Showing papers in "Canadian Journal of Urology in 2017"

Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study

Abstract: Introduction To report the five year results of a prospective, multi-center, randomized, blinded sham control trial of the Prostatic Urethral Lift (PUL) in men with bothersome lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Materials and methods At 19 centers in North America and Australia, 206 subjects ≥ 50 years old with International Prostate Symptom Score (IPSS ) > 12, peak flow rate (Qmax) ≤ 12 mL/s, and prostate volume 30 cc-80 cc were randomized 2:1 to the PUL procedure or blinded sham control. In PUL permanent UroLift implants are placed to hold open the lateral lobes of the prostate to reduce urinary obstruction. After randomized comparison at 3 months and the only opportunity to add more PUL implants, PUL patients were followed to 5 years. LUTS severity (IPSS), quality of life (QOL), BPH Impact Index (BPHII), Qmax, sexual function, and adverse events were assessed throughout follow up. Results IPSS improvement after PUL was 88% greater than that of sham at 3 months. LUTS and QOL were significantly improved by 2 weeks with return to preoperative physical activity within 8.6 days. Improvement in IPSS, QOL, BPHII, and Qmax were durable through 5 years with improvements of 36%, 50%, 52%, and 44% respectively. No difference was seen between Intent to Treat and Per Protocol populations. Surgical retreatment was 13.6% over 5 years. Adverse events were mild to moderate and transient. Sexual function was stable over 5 years with no de novo, sustained erectile or ejaculatory dysfunction. Conclusions PUL offers rapid improvement in symptoms, QOL and flow rate that is durable to 5 years. These improvements were achieved with minimal use of a postoperative urinary catheter, rapid return to normal, and preservation of both erectile and ejaculatory function. Symptom improvement was commensurate with patient satisfaction. PUL offers a minimally invasive option in the treatment of LUTS due to BPH.

Association between natural killer cell activity and prostate cancer: a pilot study.

Abstract: INTRODUCTION Natural killer (NK) cells play a significant role in tumor cell immunosurveillance. The association between the activity of NK cells and prostate cancer has previously been demonstrated using conventional research-based tests. MATERIALS AND METHODS The aim of the present pilot study was to study the association between NK cell activity (NKA) and prostate cancer using a simple blood test. Subjects that had previously been selected for prostate biopsy underwent a blood test for NKA using an in vitro diagnostic device (IVDD) (NK Vue, ATGen Canada Inc., Laval, QC, Canada) prior to biopsy. RESULTS Of the 43 subjects sent for prostate biopsy, 22 were found to have prostate cancer. The test performance of the NKA IVDD, assessed using receiver operating characteristics, showed an area under the curve of 75%, a sensitivity of 57%, a specificity of 91%, a positive predictive value of 86% and a negative predictive value of 69%, with an odds ratio of 13.33. Using a cut off of 200 pg/mL for NKA, the absolute risk of having prostate cancer with NKA values below this level was found to be 86%. CONCLUSIONS This pilot study showed that subjects with low values of NKA were more likely to have a positive outcome at prostate biopsy.

BCG: A throwback from the stone age of vaccines opened the path for bladder cancer immunotherapy.

Abstract: Introduction It is 40 years since the initial documentation of the efficacy of bacille Calmette-Guerin (BCG) in the management of non-muscle invasive bladder cancer (NMIBC) and probably an opportune a time as any to retrace the origins of this development and to reflect on the progress that has occurred on the use of immune modifiers in the treatment of NMIBC. Materials and methods A PubMed search for publications on the history of BCG was conducted, and those related to the development of the vaccine for protection against tuberculosis as well as those published in the last 40 years related to its use for treatment for NMIBC were selected for review. A manual search was also carried out for recent articles on immunotherapy for NMIBC failing to respond to BCG. Publications were selected for their usefulness in exemplifying the development of BCG as an antineoplastic agent, elucidating its mechanisms of action of BCG or introducing significant modifications in treatment regimens resulting in enhancement of its efficacy. Alternative innovative immunotherapeutic approaches were chosen to illustrate current trends in the management of this disease. Results Well thought-out modifications of the original protocol resulted in enhanced efficacy of the vaccine, which currently ranks as the best-known and most-used and investigated agent for high risk NMIBC. Despite its efficacy, a considerable number (30%-40%) of these tumors fail to respond to BCG. In addition, as a live bacterium it carries the potential for serious adverse effects and some patients are unable to tolerate it. These shortcomings have created the need for new agents. These range from other mycobacteria and viruses to monoclonal antibodies alone or in combination with other agents currently at various stages of development. Conclusion After 4 decades of use, BCG remains the most effective agent against high risk NMIBC, but it still holds substantial drawbacks. The enduring use of immunotherapy for NMIBC has created a propitious environment to search for better alternatives. There are an increasing number of promising in vitro, animal and early human clinical trials to anticipate a significant therapeutic alternative in the foreseeable future.

Stem cell therapies in post-prostatectomy erectile dysfunction: a critical review.

Abstract: Introduction Erectile dysfunction (ED) is still a common complication of radical prostatectomy. Current treatments of ED are mainly symptomatic. Mesenchymal stem cells (MSCs) have been widely investigated as a potential curative treatment. Although MSC therapy consistently improved erectile functions in the pre-clinical studies the initial expectations seem to be unmet. The aim of this study is to critically review the existing studies on use of stem cells in post-prostatectomy ED and understand factors that preclude clinical translation of the available evidence. Materials and methods A literature search for all pre-clinical and clinical studies investigating MSCs in the treatment of post-prostatectomy ED published between January 2009 and March 2016 was performed using the PubMed database. Results A total of 24 pre-clinical studies investigated MSC based treatments in cavernous nerve injury (CNI) rodent models. In the majority of these studies intracavernous injection of MSCs at the time injury improved erectile functions. There is less data on the efficacy of MSCs when applied in a chronic disease state. Allogeneic or xenogeneic MSCs were similarly effective with limited data on immunologic response. There is a lack of conclusive data on in vivo fate of MSCs and the best route of MSC administration. Conclusion MSC therapy consistently improved erectile functions after CNI. There seems to be a consensus on the disease model used and outcome evaluation however further studies focusing on immunologic response to MSCs, their mechanism of action and in vivo fate are needed before their widespread use in clinic.

Fluorescence in situ hybridization (FISH) in the diagnosis of bladder and upper tract urothelial carcinoma: the largest single-institution experience to date.

Abstract: INTRODUCTION We evaluated the UroVysion (Abbott Molecular, IL, USA) fluorescence in situ hybridization (FISH) assay for the diagnosis of urothelial cancer in patients diagnosed with or suspected to have bladder, upper tract urothelial carcinoma (UTUC), and combined upper and lower tract urothelial carcinoma (BC). MATERIALS AND METHODS A single institution retrospective analysis comparing sensitivity, specificity, positive predictive value, and negative predictive values for FISH and urinary cytology. FISH within 6 months of endoscopic evaluation were obtained from outpatient voided urine samples. Our institutional pathology department confirmed pathologic disease from specimens obtained during endoscopic evaluations for lower tract disease. For upper tract disease, disease was confirmed by retrograde ureteroscopy, biopsies of visual lesions, and site-specific upper tract cytology. RESULTS A total of 415 patients submitted FISH specimens. Overall, FISH was more sensitive than cytology 54.9% in comparison with cytology 42.2% (p = 0.01), specificity favored cytology 92.9% compared to 73.5% with FISH (p < 0.01). For BC only patients, the same significant finding of increased sensitivity and decreased specificity was identified, but for UTUC alone and combined UTUC and BC, there was no significant difference. Cytology had improved positive predictive value (PPV) over FISH, 76.9% in comparison to 64.6% (p = 0.02). Negative predictive value (NPV) also favored cytology 74.2% versus 64.9% (p = 0.02). When analyzing individual cohorts, cytology had improved PPV for BC alone patients. UTUC showed no difference for PPV and NPV. For both UTUC and BC, NPV was slightly favored for FISH over cytology 93.2% versus 91.2% (p = 0.03). CONCLUSIONS Voided urine FISH testing does offer a higher detection of urothelial carcinoma for BC compared to voided cytology; however, specificity was worse. FISH does not appear to improve detection of urothelial carcinoma in patients with either UTUC only or both BC and UTUC.

Gender differences in promotions and scholarly productivity in academic urology.

Abstract: Author(s): Awad, Mohannad A; Gaither, Thomas W; Osterberg, E Charles; Yang, Glen; Greene, Kirsten L; Weiss, Dana A; Anger, Jennifer T; Breyer, Benjamin N | Abstract: IntroductionThe gender demographics within urology are changing as more women are entering the workforce. Since research productivity strongly influence career advancement, we aim to characterize gender differences in scholarly productivity and promotions in a cohort of graduated academic urologists.Materials and methodsUrologists who graduated between 2002 and 2008 from 34 residency programs affiliated with the top 50 urology hospitals as ranked in 2009 by U.S. News a World Report were followed longitudinally. Only urologists affiliated with an academic teaching hospital were included for analysis.ResultsA total of 543 residents graduated, 459 (84.5%) males and 84 (15.5%) females. Of these, 173 entered academia, 137 (79.2%) males and 36 (20.8%) females. Women had fewer publications compared to men (mean 19.3 versus 61.7, p = 0.001). Fewer women compared to men were promoted from assistant professor 11 (30.6%) versus 83 (60.6%), p = 0.005. Fewer women achieved associate professor 10 (27.8%) versus 67 (48.9%), p = 0.005 or professor ranks 1 (2.8%) versus 16 (11.7%), p = 0.005 respectively compared to men. In a multivariate logistic regression analysis, after controlling for the number of total publications and number of years since graduation, gender was not predictive of achieving promotion, OR = 0.81 (95% CI 0.31-2.13), p = 0.673.ConclusionsWomen are underrepresented in senior faculty roles in urology. Scholarly productivity seems to play a major role in academic promotion within urology. With increasing women in academic urology, further studies are needed to explore predictors of promotion and how women can achieve higher leadership roles in the field.

Robotic prostatectomy versus brachytherapy for the treatment of low risk prostate cancer.

Abstract: INTRODUCTION To compare oncological and functional results of robot-assisted radical prostatectomy (RARP) and brachytherapy (BT) with a single-center prospective randomized study. MATERIALS AND METHODS From January 2012 to January 2014, 165 patients with low risk prostate cancer, prostate volume ≤ 50 g, normal urinary (IPSS ≤ 7 and mean flow rate ≥ 15 mL/sec) and erectile functions (IIEF-5 > 17) were enrolled and randomly assigned to the RARP or BT group. Our end points included the comparison of biochemical recurrence-free survival rates, urinary function (IPSS and EPIC scores) and potency rates (IIEF-5 score) at different time points during the first 2 years after surgery between the two groups. RESULTS The biochemical recurrence-free survival rates were 96.1% and 97.4% for the BT and RARP groups, respectively (p = 0.35). Significantly higher IPSS scores were assessed in the BT than in the RARP group at all the postoperative time points (p < 0.05). Significantly higher continence rates were assessed in the BT than in the RARP group during only the first 6 months of follow up (p < 0.05). Significantly lower potency rates were assessed in the BT than in the RARP group at all the postoperative time points (p < 0.05). CONCLUSIONS Our data showed similar biochemical recurrence-free survival rates after BT and RARP. BT patients confirmed constantly higher rates of urinary symptoms while only reporting better continence rates for the first 6 months after surgery. RARP patients reported higher potency rates than BT patients during all the follow up period.

How I do it: Balloon tamponade of prostatic fossa following Aquablation.

Abstract: Since its first report in the 1870s, control of bleeding after transurethral resection of the prostate (TURP) has remained a concern. Foley's initial report of a urinary catheter involved placement of the balloon into the prostatic fossa following TURP. Removal of prostate tissue with a high-velocity saline stream (Aquablation) is a recently reported alternative to TURP. As Aquablation is heat-free, alternatives to non-thermal hemostasis were sought to optimize the procedure. We report use of a balloon catheter in the prostatic fossa after Aquablation as a post-resection hemostatic method.

Surgical flow disruptions during robotic-assisted radical prostatectomy.

Abstract: Introduction: We sought to apply the principles of human factors research to robotic-assisted radical prostatectomy to understand where training and integration challenges lead to suboptimal and inefficient care. Materials and methods: Thirty-four robotic-assisted radical prostatectomy and bilateral pelvic lymph node dissections over a 20 week period were observed for flow disruptions (FD)- deviations from optimal care that can compromise safety or efficiency. Other variables physician experience, trainee involvement, robot model (S versus Si), age, body mass index (BMI), and American Society of Anesthesiologists (ASA) physical status were used to stratify the data and understand the effect of context. Effects were studied across four operative phases- entry to insufflations, robot docking, surgical intervention, and undocking. FDs were classified into one of nine categories. Results: An average of 9.2 (SD = 3.7) FD/hr were recorded, with the highest rates during robot docking (14.7 [SD = 4.3] FDs/hr). The three most common flow disruptions were disruptions of communication, coordination, and equipment. Physicians with more robotic experience were faster during docking (p < 0.003). Training cases had a greater FD rate (8.5 versus 10.6, p < 0.001), as did the Si model robot (8.2 versus 9.8, p = 0.002). Patient BMI and ASA classification yielded no difference in operative duration, but had phase-specific differences in FD. Conclusions: Our data reflects the demands placed on the OR team by the patient, equipment, environment and context of a robotic surgical intervention, and suggests opportunities to enhance safety, quality, efficiency, and learning in robotic surgery.

Standing cough test for evaluation of post-prostatectomy incontinence: a pilot study.

Abstract: Introduction We implemented a standardized Standing Cough Test (SCT) for assessment of men with post-prostatectomy incontinence (PPI) and stratified results according to an objective clinical grading scale in an attempt to facilitate male anti-incontinence surgical procedure selection. Materials and methods SCT was routinely performed during the initial outpatient consultation for PPI. Incontinence severity was recorded based on a novel Male Stress Incontinence Grading Scale (MSIGS) to stratify PPI. Each patient was assigned an incontinence grade score of 0 through 4 during the SCT. Men with mild stress urinary incontinence (SUI) (grades 0-2) were offered sling surgery while those with heavier SUI (grades 3-4) were offered artificial urinary sphincter (AUS). MSIGS grade was correlated to preoperative patient-reported pads per day (PPD), and patient-reported outcomes of anti-incontinence surgery were assessed. Results Among 62 consecutive PPI patients, 20 (32%) were graded as mild based on SCT, while the majority (42/62, 68%) were graded as moderate-severe. Average time from prostatectomy to treatment was 6 years. MSIGS grade demonstrated a strong correlation with preoperative PPD (r = 0.74). Among the 53 patients who underwent surgery for PPI, 14 with mild SUI received a sling, while 39 (74%) more severe cases received an AUS. Patient-reported improvement was high overall in both groups (median 95%). Conclusion Most men with chronic PPI present for definitive treatment in a delayed manner after prostatectomy despite having severe incontinence. The SCT provides immediate, objective information about the severity of PPI which strongly correlates with patient-reported pads-per-day and may expedite anti-incontinence surgical procedure selection.

Effective treatment of neurogenic detrusor overactivity in multiple sclerosis patients using desmopressin and mirabegron.

Abstract: Introduction Multiple sclerosis (MS) is the commonest progressive neurological disease affecting young people. With advancing disease, management of neurogenic detrusor overactivity (NDO) based on antimuscarinics may prove inadequate and if based on botulinum toxin, may necessitate clean intermittent self-catheterization. The aim of the study was to evaluate the effectiveness of combined mirabegron and desmopressin administration in the treatment of NDO in patients with MS. Materials and methods Sixty patients diagnosed with MS and NDO were evaluated. All had received treatment with solifenacin 10 mg/daily for 3 months and were displeased with the results. Patients were divided in four groups. In Group A (n = 15) patients continued receiving solifenacin 10 mg/daily; in Group B (n = 15) patients received mirabegron 50 mg/daily; in Group C (n = 15) patients received desmopressin 120 mcg/daily and in Group D (n = 15) patients received mirabegron 50 mg/daily and desmopressin 120 mcg/daily. All patients were assessed with a 3 day bladder diary at the beginning and at the end of the treatment. Results All patients in Groups A, B and C did not demonstrate statistically significant changes at the end of the treatment period in their 3 day bladder diary and in the presence of urinary infections. In Group D, a statistically significant improvement was noted in the mean change from baseline to end of treatment in micturition episodes (3.5 +/- 0.4 micturition/24h), in urgency episodes (2.3 +/- 0.2) and mean number of urinary incontinence (1.0 +/- 0.2 episodes/24h). Conclusions Treatment with mirabegron and desmopressin revealed both effectiveness and safety in patients with NDO and MS.

Preoperative immunonutrition prior to radical cystectomy: a pilot study.

Abstract: Introduction To investigate the use of a high-arginine immunonutrient supplement prior to radical cystectomy for bladder cancer. Materials and methods We recruited 40 patients to consume a total of four high-arginine immunonutrient shakes per day for 5 days prior to radical cystectomy. The primary outcome measures were safety, tolerability and adherence to the supplementation regimen. Ninety-day postoperative outcomes were also compared between supplemented patients and a cohort of 104 prospectively identified non-supplemented radical cystectomy patients. Multivariable logistic regression models were used to compare overall complications, infectious complications, and readmission rates between groups. Results There were no serious adverse events during supplementation. Four patients (10%) stopped supplementation due to nausea (n = 2) and bloating (n = 2). Thirty-three patients (83%) consumed all prescribed shakes. Immunonutrient supplementation was not significantly associated with overall complications (adjusted odds ratio [OR] 1.08; 95% confidence interval [CI] 0.50-2.33), infectious complications (OR 1.23; 95% CI 0.49-3.07), or readmissions (OR 1.48; 95% CI 0.62-3.51) on multivariable analyses. Conclusions Preoperative supplementation with a high-arginine immunonutrient shake was safe and well tolerated prior to radical cystectomy. Contrary to prior reports, immunonutrient supplementation was not associated with lower postoperative infectious complications in this cohort, perhaps owing to the 5 day supplementation period. Further study is needed to identify the optimal immunonutrient supplement regimen for radical cystectomy patients.

Prostate cancer detection following diagnosis of atypical small acinar proliferation.

Abstract: Introduction To report the incidence and characteristics of cancer following a diagnosis of atypical small acinar proliferation (ASAP) and comment on current clinical practice recommendations. Materials and methods We reviewed patients that underwent prostate biopsy between 2008 and 2013 at a single institution. Men with ASAP without previous cancer were included. Clinicopathologic features including prostate-specific antigen (PSA), presence of ASAP or cancer, tumor volume, number of involved cores, and Gleason score were analyzed in men that received a repeat prostate biopsy. Results Of 1450 men, ASAP was found in 75 (5%) patients. Repeat biopsy was performed in 49 (65%) patients. Fifteen (31%) were diagnosed with cancer, 10 (20%) with ASAP, and 24 (49%) were benign. PSA, age, and number of cores with ASAP were not associated with cancer. Gleason 6 disease was diagnosed in 12 (80%) patients. Gleason ≥ 7 cancer was found in 3 patients, or 6% of all patients with a repeat biopsy. The average linear amount of tumor was 3.2 mm, and the average tumor volume was 14.2%. Conclusion In a contemporary prostate biopsy series, the incidence of ASAP was 5%. Among men with ASAP, incidence of cancer at repeat biopsy was 31%, with the overwhelming majority being low grade and low volume. Patients with ASAP may not require repeat biopsy within 6 months in the appropriate clinical context.

Adverse pathologic characteristics in the small renal mass: implications for active surveillance.

Abstract: INTRODUCTION Evidence has demonstrated that tumor size is related to adverse oncologic outcomes in small renal tumors (≤ 4 cm). We evaluated the association of adverse pathologic features (APF) with tumor size and survival in patients with a small renal mass (SRM). MATERIALS AND METHODS We retrospectively reviewed the pathologic characteristics of 380 surgically resected SRMs from a single institution. APFs included lymphovascular invasion, coagulative necrosis, sarcomatoid/rhabdoid features, papillary type II histology, and perinephric fat/renal sinus invasion. The number and type of APFs were compared with tumor size. Survival analysis was performed using the Kaplan-Meier method. RESULTS There were 244 (64.2%) males and 136 (35.8%) females. The median age was 61 years, and median tumor size was 2.7 cm. The median follow up time was 65 months. A significant association was found between tumor size and presence of APFs (p = 0.018). At least 1 APF could be found in 22%, 32%, 36%, and 49% of tumors ≤ 1 cm, 1 cm-2 cm, 2 cm-3 cm, and 3 cm-4 cm, respectively. There were no differences in overall survival or recurrence free survival when compared by tumor size at diagnosis (p = 0.22 and 0.15 respectively). Compared to patients with ≤ 1 APFs, disease specific survival was worse for patients with ≥ 2 APFs (p < 0.002). CONCLUSION Our data support that aggressive tumor biology in a SRM is associated with greater size. In patients with a SRM, the decision to pursue active surveillance and the trigger for intervention should take tumor size and APFs into consideration as this may have future oncologic implications.

MRI-targeted biopsy: is systematic biopsy obsolete?

Abstract: Introduction Although prostate cancer is the most common non-cutaneous cancer in men, it is traditionally diagnosed with a non-targeted, systematic transrectal ultrasound prostate biopsy (TRUS-Bx). This technique has been demonstrated to both under-detect clinically significant (CS) cancer and over-detect clinically insignificant cancer, and performs poorly in patients with a prior negative biopsy. With recent advances in MRI technology, most prominently the advent of multiparametric MRI, MRI-targeted prostate biopsy (MRI-TB) has been gaining favor as a more accurate alternative to TRUS-Bx. In this review, we attempt to summarize the current literature on MRI-TB and to determine if there is evidence supporting the use of MRI-TB alone. Materials and methods The literature was reviewed for articles pertaining to MRI-TB and its performance compared to systematic biopsy. Results Most studies support the increased sensitivity of MRI-TB (0.90, 95% CI 0.85-0.94) compared to TRUS-Bx (0.79, 95% CI 0.68-0.87) for the detection of CS prostate cancer, as MRI-TB can detect up to 30% more high risk and 17% fewer low risk cancers. MRI-TB also tends to perform better than TRUS-Bx in patients with prior negative biopsy, as TRUS-Bx may miss up to half of CS cancers detected by MRI-TB, and in those with lesions at atypical locations. However, as the technology for imaging and image-guided biopsies continues to develop, there is still a role for TRUS-Bx in the management of patients with prostate cancer. Conclusions Our analysis of the literature suggests that although MRI-TB is superior to TRUS-Bx, there is still a role for traditional systematic biopsy.

Sepsis after elective ureteroscopy.

Abstract: Introduction We sought to determine our rate of postoperative sepsis after ureteroscopy as well as identifying associative factors, common antibiotic practices along with culture data. Materials and methods Records of all patients who underwent elective ureteroscopy from 2010 to 2015 at an urban tertiary care facility were retrospectively reviewed. Factors thought to be associated with infection were collected, along with comorbidities depicted as Charlson Age-Adjusted Comorbidity Index (CAACI) and American Society of Anesthesia (ASA) score. Each patient's course was reviewed to determine if they were treated for postoperative sepsis as defined by standardized criteria. Results A total of 345 patients underwent elective ureteroscopy with 15 (4.3%) being treated for sepsis postoperatively. This resulted in an additional 5.33 ± 3.84 days of hospitalization per patient. The sepsis group grew three gram positive organisms and five multi-drug resistant (MDR) gram negatives while 7/15 (46.7%) had negative cultures. The most common preoperative antibiotics used in the sepsis group were cefazolin (60.0%), gentamicin (48.5%) and ciprofloxacin (20.0%). Univariate analysis showed prior endoscopic procedures, recent treatment for urinary tract infections (UTI), multiple comorbidities and longer operative times associated with sepsis. However, significant variables after multivariate analysis were treatment for UTI within the last month, (OR) 7.19 (2.25-22.99), p = 0.001. Conclusions Patients with multiple comorbidities, prior endoscopic procedures, longer operative times and especially those recently treated for a urinary infection should be carefully monitored after ureteroscopy for signs of sepsis. Perioperative antibiotics in these patients should be selected to cover both MDR organisms and gram positives.

Management of refractory idiopathic overactive bladder: intradetrusor injection of botulinum toxin type A versus posterior tibial nerve stimulation.

Abstract: Introduction To compare the safety and efficacy of posterior tibial nerve stimulation (PTNS) versus an intradetrusor injection of botulinum toxin type-A (BTX-A) 100 U in the management of refractory idiopathic overactive bladder (OAB). Materials and methods We randomized 60 patients with refractory idiopathic OAB to receive an intradetrusor injection of BTX-A 100 U or PTNS. We assessed the patients at baseline, 6 weeks, 3 months, 6 months, and 9 months, and determined their clinical symptoms, overall OAB symptom score, urgency score, quality-of-life score, and urodynamic study parameters. Results The two patient groups had similar baseline characteristics. After treatment, the patients in the BTX-A group had significant improvements in all parameters compared to their baseline values. Patients in the PTNS group initially had significant improvements in all parameters, but by 9 months, this was no longer true for most parameters. In general, the improvements were more significant in the BTX group, especially at 9 months. In the BTX-A group, two patients (6.6%) needed clean intermittent catheterization; 3 patients (2 women and 1 man; 10% of patients) had mild hematuria, and 2 patients (6.6%) had urinary tract infections (UTIs). In the PTNS group, local adverse effects included minor bleeding spots and temporary pain. Conclusions Intradetrusor injection of BTX-A and PTNS are both effective to manage refractory idiopathic OAB. BTX-A is more effective than PTNS and is also durable, minimally invasive, reversible, and safe, but it also has more side effects.

Robotic repair of vesicovaginal fistulas using fibrin sealant.

Abstract: INTRODUCTION Although infrequent, when encountered vesicovaginal fistulas (VVF) are a difficult condition for both patients and physicians alike. After the first robotic repair was described in 2005, this has been an increasingly common treatment modality. At our institution between 2009 and 2014, eleven of these patients were evaluated and treated with robotic repair. However, fibrin sealant was used in place of the traditional tissue flap. Included are six patients who had previously undergone operative repair. MATERIALS AND METHODS After IRB approval was obtained, a retrospective study was undertaken to identify patients with VVF. Inclusion criteria were operative repair utilizing a da Vinci robotic system; there were no exclusion criteria. A total of eleven patients were identified, and in each case, a robot assisted laparoscopic approach was utilized and Tisseel fibrin sealant was used in lieu of tissue interposition. RESULTS All patients underwent successful repair of their VVF without evidence of recurrence at a mean follow up of 15.6 months. CONCLUSIONS Robotic vesicovaginal fistula repair with fibrin sealant seems to be a safe and viable alternative to the traditional repair utilizing a tissue flap.

Analysis of preoperative antibiotic prophylaxis in stented, distal hypospadias repair.

Abstract: Introduction Surgical site infection [SSI] is a risk for any surgical procedure, including hypospadias repair. Prophylactic antibiotic therapy for patients having surgery is often effective in preventing SSIs, but with increasing rates of antibiotic resistance, this practice has been questioned. The objectives of this study are 1) to assess the incidence of SSIs in patients following stented, distal hypospadias repair and 2) to observe for any potential difference in the incidence of SSIs for patients with and without preoperative antibiotic utilization in this setting. Materials and methods We retrospectively reviewed consecutive patients treated with stented, distal hypospadias repair from 2011 to 2014 by three surgeons and compared two groups: patients who received preoperative antibiotics and patients who did not. Patients with a history of previous hypospadias repair were excluded from the study. Results Two hundred twenty-four subjects were identified. Group 1 (135) received preoperative antibiotic and Group 2 (89) did not receive preoperative antibiotics. There was no statistically significant difference in SSI prevalence with 0 patients in Group 1 and 1 patient in Group 2 having a SSI. Conclusion Although prophylactic antibiotics prior to hypospadias repair are most often used by pediatric urologists, this study demonstrates further evidence that antibiotics prior to this procedure do not appear to lower the rate of SSI. This study is limited by its retrospective nature and disparate mean follow up in the two cohorts. Surgical site infection does not appear to be decreased by prophylactic antibiotic therapy before distal hypospadias repair.

The need for androgen deprivation therapy in patients with intermediate-risk prostate cancer treated with dose-escalated external beam radiation therapy.

Abstract: INTRODUCTION To evaluate if androgen deprivation therapy (ADT) improves outcomes for patients with localized, intermediate-risk prostate cancer treated with definitive external beam radiation therapy (EBRT) in the dose-escalated era. MATERIALS AND METHODS This is a retrospective study using a single institutional database. We included patients with localized, intermediate-risk prostate cancer treated with dose-escalated radiation therapy (RT) with 3D conformal radiotherapy or intensity-modulated radiotherapy (74-80 Gy in daily fraction of 1.8 Gy-2.0 Gy, or 70.2 Gy in daily fraction of 2.7 Gy) from 1992 to 2013. To further risk stratify the patients, PSA 10 ng/mL-20 ng/mL, Gleason 3+4, and T2b-T2c were assigned risk score (RS) of 1, while Gleason 4+3 was assigned RS of 2. Patients with prior treatment for prostate cancer, those on long term ADT (>= 23 months), or those with follow up = 2, there were still no significant differences in FFBF, FFDM, or OS when patients treated with ADT were compared to those treated with radiation alone. In multivariable analyses adjusting for RS and age, the adjusted hazard ratio for ADT use was sHR = 0.89 (95% CI = 0.64-1.66, p = 0.64) for BCF; sHR = 1.13 (95% CI = 0.48-2.65, p = 0.77) for DM. For overall mortality, adjusted HR = 1.23 (95% CI = 0.76-2.01, p = 0.40) where comorbidities (including diabetes, cardiac disease, and hypertension) were also included as covariates. CONCLUSION Our study suggested that treatment of intermediate-risk prostate cancer with definitive dose-escalated EBRT alone resulted in acceptable outcomes, and it failed to show improved outcomes in patients who received short term ADT.

State of the art: Advanced techniques for prostatic urethral lift for the relief of prostate obstruction under local anesthesia.

Abstract: Benign prostatic hypertrophy (BPH) affects an estimated 60% of men over the age of 50 and 90% of men over the age of 80. The prostatic urethral lift (PUL) is a safe and effective office-based procedure that is used worldwide for the treatment of BPH in men who are dissatisfied with medications due to side effects or lack of efficacy or don't want to have a transurethral resection of the prostate due to the side effects and invasiveness of the procedure. In 2012 Barkin et al, published the standard technique for the delivery of the Urolift implant. The objective of this article is to describe the current state of the art advanced techniques for the delivery of the UroLift implant.

Transobturator sling for post-prostatectomy incontinence: radiation's effect on efficacy/satisfaction.

Abstract: INTRODUCTION We review our experience with the AdVance sling in patients with post- prostatectomy incontinence, comparing the role that adjuvant radiation therapy plays in sling success and patient satisfaction at short and long term follow ups. MATERIALS AND METHODS Men who underwent AdVance sling placement for post-prostatectomy incontinence from 2007 to present were identified using Current Procedural Terminology (CPT) codes. Manual chart review was performed. Level of incontinence was assessed using Expanded Prostate Cancer Index Composite (EPIC) and pads per day (PPD) use. Satisfaction was assessed by willingness to recommend the procedure to a friend. Outcomes in men who received radiation were compared to radiation-naive men. RESULTS Fifty-two men underwent AdVance sling placement. Eighteen men received adjuvant radiation. Thirty-six men were available for short term (19.4 months) and 16 men for long term (61.5 months) follow up. Overall, significant improvement was seen in post-sling EPIC score (24.6, p < 0.001), EPIC incontinence score (39.1, p < .001), and pad use (3.2 PPD to 1.4 PPD, p < .001). Greater improvement in EPIC scores and PPD use was seen in radiation-free men. Irradiated men were less satisfied with the procedure at both short and long term follow up. Diminished efficacy and satisfaction occurred at extended follow up for both groups but was more pronounced with radiation. CONCLUSIONS The majority of patients undergoing the AdVance sling procedure for post-prostatectomy urinary incontinence saw a significant reduction in pad use, and were overall satisfied in both radiated and non-radiated groups at short and long term follow up. However, improvements were greater in the non-radiated groups and diminished with time.

Endoscopic placement of double-J ureteric stents in children as a treatment for primary hydronephrosis.

Abstract: INTRODUCTION The aim of this study was to determine the efficacy and potential complications of double-J ureteric stents in the treatment of primary hydronephrosis in pediatric patients. MATERIALS AND METHODS A retrospective case-records review of 133 patients (45 girls and 88 boys) treated because of primary hydronephrosis with double-J ureteric stents, in Department of Pediatric Surgery, Split University Hospital, between December 1997 and December 2014, was performed. Success of treatment, results of follow up investigations and complications were recorded. Patients were followed up clinically and radiologically for a minimum of 2 years following stent insertion. RESULTS In all, 133 endoscopic double-J ureteric stents insertions were performed. Of the total number of patients, left-sided hydronephrosis was found in 82 patients, right-sided in 38, and bilateral in 13 patients. The median age of children was 2 years (range 0-17 years). Mean hospital stay was 2 days (range 1-10 days). In primary hydronephrosis, double-J ureteric stenting alone was effective with resolution of hydronephrosis in 73% of cases (97/133 insertions). Regarding the age of the patients the highest success of 83.5% was achieved in age group 0-4 years. Success in groups 5-9 years; 10-14 years and 15-17 years were 47%; 33.5% and 0%, respectively. Several complications have been recorded: symptomatic infections, migration in the renal pelvis and bladder, progression of hydronephrosis, spontaneously prolapse of prosthesis, bleeding and perforation of the renal pelvis. A significant, decreasing trend in success rates by age of participants was observed (p < 0.001). CONCLUSIONS Ureteric stenting is minimally invasive procedure that provides an alternative to open surgery in patients with primary hydronephrosis. Endoscopic placement of ureteric double-J stents should be considered as a first-line treatment in the management of primary hydronephrosis especially in children till 4 years of age, with success rate of 83.5% and without the need for conventional surgery. In a case of failure we are time-consuming to definitive surgery.

Over half of contemporary clinical Gleason 8 on prostate biopsy are downgraded at radical prostatectomy.

Abstract: INTRODUCTION Contemporary clinical guidelines utilize the highest Gleason sum (HGS) in any one core on prostate biopsy to determine prostate cancer treatment. Here, we present a large discrepancy between prostate cancer risk stratified as high risk on biopsy and their pathology after radical prostatectomy. MATERIALS AND METHODS We retrospectively reviewed 1424 men who underwent either open or robotic-assisted prostatectomy between 2004 and 2015. We analyzed 148 men who were diagnosed with HGS 8 on prostate biopsy. Biopsy and prostatectomy pathology were compared in aggregate and over 1 year time intervals. Chi-squared test, Fisher's exact test, Student's t-test, and Wilcoxon Rank-Sum test were used for statistical analysis. RESULTS A total of 61.5% (91/148) of clinical HGS 8 diagnoses were downgraded on prostatectomy, with 58.8% (87/148) downgraded to Gleason 7 (Gleason 4 + 3 n = 59; Gleason 3 + 4 n = 28). Factors associated with downgrading include lower prostate-specific antigen (PSA) at biopsy (median 6.8 ng/mL versus 9.1 ng/mL, p < 0.001), number of Gleason 8 biopsy cores (median 1 versus 2, p < 0.02), presence of Gleason pattern 3 on biopsy cores (67.9% versus 44.8%, p < 0.03), pT2 staging (72.4% versus 55.1%, p < 0.04), positive margins (53.9% versus 69.1%, p < 0.04), extracapsular extension (53.4% versus 74.1%, p < 0.02), and smaller percent tumor (median 10% versus 15%, p < 0.004). CONCLUSION The large percentage of pathology downgrading of biopsy-diagnosed HGS 8 suggests suboptimal risk-stratification that may lead to suboptimal treatment strategies and much patient distress. Our study adds great urgency to the efforts refining prostate cancer clinical assessment.

Biologic and epidemiologic evidence assessing if statins prevent prostate cancer.

Abstract: INTRODUCTION During their lives, 1 in 8 men will be diagnosed with prostate cancer. Several drugs have been shown to decrease prostate cancer risk, but have not been widely used in prostate cancer prevention because of concerns about side-effects and cost-effectiveness. Statins are indicated for prevention of cardiovascular disease, have an excellent benefit to risk profile, and some studies suggest that statins may reduce the risk of prostate cancer. MATERIALS AND METHODS We performed a systematic search of Medline (Ovid), EMBASE (Ovid), and PubMed. This search informed a narrative review of the biological rationale for why statins may reduce prostate cancer risk and an evaluation of the existing epidemiological evidence to determine whether further studies are needed to assess the true impact of statins on prostate cancer risk. RESULTS Statins may help prevent the development of prostate cancer through inhibition of sustained proliferative signals (androgen and Ras/Rho), sensitizing potentially malignant cells to programmed cell death, minimizing inflammation, reducing angiogenesis, and impeding invasiveness by blocking adhesion molecules. The epidemiologic literature examining the effect of statin use on overall prostate cancer diagnosis is highly heterogeneous, with relative risks of 0.26 to 2.94. Out of 33 published studies, 5 show an increased risk of prostate cancer with statin use, 10 demonstrate a decreased risk, and 18 suggest no effect. CONCLUSION There is a compelling pre-clinical rationale for statins as potential chemopreventive agents. However, large, population-based studies with long pre-diagnosis drug exposure data are needed to investigate the impact of statin exposure on prostate cancer incidence.

Spontaneous passage of ureteral stones in patients with indwelling ureteral stents.

Abstract: INTRODUCTION To determine rates of spontaneous ureteral stone passage in patients with indwelling ureteral stents, and to identify factors associated with the spontaneous passage of stones while a ureteral stent is in place. MATERIALS AND METHODS From our institutional database, we identified patients who underwent ureteroscopic procedures for stone disease between January 1, 2013 and March 1, 2015. We compared the rates of spontaneous stone passage between patients who had previously undergone ureteral stent placement and those who had not. In patients with indwelling stents, multivariate logistic regression was performed to identify factors associated with spontaneous stone passage. RESULTS A total of 194 patients met inclusion criteria. Spontaneous stone passage rates were similar in the stented (17/119, 14%) and non-stented (15/75, 20%) groups (p = 0.30). In bivariate analysis of stented patients, smaller stone size (p < 0.001) and distal stone location (p = 0.01) were significantly associated with spontaneous stone passage. Multivariate logistic regression analysis of stented patients showed that only small stone size was significantly associated with the likelihood of stone passage (p = 0.01), whereas stent duration, stone location, and stone laterality were not. CONCLUSIONS A small, but clinically significant percentage of ureteral stones pass spontaneously with a ureteral stent in place. Small stone size is associated with an increased likelihood of spontaneous passage in patients with indwelling stents. These findings may help to identify patients who can potentially avoid additional surgical procedures for definitive stone removal after ureteral stent placement.

Preoperative symptoms predict continence after post-radiation transurethral resection of prostate.

Abstract: Introduction Lower urinary tract symptoms and retention are known complications of radiation for prostate cancer and traditionally transurethral resection of the prostate (TURP) has been avoided in these patients because of the risk of incontinence. The purpose of this study was to evaluate the incidence and predictors of post-TURP incontinence in previously radiated patients. Materials and methods One-hundred and eleven patients who underwent brachytherapy or external beam radiotherapy for prostate cancer with subsequent TURP performed between 1992 and 2012 at a single institution were identified. We tested for associations between post-TURP continence status and pre-TURP predictors including age, preoperative urinary symptoms and type and timing of radiation therapy. Results New-onset incontinence developed in 27% (95% CI 17%, 39%) of patients after first post-radiation TURP and 32% (95% CI 23%, 42%) of patients after any TURP, including repeat TURPs. Forty-three percent of patients had resolution of incontinence with first TURP (95% CI 25%, 63%); only 25% (95% CI 7%, 52%) of patients had resolution following repeat TURPs. Age was significantly associated with incontinence (OR per 10 years 2.02, 95% CI 1.10, 3.74, p = 0.024). Post-TURP incontinence was more common in men with pre-TURP urgency. Conclusions Rates of post-TURP incontinence were higher in men who were older or had pre-TURP urinary urgency. Assessment of preoperative symptoms would allow for better patient selection. Further research should determine whether this results in better outcomes, including decreased incidence of new onset incontinence and increase in resolution of incontinence.

Postwash total motile sperm count: should it be included as a standard male infertility work up.

Abstract: Introduction Pregnancy rates after intrauterine insemination (IUI) varies greatly. We aimed to identify pre and post processing semen analysis parameters that may be predictive of successful pregnancy in couples undergoing IUI. Materials and methods A retrospective study of the records of all couples underwent IUI for a 2 year period at our infertility center. Different characteristics of female subjects, pre and post processing semen parameters and treatment parameters were compared statistically. Results Thirty-two clinical pregnancies followed 526 IUI cycles in 294 couples, for a clinical pregnancy rate of 6.1% per cycle and a 10.9% per couple. The mean age of the women at IUI was 31.14 ± 6 years (range 19-45 years). Neither maternal age, body mass index, number of mature follicles, maximum day 3 follicle stimulating hormone level, presence or absence of previous children, number of previous miscarriages, nor prewash semen parameters had any impact on pregnancy rate post IUI. Postwash total motile sperm count (TMSC) (p = .027) and number of cycles (p = .042) were independent predictors of successful pregnancy after IUI. Conclusions A postwash TMSC of 5 million sperm or more is significantly associated with a high pregnancy rate. After ruling out medically or surgically correctable male factors that may contribute to infertility, we recommend including a pretreatment sperm processing during routine male fertility work up for proper patient counseling and direction to the suitable assisted reproduction technique.

Improving the quality of operative reports for transurethral resection of bladder tumor surgery in resident education.

Abstract: INTRODUCTION To assess the quality of resident dictations for transurethral resection of bladder tumor (TURBT). One indicator of surgical quality is the completeness of the operative report. Surprisingly, there is a paucity of standardized operative templates for TURBT and little formalized instruction for learners. The quality of TURBT dictations was assessed and areas of improvement were determined after implementation of a 10 item TURBT checklist. MATERIALS AND METHODS A retrospective review of the last 50 TURBT operative reports dictated by residents was performed. A 'TURBT checklist' was used assessing 10 key factors in documentation. A formal training session regarding TURBT dictations was given with TURBT checklists handed out to each trainee. Fifty TURBT dictations were subsequently analyzed. RESULTS TURBT dictations improved across the board following checklist implementation. Total number of checklist items dictated increased to 7.0 from 2.6 prior (p < 0.05). When stratified by resident experience, TURBT dictations improved across different resident years (p < 0.05). Junior resident dictations statistically improved in every checklist item (p < 0.05). Senior resident dictations improved in almost every category but only two reached statistical significance. A regression model demonstrated checklist implantation to be a significant predictor of improvement in mean number of checklist items dictated independent of PGY level. CONCLUSIONS Our study demonstrates that prior to implementation, TURBT operative dictations performed by residents lacked many of the critical components required for a quality TURBT. However, once properly instructed, a relatively simple 'checklist' can be easily implemented and serve as a teaching tool for residents in training to ensure critical procedural elements are documented.