18 of 108) using the electronic mail respondents or as low as 3.3% (21 of 627) according to clinic follow-up. On univariate analysis, baseline age, International Index of Erectile Function 5-item questionnaire, prostate weight, bother score (all P ≤ .05), and body mass index (P = .058) were associated with an increased risk of an IH. After adjusting for baseline factors on multivariate logistic regression analysis, the relative odds of developing an IH with a vertical versus transverse incision was 11 (95% confidence interval 1.5–82). The average maximal scar width was reduced from 5.5 to 2.0 mm (P < .0001).
CONCLUSION
In the present sample population, the vertical IH rate was estimated to be potentially as low as 3.3% or as great as 16.7%. On multivariate analysis, a greater body mass index and larger prostate size significantly increased the risk of hernia development. Transverse incisions dramatically reduced the rate of IHs and the maximal scar width. The IH rates varied significantly by reporting method.
doi:10.1016/j.urology.2011.03.067
PMCID: PMC4230820  PMID: 21741689
21.  Impact of Graft Position on Failure of Single-Stage Bulbar Urethroplasties with Buccal Mucosa Graft 
Urology  2013;82(5):1166-1170.
OBJECTIVE
To determine whether patency rates after bulbar urethroplasty with buccal mucosa graft onlay differ based on whether the graft is placed ventrally or dorsally.
METHODS
This was a retrospective, single-center study of all single-stage bulbar urethroplasties performed from 2001- 2011 by two surgeons in which buccal mucosa was used as an onlay graft. Failure was defined as the need for endoscopic or open revision of the reconstruction, or placement of a suprapubic catheter for urinary retention.
RESULTS
A total of 103 patients were reviewed; 41 underwent dorsal onlay, and 62 underwent ventral onlay. Mean age was 40.8 years. Most (84%) patients underwent a prior procedure, which consisted of DVIU in 69%, dilation in 53%, and urethroplasty in 14%. Mean stricture length was 3.9cm. At a mean follow-up of 36 months, failure occurred in 19 patients (12 ventral, 7 dorsal). The vast majority of these patients (79%) were successfully treated with a single dilation or DVIU. There was no difference in failure rate or time to failure according to whether graft position was ventral or dorsal. In multivariate analysis, diabetes was predictive of failure (OR 8.7, 95% CI 1.6-46.5, p = 0.01).
CONCLUSIONS
Single-stage bulbar urethroplasty with buccal mucosa graft is an effective procedure for patients with a bulbar urethral stricture that is not amenable to primary anastomosis. From our experience, we cannot conclude that dorsal or ventral graft position is inherently superior. Patients with diabetes may be more likely to require additional procedures following bulbar urethroplasty with buccal grafting.
doi:10.1016/j.urology.2013.07.013
PMCID: PMC4066651  PMID: 24055240
Anterior Urethral Stricture; Urethral Stricture; Anterior; Urethral Stenosis; Buccal Mucosa; Grafting; Skin
22.  Pediatric Genital Injury: An Analysis of the National Electronic Injury Surveillance System 
Urology  2013;82(5):10.1016/j.urology.2013.05.042.
Objective
To describe the characteristics of pediatric genital injuries presenting to United States emergency departments (EDs).
Methods
A retrospective cohort study utilizing the U.S. Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS) from 1991-2010 to evaluate pediatric genital injuries was performed.
Results
Pediatric genital injuries represented 0.6% of all pediatric injuries with the incidence of injuries rising through the period studied, 1991-2010. The mean age at injury was 7.1 years old and was distributed 56.6% girls and 43.4% boys. A total of 43.3% had lacerations and 42.2% had contusions/abrasions. The majority of injuries occurred at home (65.9%), and the majority of patients (94.7%) were treated and released from the hospital. The most common consumer products associated with pediatric genital trauma were: bicycles (14.7% of all pediatric genital injuries), bathtubs (5.8%), daywear (5.6%), monkey bars (5.4%), and toilets (4.0%).
Conclusion
Although pediatric genital injuries represent a small proportion of overall injuries presenting to the ED, genital injuries continue to rise despite public health measures targeted to decrease childhood injury. Our results can be used to guide further prevention strategies for pediatric genital injury.
doi:10.1016/j.urology.2013.05.042
PMCID: PMC3825779  PMID: 23953603
23.  Predicting Risk of Prostate Cancer in Men Receiving Finasteride: Effect of Prostate Volume, Number of Biopsy Cores, and American Urological Association Symptom Score 
Urology  2013;82(5):10.1016/j.urology.2013.07.041.
OBJECTIVE
To examine the effect of prostate volume, number of biopsy cores, and American Urological Association symptom score (AUASS) for prostate cancer risk assessment among men receiving finasteride in the Prostate Cancer Prevention Trial.
METHODS
Data from 4509 men on the finasteride arm of the Prostate Cancer Prevention Trial who were on treatment at the time of their AUASS and prostate-specific antigen (PSA) measurement before biopsy were included in multivariable logistic regression analyses.
RESULTS
Six hundred eighty-two (15.1%) participants had prostate cancer; 257 (37.7%) of these had high-grade disease. For prostate cancer risk, the model included PSA (odds ratio corresponding to a 2-fold increase in PSA: 2.70; P <.0001), digital rectal examination (2.53; P <.0001), age (1.03; P = .001), and prostate volume (odds ratio 0.54 for a 2-fold increase in volume; P <.0001). For high-grade disease, PSA (3.39; P <.0001), digital rectal examination (2.75; P <.0001), age (1.05; P = .001), and volume (0.55; P <.0001) were statistically significant. AUASS was not statistically significant in any of the models that included prostate volume, but was in models in which volume was not included. The number of biopsy cores did not significantly improve risk assessment in any of the models considered.
CONCLUSION
Although in the general population, obtaining a cancer diagnosis is improved by assessing prostate volume and increasing the number of biopsy cores, neither steps are required in men receiving finasteride. Obtaining fewer biopsy cores in men receiving finasteride preserves biopsy sensitivity and will likely reduce cost and morbidity. UROLOGY 82: 1076–1082, 2013.
doi:10.1016/j.urology.2013.07.041
PMCID: PMC3874369  PMID: 24055241
24.  Inhibitory Role of the Spinal Galanin System in the Control of Micturition 
Urology  2013;82(5):1188.e9-1188.13.
OBJECTIVE
To investigate the effect of intrathecal galanin on the micturition reflex in rats.
METHODS
Continuous cystometrograms (0.04 mL/min infusion rate) were performed in female Sprague-Dawley rats (225-248 g) under urethane anesthesia. After stable micturition cycles were established, galanin was administered intrathecally to evaluate changes in bladder activity. Then, in order to examine the involvement of opioid systems in the galanin effects, galanin was administered intrathecally when the first bladder contraction was observed after intrathecal administration of naloxone, an opioid receptor antagonist.
RESULTS
Intrathecal administration of galanin (1 to 10 μg) increased intercontraction intervals in a dose-dependent fashion. Intrathecal administration of galanin (1 to 10 μg) also increased pressure threshold in a dose-dependent fashion. These inhibitory effects of galanin (10 μg) were partially antagonized by intrathecal administration of naloxone (10 μg).
CONCLUSION
These results indicate that in urethane-anesthetized rats galanin delays the onset of micturition through activation of the opioid mechanism, suggesting the inhibitory role of galanin system in the control of the micturition reflex.
doi:10.1016/j.urology.2013.06.056
PMCID: PMC3920735  PMID: 24035037
25.  Hyperglycemia, Hyperinsulinemia, Insulin Resistance and the Risk of BPH/LUTS Severity and Progression Over Time in Community Dwelling Black Men: The Flint Men’s Health Study 
Urology  2013;82(4):881-886.
Objective
To examine the associations between fasting serum glucose, insulin concentrations, and insulin resistance and BPH in a population-based cohort of African-American men.
Methods
Using the Flint Men’s Health Study (FMHS), we examined how fasting serum glucose and insulin concentrations and calculated HOMA-IR related to burden and progression of clinical markers of BPH in African-American men aged 40–79.
Results
Among 369 men at baseline, mean age was 56.6 years and approximately 70% were overweight/obese (BMI≥25 kg/m2). 148 men (34.4%) reported moderate to severe lower urinary tract symptoms (LUTS) (AUASI≥8). There were no significant trends of metabolic disturbances as measured by serum glucose, insulin or HOMA-IR in men with indications of BPH compared to those without.
Conclusion
In this population-based study of African-American men aged 40–79, we did not observe any significant associations between hyperglycemia, hyperinsulinemia and insulin resistance and burden and progression of BPH after adjustment for age and BMI. This may be due in part to the single measurement and glucose and insulin which may not adequately reflect average glucose metabolism. Further studies examining measures of long-term glycemic control and BPH in racially diverse populations are warranted.
doi:10.1016/j.urology.2013.05.034
PMCID: PMC3788001  PMID: 23915515
diabetes; BPH; LUTS; diabetes; men; aging

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