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1.  Internal validation of the Renal Pelvic Score: a novel marker of renal pelvic anatomy that predicts urine leak following partial nephrectomy 
Urology  2014;84(2):351-357.
Objective
To internally validate the Renal Pelvic Score (RPS) in an expanded cohort of patients undergoing PN.
Materials and Methods
Our prospective institutional RCC database was utilized to identify all patients undergoing PN for localized RCC from 2007–2013. Patients were classified by RPS as having an intra or extraparenchymal renal pelvis. Multivariate logistic regression models were used to examine the relationship between RPS and urine leak.
Results
831 patients (median age 60±11.6 years; 65.1% male) undergoing PN (57.3% robotic) for low (28.9%), intermediate (56.5%), and high complexity (14.5%) localized renal tumors (median size 3.0±2.3cm, median NS 7.0±2.6) were included. 54 (6.5%) patients developed a clinically significant or radiographically identified urine leak. 72/831 (8.7%) of renal pelvises were classified as intraparenchymal. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (43.1% vs. 3.0%; p<0.001), major urine leak requiring intervention (23.6% vs. 1.7%; p<0.001), and minor urine leak (19.4% vs. 1.2%; p<0.001) compared to patients with an extrarenal pelvis. Following multivariable adjustment, RPS (intraparenchymal renal pelvis) (OR 24.8 [CI 11.5–53.4]; p<0.001) was the most predictive of urine leak as was the tumor endophyticity (“E” score of 3 (OR 4.5 [CI 1.3–15.5]; p=0.018)), and intraoperative collecting system entry (OR 6.1 [CI 2.5–14.9]; p<0.001).
Conclusions
Renal pelvic anatomy as measured by the RPS best predicts urine leak following open and robotic partial nephrectomy. While external validation of the RPS is required, pre-operative identification of patients at increased risk for urine leak should be considered in peri-operative management and counseling algorithms.
doi:10.1016/j.urology.2014.05.001
PMCID: PMC4115009  PMID: 24975712
Renal cell carcinoma; renal pelvic score; urine leak; renal pelvis anatomy; partial nephrectomy
2.  Assessment of bladder sensation in mice with a novel device 
Urology  2014;84(2):490.e1-490.e6.
Objective
To develop and test the efficacy of an implantable bladder electrode device that can be used with the Neurometer® electrodiagnostic stimulator to assess fiber-specific afferent bladder sensation in the mouse.
Methods
We constructed a ball-tipped platinum electrode and surgically implanted it into the mouse bladder. The Neurometer® was connected to the electrode to apply selective nerve fiber stimuli (250 Hz for Aδ fibers and 5 Hz for C fibers) of increasing intensities to the bladder mucosa in the mouse to determine bladder sensory threshold (BST) values. Using 58 female C57BL/6J mice, we measured the temporal and interobserver consistency of BST measurements, the effects of intravesical administration of lidocaine and resiniferatoxin on the BST, and the effects of our device on voiding behavior and bladder mucosal integrity.
Results
BST values at 250 and 5 Hz did not vary significantly when measured 2, 4, and 6 days after device implantation, or when obtained by two blinded, independent observers. Intravesical lidocaine yielded a transient increase in BST values at both 250 Hz and 5 Hz, whereas resiniferatoxin yielded a significant increase only at the 5 Hz stimulus frequency after 24 hours. Moderately increased micturition frequency and decreased volume per void were observed 4 and 6 days after device implantation. Histology revealed mild inflammatory changes in the area of the bladder adjacent to the implanted BST device.
Conclusion
Assessment of neuroselective bladder sensation in mice is feasible with our device, which provides reproducible BST values for autonomic bladder afferent nerve fibers.
doi:10.1016/j.urology.2014.04.024
PMCID: PMC4114992  PMID: 24958485
Bladder Sensory Threshold; Afferent Nerve; Electrode; Resiniferatoxin; Lidocaine
3.  Anatomic complexity quantitated by nephrometry score is associated with prolonged warm ischemia time during robotic partial nephrectomy 
Urology  2014;84(2):340-344.
Objective
To assess the association between Nephrometry Score (NS) and prolonged warm ischemia time (WIT) in patients undergoing robotic partial nephrectomy (RPN) for clinically localized renal masses.
Methods
We queried our prospectively maintained kidney cancer database to identify all patients undergoing RPN for localized tumors from 2007–2012. Patient and tumor characteristics were compared between complexity groups using ANOVA and Chi square tests. Multivariable logistic regression models were used to examine the relationship between NS complexity and warm ischemia >30 minutes.
Results
375 patients (mean age 59±11 years, mean CCI 1.0 ±1.3) undergoing RPN under warm ischemia for clinically localized renal tumors (mean tumor size 3.1±1.5 cm, mean NS 6.8±1.8) met inclusion criteria and had NS available. Stratified by complexity, groups differed with respect to age at surgery, tumor size, proximity to the hilum, collecting system entry, EBL, and operative time (all p values ≤ 0.05). Significant differences in mean warm ischemia time were observed when comparing low (19.4±12.1 min), intermediate (28.6±12.8 min) and high (36.1±13.7 min) NS complexity groups (p<0.0001). Adjusting for confounders, patients with intermediate (OR 2.1 [CI 1.2–3.9]) and high (OR 3.7 [CI 1.1–11.8]) NS complexity were more likely to require prolonged warm ischemia time when compared to patients with low complexity tumors.
Conclusions
In our large institutional cohort, quantification of anatomic complexity using the NS is associated with WIT greater than 30 minutes in patients undergoing RPN for localized renal tumors. This provides further evidence that standardized reporting of tumor anatomic complexity affords meaningful outcome comparisons.
doi:10.1016/j.urology.2014.04.013
PMCID: PMC4114993  PMID: 24925833
Renal cell carcinoma; ischemia time; robotic surgery; partial nephrectomy; nephrometry score
4.  Preclinical safety and effectiveness studies of ultrasonic propulsion of kidney stones 
Urology  2014;84(2):484-489.
Objective
To provide an update on a research device to ultrasonically reposition kidney stones transcutaneously. This paper reports preclinical safety and effectiveness studies, survival data, modifications of the system, and testing in a stone-forming porcine model. These data formed the basis for regulatory approval to test the device in humans.
Materials and Methods
The ultrasound burst was shortened to 50ms from previous investigations with 1s bursts. Focused ultrasound was used to expel 2–5mm calcium oxalate monohydrate stones placed ureteroscopically in five pigs. Additionally, de novo stones were imaged and repositioned in a stone-forming porcine model. Acute safety studies were performed targeting two kidneys (6 sites) and three pancreases (8 sites). Survival studies followed 10 animals for one week after simulated treatment. Serum and urine analyses were performed and tissues were evaluated histologically.
Results
All ureteroscopically-implanted stones (6/6) were repositioned out of the kidney in 14 ± 8 minutes with 13 ± 6 bursts. On average, three bursts moved a stone more than 4mm and collectively accounted for the majority of relocation. Stones (3mm) were detected and repositioned in the 200-kg stone-forming model. No injury was detected in the acute or survival studies.
Conclusions
Ultrasonic propulsion is safe and effective in the porcine model. Stones were expelled from the kidney. De novo stones formed in a large porcine model were repositioned. No adverse effects were identified with the acute studies directly targeting kidney or pancreatic tissue or during the survival studies indicating no evidence of delayed tissue injury.
doi:10.1016/j.urology.2014.04.041
PMCID: PMC4304777  PMID: 24975708
kidney; ultrasonography; kidney calculi; lithotripsy
5.  Prostate Size and Adverse Pathologic Features in Men Undergoing Radical Prostatectomy 
Urology  2014;84(1):153-157.
OBJECTIVE
To investigate the relationship between prostate volume measured from preoperative imaging and adverse pathologic features at the time of radical prostatectomy and evaluate the potential effect of clinical stage on such relationship.
METHODS
In 1756 men who underwent preoperative magnetic resonance imaging and radical prostatectomy from 2000 to 2010, we examined associations of magnetic resonance imaging-measured prostate volume with pathologic outcomes using univariate logistic regression and with postoperative biochemical recurrence using Cox proportional hazards models. We also analyzed the effects of clinical stage on the relationship between prostate volume and adverse pathologic features via interaction analyses.
RESULTS
In univariate analyses, smaller prostate volume was significantly associated with high pathologic Gleason score (P < 0.0001), extracapsular extension (P < 0.0001), and positive surgical margins (P = 0.032). No significant interaction between clinical stage and prostate volume was observed in predicting adverse pathologic features (all P > 0.05). The association between prostate volume and recurrence was significant in a multivariable adjusting for postoperative variables (P = 0.031), but missed statistical significance in the preoperative model (P = 0.053). Addition of prostate volume did not change C-Indices (0.78 and 0.83) of either model.
CONCLUSION
Although prostate size did not enhance the prediction of recurrence, it is associated with aggressiveness of prostate cancer. There is no evidence that this association differs depending on clinical stage. Prospective studies are warranted assessing the effect of initial method of detection on the relationship between volume and outcome.
doi:10.1016/j.urology.2014.04.006
PMCID: PMC4076683  PMID: 24976228
prostate; prostatic neoplasms; organ size; pathology
6.  Androgen Receptor CAG Repeat Length and TMPRSS2:ETS Prostate Cancer Risk: Results from the Prostate Cancer Prevention Trial 
Urology  2014;84(1):127-131.
Objective
To investigate the association between the length of the polymorphic trinucleotide CAG microsatellite repeats in exon 1 of the AR gene and risk of prostate cancer containing TMPRSS2:ETS fusion genes.
Methods
This nested case-control study came from subjects enrolled in the Prostate Cancer Prevention Trial and included 195 biopsy-proven prostate cancer cases with known TMPRSS2:ETS status and 1344 matched controls.
Results
There was no association between CAG repeat length and risk of TMPRSS2:ETS-positive (OR=0.97, 95% CI, 0.91–1.04) or TMPRSS2:ETS-negative prostate cancer (OR=1.04, 95% CI, 0.97–1.11) and in patients with low- or high-grade disease.
Conclusion
Our findings suggested that AR CAG repeats are not associated with TMPRSS2:ETS formation in prostate cancer.
doi:10.1016/j.urology.2014.03.015
PMCID: PMC4077907  PMID: 24824408
androgen receptor; prostate cancer; CAG repeat; TMPRSS2:ETS
7.  Counseling the post-radical prostatectomy patients about functional recovery: high predictiveness of current status 
Urology  2014;84(1):158-163.
Objectives
To develop prediction models to help counsel post-radical prostatectomy patients about functional recovery.
Methods
The study included 2162 patients undergoing radical prostatectomy at a major cancer center who reported urinary and erectile function at one year or at two years and at least 1 prior follow-up at 3, 6, 9, or 12 months. We created logistic regression models predicting function at one or two years on the basis of function at 3, 6, 9, and 12 months (2 years only), with the additional predictors of age, stage, grade, PSA, nerve-sparing status and baseline functional score.
Results
No variable other than current functional score had a consistent, statistically significant relationship with outcome. The area-under-the-curves for predicting function at 2 years based on current function alone at 3, 6, 9, and 12 months were, respectively, 0.796, 0.831, 0.882, and 0.885 for erectile function and 0.789, 0.862, 0.869 and 0.876 for urinary function. Patients using one pad at 6 months had only a 50% probability of being pad free at 2 years; this dropped to 36% for patients using 2 pads. This suggests that there is an opportunity for early identification and possible referral of patients likely to have long-term urinary dysfunction.
Conclusions
Assessment of urinary and erectile function in the first post-operative year is strongly predictive of long-term outcome and can guide patient counseling and decisions about rehabilitative treatments.
doi:10.1016/j.urology.2014.02.049
PMCID: PMC4095774  PMID: 24824411
radical prostatectomy; urinary function; erectile function; prediction
8.  A population based analysis of contemporary rates of reoperation for penile prosthesis procedures 
Urology  2014;84(1):112-116.
OBJECTIVES
To perform a population based comparison of inflatable versus semi-rigid penile prostheses to determine contemporary rates of re-operation and identify factors impacting the type of prosthetic implanted.
METHODS
Patient level discharge data and revisit files from the Agency for Healthcare Research and Quality for semi-rigid and inflatable prosthesis procedures performed for erectile dysfunction from 2006-2009 in the state of California were examined. Regression analysis was performed to determine differences between the procedures in terms of infectious and non-infectious failure. Regression analysis was performed to identify factors associated with revision and to identify associations between potential risk factors and the type of implant performed.
RESULTS
A total of 2263 cases were included in the study (1824 inflatable, 439 semi-rigid). The overall re-operation rate was 7.42%. There was no difference in the overall revision rate between the 2 groups (7.52% semi-rigid, 7.40% inflatable, p=0.94). The re-operation rate secondary to infectious complications was 3.6% (4.5% semi-rigid vs 3.23% inflatable, p= 0.18). The revision rate secondary to non-infectious failure was 2.96% in the semi-rigid versus 4.17% in the inflatable group (p=0.25). Medicaid insurance (OR 2.25, CI 1.41, 3.61), African American (OR 1.7, CI 1.20, 2.49) race, age over 80 (p=0.046), and diabetes (OR 1.67, CI 1.07, 2.59) were associated with receiving a semi-rigid implant.
CONCLUSIONS
Re-operation rates for infectious and non-infectious failure are equivalent between the semi-rigid and inflatable penile prostheses. Socio-demographic factors appear to significantly influence the type of prosthesis a patient receives.
doi:10.1016/j.urology.2014.02.028
PMCID: PMC4252045  PMID: 24785986
Penile prosthesis; Prosthesis-related infections; device removal; Erectile dysfunction; prosthesis failure
9.  Factors Influencing Urologist Treatment Preference in Surgical Management of Stone Disease 
Urology  2012;79(5):996-1003.
Objective
To assess the surgeon factors influencing the surgical treatment decisions for symptomatic stone disease. The factors influencing the selection of shock wave lithotripsy (SWL), ureteroscopy, or percutaneous nephrolithotomy to treat symptomatic stone disease are not well studied.
Methods
Electronic surveys were sent to urologists with American Medical Association membership. Information on training, practice, and ideal treatment of common stone scenarios was obtained and statistically analyzed.
Results
In November 2009, 600 surveys were sent and 180 were completed. High-volume SWL practices (>100 cases annually) were more common in community practice (P < .01), and high-volume ureteroscopy and percutaneous nephrolithotomy practices were more common in academic practice (P = .03). Community practice was associated with SWL selection for proximal urolithiasis and upper pole nephrolithiasis (P < .005). An increasing time since urologic training was associated with SWL selection for proximal urolithiasis and upper pole nephrolithiasis (P < .01). Urologists reporting shock wave lithotriptor ownership were 3-4 times more likely to select SWL for urolithiasis or nephrolithiasis compared with urologists who did not own a lithotripter (P < .01). Routine concern for stent pain and rigid ureteroscope preference (vs flexible) were associated with SWL selection (P < .03).
Conclusion
Surgeon factors significantly affected urolithiasis treatment selection. SWL was associated with community urology practice, increasing time since training, shock wave lithotriptor ownership, concern for stent pain, and ureteroscope preference.
doi:10.1016/j.urology.2011.11.024
PMCID: PMC4465295  PMID: 22245295
10.  NADiA® ProsVue™ PSA Slope Is an Independent Prognostic Marker for Identifying Men at Reduced Risk for Clinical Recurrence of Prostate Cancer after Radical Prostatectomy 
Urology  2012;80(6):1319-1325.
Objectives
To validate the hypothesis that men displaying serum PSA slopes ≤2.0 pg/mL/month postprostatectomy, measured with a new immuno-PCR diagnostic test (NADiA® ProsVue™) were at a reduced risk of clinical recurrence as determined by positive biopsy, imaging or death due to prostate cancer.
Methods
From 4 clinical sites, we selected a cohort of 304 men followed up to 17.6 years postprostatectomy for clinical recurrence. We assessed the prognostic value of a PSA slope cutpoint of 2.0 pg/mL/month against established risk factors to identify men at very low risk of clinical recurrence using uni- and multivariate Cox proportional hazards regression and Kaplan-Meier analysis.
Results
The univariate HR (95% CI) of a PSA slope >2.0 pg/mL/month was 18.3 (10.6–31.8), compared to a slope ≤2.0 pg/mL/month (P <0.0001). Median disease-free survival was 4.8 years versus >10 years in the 2 groups (P <0.0001). Multivariate HR for PSA slope with the covariates of preprostatectomy PSA, pathologic stage and Gleason score was 9.8 (5.4–17.8), an 89.8% risk reduction, for men with PSA slopes ≤2.0 pg/mL/month (P <0.0001). Gleason Score (<7 vs. ≥7) was the only other significant predictor (HR 5.4, 2.1–13.8, P = 0.0004).
Conclusions
Clinical recurrence following radical prostatectomy is often difficult to predict since established factors do not reliably stratify risk. We demonstrate that a NADiA ProsVue slope ≤2.0 pg/mL/month postprostatectomy is prognostic for reduced risk of prostate cancer recurrence and adds predictive power to established risk factors.
doi:10.1016/j.urology.2012.06.080
PMCID: PMC4452955  PMID: 23107099
NADiA Pros Vue; PSA; prostate cancer; prostatectomy
11.  PROSTATE CANCER PREVENTION TRIAL RISK CALCULATOR 2.0 FOR THE PREDICTION OF LOW- VERSUS HIGH-GRADE PROSTATE CANCER 
Urology  2014;83(6):1362-1368.
OBJECTIVES
To modify the Prostate Cancer Prevention Trial Risk Calculator (PCPTRC) to predict low- versus high-grade (Gleason grade ≥ 7) prostate cancer and incorporate percent free PSA.
METHODS
Data from 6664 PCPT placebo arm biopsies [5826 individuals] where prostate-specific antigen (PSA) and digital rectal examination (DRE) results were available within one year prior to the biopsy and PSA was ≤ 10 ng/mL were used to develop a nominal logistic regression model to predict the risk of no versus low-grade (Gleason grade < 7) versus high-grade (Gleason grade ≥ 7) cancer. Percent free PSA was incorporated into the model based on likelihood ratio (LR) analysis of a San Antonio Biomarkers of Risk cohort. Models were externally validated on ten Prostate Biopsy Collaborative Group cohorts and one Early Detection Research Network (EDRN) reference set.
RESULTS
5468 (82.1%) of the PCPT biopsies were negative for prostate cancer, 942 (14.1%) detected low-grade and 254 (3.8%) high-grade disease. Significant predictors were (log-base-2) PSA (OR for low-grade versus no cancer: 1.29*, high-grade versus no cancer: 2.02*, high-grade versus low-grade cancer: 1.57*), DRE (0.96, 1.49*, 1.55*, respectively), age (1.02*, 1.05*, 1.03*), African American race (1.13, 2.83*, 2.51*), prior biopsy (0.63*, 0.81, 1.27), and family history (1.31*, 1.25, 0.95), where * indicates p-value < 0.05. The new PCPTRC 2.0 either with or without percent free PSA (also significant by the LR method) validated well externally.
CONCLUSIONS
By differentiating risk of low- versus high-grade disease on biopsy, PCPTRC 2.0 better enables physician-patient counseling concerning whether to proceed to biopsy.
doi:10.1016/j.urology.2014.02.035
PMCID: PMC4035700  PMID: 24862395
Low-grade prostate Cancer; High-grade prostate Cancer; Prostate-specific Antigen; Percent free PSA; Prostate Cancer Prevention Trial; Risk prediction
12.  Gross Hematuria and Urinary Retention among Men from a Nationally Representative Survey in Sierra Leone 
Urology  2014;83(6):1273-1279.
Objectives
To estimate the prevalence of gross hematuria and urinary retention among men in Sierra Leone and report on barriers to care and associated disability. Gross hematuria and urinary retention are classic urologic complaints that require medical attention for significant underlying pathology, but their burden has not been quantified in a developing country.
Methods
A cluster randomized, cross-sectional household survey was administered in Sierra Leone using the Surgeons OverSeas Assessment of Surgical need tool as a verbal head-to-toe examination. A total of 2 respondents in each of 25 households in 75 clusters were surveyed to assess surgical needs. Data on questions related to blood from the penis and the inability to urinate for men >12 years of age were included in the present analysis to determine the period and point prevalence of hematuria and urinary retention.
Results
From 3645 total respondents, 1054 (28.9%) were men >12 years old included in the analysis. Period and point prevalence of gross hematuria were 21.8 per 1,000 (95%CI 13.0-30.7) and 12.3 per 1,000 (95%CI 5.7-19.0), respectively, and for urinary retention they were 19.9 per 1,000 (95%CI 11.5-28.4) and 4.7 per 1,000 (95%CI 0.5-8.9), respectively. Lack of financial resources was the major barrier to care. Disability assessment showed 19.1% were not able to work as a result of urinary retention and 34.8% felt ashamed of their gross hematuria.
Conclusions
The results provide a prevalence estimate of gross hematuria and urinary retention for men in Sierra Leone. Accessible medical and surgical care will be critical for early intervention and management.
doi:10.1016/j.urology.2014.01.038
PMCID: PMC4037342  PMID: 24726148
hematuria; urinary retention; Sierra Leone; prevalence; health surveys
13.  Urologists and Global Health 
Urology  2014;83(6):1278-1279.
doi:10.1016/j.urology.2014.01.039
PMCID: PMC4257599  PMID: 24726146
14.  Readmission After Robot-assisted Radical Cystectomy: Outcomes and Predictors at 90-Day Follow-up 
Urology  2014;83(2):350-356.
OBJECTIVE
To characterize the outcomes and predictors of readmission after robot-assisted radical cystectomy (RARC) during early (30-day) and late (31–90–day) postoperative periods.
METHODS
We retrospectively evaluated our prospectively maintained RARC quality assurance database of 272 consecutive patients operated between 2005 and 2012. We evaluated the relationship of readmission with perioperative outcomes and examined possible predictors during the postoperative period.
RESULTS
Overall 30- and 90-day mortality was 0.7% and 4.8%, respectively, with 25.5% patients readmitted within 90 days after RARC (61% of them were readmitted within 30 days and 39% were readmitted between 31–90 days postoperatively). Infection-related problems were the most common cause of readmission during early and late periods. Overall operative time and obesity were significantly associated with readmission (P = .034 and .033, respectively). Body mass index and female gender were independent predictors of 90-day readmission (P = .004 and .014, respectively). Having any type of complication correlated with 90-day readmission (P = .0045); meanwhile, when complications were graded on the basis of Clavien grading system, only grade 1–2 complications statistically correlated with readmission (P = .046). Four patients needed reoperation (2 patients in early “for appendicitis and adhesive small bowel obstruction” and 2 in late “for ureteroenteric stricture” readmission); meanwhile, 6 patients needed percutaneous procedures (4 patients in early “1 for anastomotic leak and 3 for pelvic collections” and 2 “for pelvic collections and ureterocutaneous fistula” in late readmission).
CONCLUSION
The rate of readmission within 90 days after RARC is significant. Female gender and body mass index are independent predictors of readmission. Outcomes at 90 days provide more thorough results, essential to proper patient counseling.
doi:10.1016/j.urology.2013.09.056
PMCID: PMC4431627  PMID: 24468509
15.  Nicotine Acutely Inhibits Erectile Tumescence by Altering Heart Rate Variability 
Urology  2014;83(5):1093-1098.
Objective
To examine potential mechanisms underlying nicotine’s effects on male sexual arousal by exploring the mediating role of heart rate variability (HRV).
Methods
The sample comprised 22 healthy, nicotine-naïve men (Mage = 20.91 years; SD = 2.43). Data were taken from a double-blind, randomized, placebo-controlled, crossover trial previously completed and published elsewhere. During each laboratory visit, time-domain parameters of HRV (standard deviation of normal-to-normal [NN] intervals [SDNN], square root of the mean squared difference of successive NN intervals [RMSSD], percent of NN intervals for which successive heartbeat intervals differed by at least 50 ms [pNN50]) were assessed, as well as objective (via penile plethysmography) and subjective indices of sexual arousal.
Results
Acute nicotine ingestion (compared to placebo) was associated with dysregulated sympathovagal balance, which in turn was related to relatively reduced erectile tumescence. HRV did not mediate relations between nicotine intake and self-reported indices of sexual arousal.
Conclusions
HRV mediated the association between nicotine ingestion and erectile capacity. Findings suggest that dysfunctional cardiac autonomic tone may be an underlying mechanism by which nicotine exerts its deleterious effects on erectile health.
doi:10.1016/j.urology.2014.01.006
PMCID: PMC4004643  PMID: 24642073
Nicotine; heart rate variability; cardiac autonomic function; sexual arousal; erectile physiology
16.  Robot-Assisted Laparoscopic Hysterectomy,Gonadal Biopsy, and Orchiopexies in an Infant with Persistent Mullerian Duct Syndrome 
Urology  2013;83(4):915-917.
An infant born with hypospadias and no palpable gonads was diagnosed with persistent mullerian duct syndrome (PMDS) based on history, physical examination, laboratory testing, and radiologic imaging. A robot-assisted laparoscopic hysterectomy, right gonadal biopsy, and bilateral orchiopexies were performed without incident. Final pathology confirmed the diagnosis of PMDS. To our knowledge, this is only the second report of PMDS managed through a robot-assisted laparoscopic approach.
doi:10.1016/j.urology.2013.10.006
PMCID: PMC3972322  PMID: 24246315
persistent mullerian duct syndrome; robotic surgery; infant; hysterectomy; orchiopexy
17.  Utilization of Renal Mass Biopsy in Patients with Renal Cell Carcinoma 
Urology  2014;83(4):774-780.
Objectives
To examine the patient, tumor, and temporal factors associated with receipt of RMB in a contemporary nationally representative sample.
Methods
We queried the Surveillance, Epidemiology, and End Results-Medicare dataset for incident cases of RCC diagnosed between 1992 and 2007. We tested for associations among receipt of RMB and patient and tumor characteristics, type of therapy, and procedure type. Temporal trends in receipt of RMB were characterized over the study period.
Results
Approximately one in five (20.7%) patients diagnosed with RCC (n=24,702) underwent RMB before instituting therapy. There was a steady and modest increase in RMB utilization, with the highest utilization (30%) occurring in the final study year. Among patients who underwent radical (n=15,666) or partial (n=2,211) nephrectomy, 17% and 20%, respectively, underwent RMB in advance of surgery. Sixty-five percent of patients who underwent ablation (n=314) underwent RMB before or in conjunction with the procedure. Roughly half of patients (50.4%) treated with systemic therapy alone underwent RMB. Factors independently associated with use of RMB included younger age, black race, Hispanic ethnicity, tumor size < 7cm, and metastatic disease at presentation.
Conclusions
At present, most patients who eventually undergo radical or partial nephrectomy do not undergo RMB, whereas most patients who eventually undergo ablation or systemic therapy do. The optimal use of RMB in the evaluation of kidney tumors has yet to be determined.
doi:10.1016/j.urology.2013.10.073
PMCID: PMC3972335  PMID: 24529579
kidney neoplasms; kidney neoplasms epidemiology; kidney neoplasms diagnosis; biopsy
18.  Assessing the burden of complications following surgery for clinically localized kidney cancer by age and co-morbidity status 
Urology  2014;83(4):843-850.
Purpose
To examine the association between high-risk patient status (age >75 years or Charlson comorbidity [CCI] count >2) and post-operative complications in patients undergoing surgical management for clinically localized renal tumors.
Materials and Methods
Patients undergoing radical (RN) or PN (2005-2012) for localized RCC were analyzed. Multivariate logistic regressions were used to test the association between high-risk status and post-operative complications adjusting for patient, tumor, and operative characteristics.
Results
Of 1,092 patients undergoing PN (71.9%) or RN (28.1%) for clinically localized renal tumors, 255 (23.4%) were classified as high risk, and 175 patients (16%) suffered at least one complication (mean 1.6±1.0). 22.4% and 14.1% of high and low risk patients suffered a complication, respectively (p=0.002). Comparing high and low risk patients, significant differences in Clavien III (20.4 vs. 11.1%; p<0.001) and medical (16.1 vs. 8.1%, p<0.001) complications were observed, while no differences were seen in Clavien III-V or surgical complications. No differences in complications were observed comparing patients treated with RN and PN, albeit high-risk patients were more likely to undergo RN (35.3 vs. 25.9%, p=0.04). Following adjustment, the odds of incurring any complication were 1.9 times higher in high compared to low risk patients (OR 1.9 [CI 1.3-2.8]).
Conclusions
Regardless of surgical type, patients deemed high risk by age and comorbidity criteria were more likely to incur a post-operative complication following renal mass resection. Improved understanding of surgical risks in the elderly and infirmed will help better inform patients deciding between active surveillance and resection of renal tumors.
doi:10.1016/j.urology.2013.12.048
PMCID: PMC3972626  PMID: 24680455
Renal cell carcinoma; complications; surgery; robotics; partial nephrectomy; nephrectomy
19.  Reproductive History and Progression of Lower Urinary Tract Symptoms in Women: Results from a Population-Based Cohort Study 
Urology  2014;83(4):788-794.
Objective
To examine whether reproductive history and related conditions are associated with the development and persistence of lower urinary tract symptoms (LUTS) other than urinary incontinence in a racially/ethnically diverse population-based sample of women.
Materials and Methods
The Boston Area Community Health Survey enrolled 3,201 women aged 30–79y of black, Hispanic, or white race/ethnicity. Baseline and 5-year follow-up interviews were completed by 2,534 women (conditional response rate 83.4%). The association between reproductive history factors and population-weighted estimates of LUTS progression and persistence was tested using multivariable logistic regression models.
Results
Between baseline and 5-year follow-up, 23.9% of women had LUTS progression. In age-adjusted models, women who had delivered ≥2 child births had higher odds of LUTS progression, but the association was completely accounted for by vaginal child delivery (e.g., 2 vaginal childbirths vs. none, multivariable-adjusted OR=2.21, 95% CI 1.46–3.35, P<0.001). No increased odds of LUTS progression was found for women with only 1 vaginal delivery or who only had C-section(s). Uterine prolapse was associated with higher odds of LUTS progression (multivariable-adjusted OR=3.05, 95% CI 1.43–6.50, P=0.004). Gestational diabetes was associated with approximately twice the odds of LUTS progression, but only among younger women (P-interaction=0.003).
Conclusions
In this cohort study, ≥2 vaginal child deliveries, uterine prolapse, and among younger women, gestational diabetes were robust predictors of LUTS progression. Clinicians should assess the presence of bothersome urinary frequency, urgency, and voiding symptoms among women who have had multiple vaginal childbirths or gestational diabetes.
doi:10.1016/j.urology.2013.12.016
PMCID: PMC4151256  PMID: 24560971
Urinary incontinence; Female; Lower urinary tract symptoms; Epidemiology; Urinary bladder, overactive
20.  Short-term Outcomes of Vaginal Mesh Placement Among Female Medicare Beneficiaries 
Urology  2014;83(4):768-773.
Objectives
To compare short-term outcomes between prolapse repairs with and without mesh using a national dataset. Mesh use in surgical treatment of pelvic organ prolapse (POP) has gained wide popularity. However, mesh complications have increased concomitantly with its use.
Methods
Public Use File data were obtained for a 5% random national sample of female Medicare beneficiaries age 65 and over. Women who underwent prolapse surgery were identified by CPT-4 codes. Since the code for mesh placement was effected in 2005, we separated patients into three cohorts: those who underwent prolapse repairs from 1999–2000 (presumably without mesh), those who underwent repairs in 2007–2008 (presumably without mesh), and those with mesh (based on CPT-4 code 57267) in 2007–2008. One-year outcomes were identified using ICD-9 diagnosis and procedure codes and CPT-4 procedure codes.
Results
9,180 prolapse repairs without mesh were performed in 1999–2000, 7,729 without mesh in 2007–2008, and 1,804 prolapse repairs with mesh were performed in 2007–2008. Prolapse re-operation within one year of surgery was higher in non-mesh vs. mesh cohorts (6–7% vs. 4%, p < 0.02). Mesh removal rates were higher in mesh vs. non-mesh group (4% vs. 0–1%, p < 0.001). Mesh use was associated with more dyspareunia, mesh-related complications, and urinary retention, even when controlling for concomitant sling.
Conclusions
Mesh to treat POP and stress urinary incontinence (SUI) was associated with a small decrease in early re-operation for prolapse. This decrease came at the expense of increased rates of pelvic pain, retention, mesh-related complications, and mesh removal.
doi:10.1016/j.urology.2013.10.072
PMCID: PMC4309266  PMID: 24680446
claims data; complications; mesh; pelvic organ prolapse; re-operation
21.  Probability of an Abnormal Screening PSA Result Based on Age, Race, and PSA Threshold 
Urology  2014;83(3):599-605.
Objective
To determine the distribution of screening PSA values in older men and how different PSA thresholds affect the proportion of white, black, and Latino men who would have an abnormal screening result across advancing age groups.
Methods
We used linked national VA and Medicare data to determine the value of the first screening PSA test (ng/mL) of 327,284 men age 65+ who underwent PSA screening in the VA healthcare system in 2003. We calculated the proportion of men with an abnormal PSA result based on age, race, and common PSA thresholds.
Results
Among men age 65+, 8.4% had a PSA >4.0ng/mL. The percentage of men with a PSA >4.0ng/mL increased with age and was highest in black men (13.8%) versus white (8.0%) or Latino men (10.0%) (P<0.001). Combining age and race, the probability of having a PSA >4.0ng/mL ranged from 5.1% of Latino men age 65–69 to 27.4% of black men age 85+. Raising the PSA threshold from >4.0ng/mL to >10.0ng/mL, reclassified the greatest percentage of black men age 85+ (18.3% absolute change) and the lowest percentage of Latino men age 65–69 (4.8% absolute change) as being under the biopsy threshold (P<0.001).
Conclusions
Age, race, and PSA threshold together affect the pre-test probability of an abnormal screening PSA result. Based on screening PSA distributions, stopping screening among men whose PSA < 3ng/ml means over 80% of white and Latino men age 70+ would stop further screening, and increasing the biopsy threshold to >10ng/ml has the greatest effect on reducing the number of older black men who will face biopsy decisions after screening.
doi:10.1016/j.urology.2013.10.051
PMCID: PMC3943595  PMID: 24439009
Geriatrics; Prostate-Specific Antigen; Prostate Neoplasm; Early Detection of Cancer
22.  Quality of Life and Health Status among Prostate Cancer Survivors and Non-cancer Population Controls 
Urology  2014;83(3):658-663.
Objective:
To examine whether quality of life (QOL), health status, and the relationships between them varied by having a prostate cancer history. This study helps to inform the interface between aging-related health decline and the survival state among older men with prostate cancer, which is an important yet understudied public health issue.
Methods:
Hierarchical linear models were used to analyze the cross-sectional data from the nationally representative population-based Medical Expenditure Panel Survey. Using propensity score matching, survivors (respondents with prostate cancer history) and controls (respondents without a history of any cancer) (N=193 pairs) were matched based on seven socio-demographic and health-related factors. QOL was measured using the mental and physical component scores of the SF12. Health status included comorbidities, activities of daily living (ADL), instrumental activities of daily living (IADL), and depressed mood.
Results:
In bivariate analyses, survivors reported worse physical (42,72 vs 45.45 respectively, p=.0040) and mental QOL (51.59 vs 53.73 respectively, p=0.0295) and more comorbidities (3.25 vs 2.78 respectively, p=0.0139) than controls. In multivariate analyses, for both survivors and controls, better physical QOL was associated with fewer comorbidities (p<0.0001), no need help with ADL (p=0.0011) and IADL (p=0.0162), and less depressed mood (p<0.0001); better mental QOL was associated with no need help with IADL (p=.0005) and less depressed mood (p<0.0001).
Conclusions:
QOL of older men is affected by physical, functional, and psychological factors rather than by prostate cancer history. Clinicians need to attend to aging-related health issues when providing care for prostate cancer survivors to improve QOL.
doi:10.1016/j.urology.2013.12.009
PMCID: PMC3947555  PMID: 24581528
quality of life; comorbidity; activity of daily living (ADL); depressed mood; propensity score; prostate cancer
23.  Racial Disparities in Oncologic Outcomes After Radical Prostatectomy: Long-term Follow-up 
Urology  2014;84(6):1434-1441.
OBJECTIVE
To report race-based outcomes after radical prostatectomy (RP) in a cohort stratified by National Comprehensive Cancer Network (NCCN) risk category with updated follow-up.
MATERIALS AND METHODS
Studies describing racial disparities in outcomes after RP are conflicting. We studied 15,993 white and 1634 African American (AA) pretreatment-naïve men who underwent RP at our institution (1992–2013) with complete preoperative and pathologic data. Pathologic outcomes were compared between races using appropriate statistical tests; biochemical recurrence (BCR) for men with complete follow-up was compared using multivariate models that controlled separately for preoperative and postoperative covariates.
RESULTS
Very low- and low-risk AA men were more likely to have positive surgical margins (P <.01), adverse pathologic features (P <.01), and be upgraded at RP (P <.01). With a median follow-up of 4.0 years after RP, AA race was an independent predictor of BCR among NCCN low-risk (HR, 2.16; P <.001) and intermediate-risk (hazard ratio [HR], 1.34; P = .024) classes and pathologic Gleason score ≤6 (HR, 2.42; P <.001) and Gleason score 7 (HR, 1.71; P <.001). BCR-free survival for very low-risk AA men was similar to low-risk white men (P = .890); BCR-free survival for low-risk AA men was similar to intermediate-risk white men (P = .060).
CONCLUSION
When stratified by NCCN risk, AA men with very low-, low-, or intermediate-risk prostate cancer who undergo RP are more likely to have adverse pathologic findings and BCR compared with white men. AA men with “low risk” prostate cancer, especially those considering active surveillance, should be counseled that their recurrence risks can resemble those of whites in higher risk categories.
doi:10.1016/j.urology.2014.08.039
PMCID: PMC4337854  PMID: 25432835
24.  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
25.  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

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