The Journal of Urology

This Month in Adult Urology

William D. Steers — 2011-12-19

It has long been recognized that the anogenital distance correlates with androgen levels in male animals. Eisenberg et al (page 594) from Texas and Denmark measured the anogenital distance, penile length and testis in 116 men, and concluded that anogenital distance was associated with serum testosterone levels while testis size was not. No relationship was identified between genital length and luteinizing hormone, follicle-stimulating hormone or estradiol. The authors noted that serum testosterone increased 20 ng/dl for each cm increase in anogenital distance. On multivariate analysis no relationship existed between penile length and testosterone levels. The authors conclude that this may be an interesting surrogate for estimating androgen levels.

This Month in Pediatric Urology

Michael L. Ritchey — 2011-12-19

Boys with unilateral nonpalpable gonads are equally likely to have an abdominal undescended testis or an absent testis. In the latter setting the “vanishing” testis is usually presumed to be the result of prenatal torsion. Although there is a known potential risk of subfertility in boys with undescended testes, the risk for boys with a solitary testis due to prenatal torsion is unknown. Kraft et al (page 676) from Philadelphia, Pennsylvania performed biopsy of the solitary descended testis in 239 children at the time of orchiopexy (group 1). They compared this group to an age matched cohort of boys who had undergone bilateral testicular biopsy at the time of orchiopexy for a unilateral undescended testis (group 2). Analysis of the 2 groups revealed the mean testicular volume to be significantly greater in group 1 (1.56 ± 0.73 ml) than in group 2 (1.01 ± 0.89 ml, t = 7.35, p <0.001) as well as the mean total germ cell count (2.43 ± 2.06 GC/T) vs (1.91 ± 1.70 GC/T, t = 2.95, p = 0.002). These findings suggest an absence of endocrinopathy in this group of patients. Although further followup is needed, these results suggest that fertility will be normal in these patients.

This Month in Investigative Urology

Karl-Erik Andersson — 2011-12-19

Nitric oxide (NO) is the major neuronal mediator of penile erection but its role in erectile function status after cavernous nerve injury is uncertain. Sezen et al (page 757) from Baltimore, Maryland determined the function of neuronal NO signaling in the recovery of erectile function after partial cavernous injury in mice using genetic and pharmacological approaches. The investigators evaluated erectile function in wild-type (WT) and neuronal NO synthase-α knockout mice 1, 3 and 7 days after unilateral crush or sham injury, at day 7 in WT mice treated with the NO synthase inhibitor L-NAME (l-nitro arginine methyl ester) at baseline and for 6 days after unilateral crush injury. Apoptosis in the penis was evaluated by Western blot analysis of p-Akt-S473, 3-nitrotyrosine and caspase-3 after bilateral crush injury.

Being Wrong

William D. Steers — 2011-12-15

“It infuriates me to be wrong when I know I'm right” —Moliere “… computers will never be intelligent unless they are allowed to make mistakes. The human mind is not deterministic, it is not flawless.” —Alan Turing

Using Gene Polymorphisms to Assess Bladder Cancer Risk: Progress and Challenges

Anne E. Kiltie — 2011-12-15

As of October 31, 2011, a MEDLINE® search of “gene polymorphisms AND bladder cancer risk” yielded 414 publications, all published since 1987. The majority of these papers describe polymorphisms in genes that code various enzymes responsible for metabolism of carcinogens and more recently in DNA repair genes.

Interstitial Cystitis—Is it Time to Look Beyond the Bladder?

Kenneth M. Peters — 2011-12-15

Interstitial cystitis (IC) was first described more than 95 years ago as a distinct ulcer seen in the bladder on cystoscopy (ulcerative IC). This was truly a bladder disease that was associated with inflammatory infiltrates on biopsy, and resulted in severe urinary urgency, frequency and pelvic pain. Since that time the definition was expanded to include symptoms of urinary urgency, frequency and pelvic pain without the need for cystoscopic findings. A driving force for this expanded definition came from the pharmaceutical industry. Clinicians were told that for their patients complaining of pelvic pain and urinary symptoms they only had to administer a questionnaire and perhaps instill potassium in the bladder to confirm a diagnosis of IC. This process resulted in millions of patients being labeled as having IC and a dramatic increase in the sale of pentosan polysulfate, the only Food and Drug Administration approved oral treatment for IC. The risk of simplifying the diagnosis of IC is that of missing other conditions that may mimic these symptoms, such as bladder cancer. Years of well controlled clinical trials on bladder directed therapy for IC have failed to demonstrate improvement in symptoms compared to placebo. Thus, changes in terminology have been proposed to reflect that this may be a syndrome. These include painful bladder syndrome (PBS) and bladder pain syndrome (BPS), and both of these definitions require that we rule out other identifiable causes of urinary and pain symptoms.

Predicting Treatment Outcomes of Nocturnal Enuresis—Is it Possible?

Piet Hoebeke, Johan Vande Walle — 2011-12-15

Monosymptomatic nocturnal enuresis is one of the most common nocturnal problems in children with an estimated prevalence of approximately 10% among 7-year-olds. Before the 1980s it was considered a benign condition with a chance of spontaneous cure of 15% per year. Insights into the pathophysiology were limited and no research was done. Treatment was mainly based on behavioral methods, wetting alarms and imipramine.

Vasectomy Reversal: Indications and Outcomes

Robert E. Brannigan — 2011-12-15

Approximately 6% of men who have had a vasectomy subsequently decide to pursue a pregnancy and undergo a vasectomy reversal. Before 1992 vasectomy reversal was the only option for these patients. However, with the first report of successful clinical pregnancies and live births with in vitro fertilization (IVF) with intracytoplasmic sperm injection in 1992 by Palermo et al, couples' options expanded dramatically. These advances in assisted reproductive techniques have remarkably broadened couples' reproductive opportunities after vasectomy. However, with these increased options comes the challenge for each couple to determine which pathway is best for them: vasectomy reversal or sperm extraction with IVF?

A Nonischemic Approach to Partial Nephrectomy is Optimal

Monish Aron, Inderbir S. Gill, Steven C. Campbell — 2011-12-15

Intuitive and logical, the fact that kidney quantity and quality fundamentally drive ultimate function after partial nephrectomy (PN) has long been recognized. The practical issue at debate is whether it is worthwhile to attempt to minimize renal ischemia.

Systematic Review of Urological Followup After Spinal Cord Injury

Anne P. Cameron, Gianna M. Rodriguez, Katherine G. Schomer — 2011-12-15

Purpose: There is no consensus on the appropriate urological followup of individuals after spinal cord injury but it is well known that they are at risk for renal deterioration, bladder cancer and stones. We systematically reviewed the literature to evaluate evidence of urological screening in this population. Materials and Methods: We reviewed 385 abstracts, of which 50 met study inclusion criteria. We rated evidence using American Academy of Neurology 2004 guidelines. Results: A total of 12 articles evaluated urinary tract infection screening. Patient reported symptoms used to predict urinary tract infection yielded mixed results and urine dipstick testing had the same accuracy as microscopy. Routine urine culture was unnecessary in healthy, asymptomatic individuals with normal urinalysis. Urodynamics probably must be done periodically (6 articles) but there was no information on frequency. In 11 articles ultrasound was recommended as a useful, noninvasive and possibly cost-effective screening method. Renal scan was a good method for further testing, especially if ultrasound was positive (11 articles). Evidence was sufficient (11 articles) to recommend ultrasound of the urinary tract to detect urinary tract stones with good sensitivity but not plain x-ray of the kidneys, ureters and bladder (2 articles). There was insufficient evidence to recommend urine markers or cytology for bladder cancer screening (9 articles). Conclusions: Based on this review no definitive recommendations for screening can be made except routine renal ultrasound. Urodynamics are an important part of screening but the frequency is unclear. The optimum bladder cancer screening method has not been defined.

Do We Continue to Unnecessarily Perform Ipsilateral Adrenalectomy at the Time of Radical Nephrectomy? A Population Based Study

2011-12-15

Purpose: Since the mid 1990s evidence has supported ipsilateral adrenal gland sparing radical nephrectomy unless the gland appears involved on imaging or the primary tumor is large and located in the upper pole. However, it is unclear whether this shift in surgical practice has been adopted at the population level. Materials and Methods: Using the Ontario Cancer Registry we identified 5,135 patients in the province of Ontario who underwent radical nephrectomy between 1995 and 2004. Ipsilateral adrenalectomy and tumor involvement of the adrenal gland were ascertained from pathology reports. Further variables analyzed included age, gender, pathology, surgeon year of graduation, academic status of hospital/surgeon, hospital and surgeon volume, and year of surgery. We used multivariable logistic regression to assess outcomes. Results: The overall rate of adrenal gland involvement with cancer was 1.4%. The adrenal was involved in 3.2% of tumors larger than 7 cm vs only 0.89% of tumors 4 to 7 cm and 0.63% of tumors smaller than 4 cm. Factors predictive of adrenal involvement on multivariable analysis were tumor size greater than 7 cm and fat invasion. The overall adrenalectomy rate was 40.1%, which decreased slightly over time (40.6% in 1995 vs 34.8% in 2004). Variables predictive of adrenal removal on multivariable analysis included tumor size greater than 7 cm, presence of venous thrombus, upper pole location, higher hospital volume, and academic status of hospital or surgeon. Conclusions: Despite evidence to support preservation of the ipsilateral adrenal gland during radical nephrectomy, the rate of adrenalectomy decreased only slightly in 10 years. Adrenalectomy remains overused in populations that are unlikely to benefit from the procedure.

Hospital Volume is a Determinant of Postoperative Complications, Blood Transfusion and Length of Stay After Radical or Partial Nephrectomy

2011-12-15

Purpose: We examined the impact of hospital volume on short-term outcomes after nephrectomy for nonmetastatic renal cell carcinoma. Materials and Methods: Using the Nationwide Inpatient Sample we identified 48,172 patients with nonmetastatic renal cell carcinoma treated with nephrectomy (1998 to 2007). Postoperative complications, blood transfusions, prolonged length of stay and in-hospital mortality were examined. Stratification was performed according to teaching status, nephrectomy type (partial vs radical nephrectomy) and surgical approach (open vs laparoscopic). Multivariable logistic regression models were fitted. Results: Patients treated at high volume centers were younger and healthier at nephrectomy. High hospital volume predicted lower blood transfusion rates (8.5% vs 9.7% vs 11.8%), postoperative complications (14.4% vs 16.6% vs 17.2%) and shorter length of stay (43.1% vs 49.8% vs 54.0%, all p <0.001). In multivariable analyses stratified according to teaching status, nephrectomy type and surgical approach, high hospital volume was an independent predictor of lower rates of postoperative complications (OR 0.73–0.88), blood transfusions (OR 0.71–0.78) and prolonged length of stay (OR 0.76–0.89, all p <0.001). Exceptions were postoperative complications at nonteaching centers (OR 0.94, p >0.05) and blood transfusions in nephrectomies performed laparoscopically (OR 0.68, p >0.05). Conclusions: On average, high hospital volume results in more favorable outcomes during hospitalization after nephrectomy.

Followup of Neutrophil-to-Lymphocyte Ratio and Recurrence of Clear Cell Renal Cell Carcinoma

2011-12-15

Purpose: An increase in the pretreatment neutrophil-to-lymphocyte ratio is associated with poor prognosis for various cancers, including renal cell carcinoma. However, the clinical implication of a posttreatment change in the neutrophil-to-lymphocyte ratio in patients with cancer remains unclear. Materials and Methods: We reviewed the records of 250 patients with nonmetastatic clear cell renal cell carcinoma and analyzed associations among clinicopathological variables, the preoperative and postoperative neutrophil-to-lymphocyte ratio, and recurrence-free survival. Results: The 10-year recurrence-free survival rate for patients with a preoperative neutrophil-to-lymphocyte ratio of 2.7 or greater was significantly lower than that for those with a ratio of less than 2.7 (64.4% vs 83.7%, p = 0.0004). When combined with the postoperative ratio, patients with a preoperative ratio of 2.7 or greater could be further divided into 2 groups with a significantly different prognosis. The 10-year recurrence-free survival rate for patients with a preoperative neutrophil-to-lymphocyte ratio of 2.7 or greater and postoperative ratio of less than 2.7 was significantly lower than that for those with a preoperative and postoperative ratio of 2.7 or greater (52.0% vs 83.5%, p = 0.0487). The latter was similar to the 83.7% for patients with a preoperative ratio of less than 2.7. In patients with recurrence the ratio at recurrence was significantly increased compared with the postoperative ratio (mean ± SD 2.82 ± 1.63 vs 2.00 ± 0.90, p = 0.0090). Multivariate analysis showed that tumor size, pathological tumor stage and the neutrophil-to-lymphocyte ratio change (a combination of the preoperative and postoperative ratios) were independent predictors of recurrence. Using these 3 significant variables patients were stratified into low, intermediate and high risk groups, among which the recurrence-free survival rate significantly differed. Conclusions: The posttreatment neutrophil-to-lymphocyte ratio change was a significant prognostic factor for recurrence as well as tumor size and pathological tumor stage in patients with clear cell renal cell carcinoma.

Prognostic Value of Microvascular Invasion in Predicting the Cancer Specific Survival and Risk of Metastatic Disease in Renal Cell Carcinoma: A Multicenter Investigation

2011-12-15

Purpose: While microvascular invasion is an accepted risk factor in various cancers, its prognostic role in renal cell carcinoma is still unclear. Therefore, a large multicenter study examining the experience of 5 international institutions was performed to evaluate the prognostic value of microvascular invasion in the occurrence of metastases and cancer specific survival. Materials and Methods: A total of 2,596 patients (475 with microvascular invasion and 2,121 without microvascular invasion) having up to 212 (median 22.4) months of followup were compared for differences in clinicopathological features, occurrence of metastases and cancer specific survival. Results: Patients with microvascular invasion presented with higher age (p = 0.001) and a worse Eastern Cooperative Oncology Group performance status (p <0.0001). Microvascular invasion was associated with larger tumor diameter (p <0.0001), higher Fuhrman grade (p <0.0001), more advanced pT stage (p <0.0001), and the presence of lymph node and distant metastases (p <0.0001). In particular, in nonmetastatic cases worse survival was associated with microvascular invasion (p <0.0001, HR 2.38). Univariate analysis demonstrated a strong correlation between microvascular invasion and cancer specific survival (p <0.0001). However, after controlling for gender, Eastern Cooperative Oncology Group performance status, Fuhrman grade and TNM stage statistical significance was lost. Of interest, low stage tumors with microvascular invasion were strongly correlated with the occurrence of metastases (p <0.0001). Conclusions: Microvascular invasion occurs in nearly 1 of 5 patients with renal cell carcinoma, is tightly correlated with adverse clinicopathological features and is an independent predictor of metastatic spread including in those presenting with low stage tumors.

Genetic Variability in 8q24 Confers Susceptibility to Urothelial Carcinoma of the Upper Urinary Tract and is Linked With Patterns of Disease Aggressiveness at Diagnosis

2011-12-15

Purpose: Upper urinary tract urothelial carcinoma is rare. Evidence shows that it behaves differently from urothelial bladder tumors. A polymorphism located at the T allele of rs9642880 on chromosome 8q24 is linked to an enhanced risk of bladder tumors. We explored the association of this polymorphism with susceptibility to upper urinary tract urothelial carcinoma. Materials and Methods: We genotyped the constitutional DNA of 261 patients with upper urinary tract urothelial carcinoma and 261 healthy controls matched for age, gender, smoking habit and ethnicity. Polymorphisms at rs9642880 on chromosome 8q24 were determined using the 5′ nuclease polymerase chain reaction method with specific primers and probes. Frequencies were compared between cases and controls. Genotypes were in Hardy-Weinberg equilibrium for cases and controls. Results: Mean patient age was 68.7 years. The T/T genotype resulted in a significantly higher risk of upper urinary tract urothelial carcinoma (OR 1.72, 95% CI 1.1–2.8, p = 0.028). Using single polytomous regression analysis the T/T genotype was also associated with aggressive tumors when stratified by stage (p = 0.003), or grade G2 (p = 0.04) or G3 (p = 0.01). Conclusions: Our results strongly suggest that the T/T rs9642880 genotype is a risk factor for upper urinary tract urothelial carcinoma, as previously shown for bladder tumors. In contrast to bladder carcinoma, for upper urinary tract urothelial carcinoma the T/T genotype is associated with aggressiveness.

Renal Function and Oncologic Outcomes of Parenchymal Sparing Ureteral Resection Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

2011-12-15

Purpose: We compared renal function and oncologic outcomes of parenchymal sparing ureteral resection with radical nephroureterectomy for the treatment of upper tract urothelial carcinoma confined to the ureter. Materials and Methods: Review of a large institutional database identified 367 patients treated for primary upper tract urothelial carcinoma with radical nephroureterectomy or parenchymal sparing ureteral resection from 1994 to 2009. Patients with known renal pelvis tumors, muscle invasive urothelial carcinoma, prior cystectomy, contralateral upper tract urothelial carcinoma, metastatic disease or chemotherapy were excluded, leaving 120 patients for analysis. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Recurrence-free, cancer specific and overall survival were estimated using Kaplan-Meier analysis. Results: Radical nephroureterectomy was performed in 87 patients and parenchymal sparing ureteral resection in 33. Median age at surgery was 73 years in the radical nephroureterectomy group (IQR 64–76) vs 70 years (IQR 59–77) in the parenchymal sparing ureteral resection group (p = 0.5). The radical nephroureterectomy and parenchymal sparing ureteral resection cohorts had several disparate clinicopathological variables including preoperative hydronephrosis (80% vs 45%, p = 0.0006), stage (pT3 or greater 26% vs 9%, p = 0.01) and baseline estimated glomerular filtration rate (51 vs 63 ml/minute/1.73 m2, p = 0.009). Patients who underwent radical nephroureterectomy experienced a significantly greater decrease in estimated glomerular filtration rate after surgery (median −7 vs 0 ml/minute/1.73 m2, p <0.001). Median followup was 4.2 years. Of the patients 79 experienced cancer recurrence and 44 died (28 of upper tract urothelial carcinoma). There were no obvious differences in the rates of recurrence, cancer specific death or overall death by procedure type. However, due to the limited number of events we cannot exclude the possibility that there are large differences in oncologic outcomes by procedure type. Conclusions: Parenchymal sparing ureteral resection is associated with superior postoperative renal function. However, the impact on cancer control cannot be determined conclusively due to the small sample size and putative selection bias.

Intravesical Bacillus Calmette-Guérin Outcomes in Patients With Bladder Cancer and Asymptomatic Bacteriuria

Harry W. Herr — 2011-12-15

Purpose: The outcome of intravesical bacillus Calmette-Guérin therapy was studied in patients with asymptomatic bacteriuria. Materials and Methods: A total of 243 patients with high risk, nonmuscle invasive bladder cancer received induction intravesical bacillus Calmette-Guérin therapy. Before starting bacillus Calmette-Guérin they submitted voided urine samples for culture and were treated with bacillus Calmette-Guérin regardless of culture results without antibiotics. Patients were followed every 3 months for tumor recurrence or progression up to 2 years. Results: Of the 243 patients 61 (25%) had significant bacteriuria (greater than 104 or greater than 105 cfu/ml single organism). Febrile urinary tract infection developed in 1 patient (1.6%) and 2 overall (0.8%) after completing induction bacillus Calmette-Guérin therapy. No patients were admitted to the hospital for bacillus Calmette-Guérin or bacterial sepsis. The 2-year recurrence-free survival rate was 71% vs 73% in uninfected patients (p = 0.73). Conclusions: These data suggest that intravesical bacillus Calmette-Guérin is safe in patients who have asymptomatic bacteriuria and the 2-year disease-free intervals are similar to those of uninfected patients. Such strategy facilitates the timely administration of bacillus Calmette-Guérin therapy and avoids the overuse of antibiotics.

Anti-Angiogenic Effects of the Superantigen Staphylococcal Enterotoxin B and Bacillus Calmette-Guérin Immunotherapy for Nonmuscle Invasive Bladder Cancer

2011-12-15

Purpose: We compared and characterized the effects of intravesical bacillus Calmette-Guérin and/or staphylococcal enterotoxin B for nonmuscle invasive bladder cancer. Materials and Methods: A total of 75 female Fisher 344 rats were anesthetized. Of the rats 15 received 0.3 ml saline (control) and 60 received 1.5 mg/kg MNU (N-methyl-n-nitrosourea) intravesically every other week for 6 weeks. The rats were divided into 5 groups. The MNU and control groups received 0.3 ml saline. The bacillus Calmette-Guérin group received 106 cfu bacillus Calmette-Guérin. The staphylococcal enterotoxin B group received 10 μg/ml staphylococcal enterotoxin B. The bacillus Calmette-Guérin plus staphylococcal enterotoxin B group received the 2 treatments simultaneously. Each group was treated intravesically for 6 weeks. At 15 weeks all bladders were collected for histopathological and immunological evaluation, and Western blot. Results: Papillary carcinoma (pTa) and high grade intraepithelial neoplasia (carcinoma in situ) were more common in the MNU group. Papillary hyperplasia was more common in the bacillus Calmette-Guérin and enterotoxin groups. Flat hyperplasia was more common in the bacillus Calmette-Guérin plus enterotoxin group. No significant toxicity was observed. The apoptosis and cellular proliferation indexes decreased in the bacillus Calmette-Guérin, enterotoxin and bacillus Calmette-Guérin plus enterotoxin groups compared to the MNU group. Intensified vascular endothelial growth factor, matrix metalloproteinase-9, Ki-67 and insulin-like growth factor receptor-1 immunoreactivity was verified in the MNU group, moderate in the bacillus Calmette-Guérin and enterotoxin groups, and weak in the bacillus Calmette-Guérin plus enterotoxin and control groups. In contrast, intense endostatin immunoreactivity was verified in the control and bacillus Calmette-Guérin plus enterotoxin groups. Conclusions: Bacillus Calmette-Guérin and staphylococcal enterotoxin B showed similar anti-angiogenic effects. Bacillus Calmette-Guérin plus enterotoxin treatment had additional activity compared to that of monotherapy. It was more effective in restoring apoptosis and balancing cellular proliferation, and it correlated with increased endostatin, and decreased vascular endothelial growth factor, matrix metalloproteinase-9, Ki-67 and insulin-like growth factor receptor-1 reactivity.

Standard Lymph Node Dissection for Bladder Cancer: Significant Variability in the Number of Reported Lymph Nodes

2011-12-15

Purpose: We compared the nodal yield after histopathological examination of extended bilateral pelvic lymph node dissection specimens for bladder cancer at 2 hospitals. Surgery at each hospital was done by the same 4 staff urologists using a standardized extended bilateral pelvic lymph node dissection template. Materials and Methods: All consecutive patients with bladder cancer who underwent extended bilateral pelvic lymph node dissection from January 1, 2007 to December 31, 2009 were included in this study. Specimens were sent for pathological evaluation in a minimum of 2 packages per side. At the 2 pathology departments specimens were processed according to institutional protocols. Results: A total of 174 patients with a mean age of 62.7 years were included in analysis. At hospital 1 a mean of 16 lymph nodes were found after dissection vs a mean of 28 reported at hospital 2 (p <0.001). No significant differences were found in the number of tumor positive lymph nodes (p = 0.65). Mean lymph node density at hospitals 1 and 2 was 9.3% and 3.9%, respectively (p = 0.056). Conclusions: Despite equal anatomical clearance by the same experienced surgeons we report a statistically significant difference between 2 pathology departments where the number of lymph nodes was evaluated after extended bilateral pelvic lymph node dissection for bladder cancer. Unless standardized methods are agreed on by pathologists, the number of reported lymph nodes as an indicator of surgical quality and lymph node density as a prognostic factor should be used cautiously.

Detailed Histological Investigation of the Female Urethra: Application to Radical Cystectomy

2011-12-15

Purpose: We histologically examined the urethral anatomy to assess whether the surgical procedure for radical cystectomy should be modified in females. Materials and Methods: Anatomical and histological studies were performed on 20 adult female cadavers. Semiserial sections were processed for histological examination and immunohistochemistry. To assess the clinical value of the antegrade approach we examined blood loss and function in 12 consecutive patients who underwent radical cystectomy by this approach. Results: Vaginal wall smooth muscle contributed to urethral wall formation, in addition to a thin layer of proper urethral smooth muscle, particularly when the bladder detrusor was poorly developed or degenerated. The middle urethra was attached tightly to the vaginal smooth muscles with abundant veins running at the interface. The urethral sphincter and its inferoposterior continuation (urethrovaginal sphincter) were embedded in the elastic fiber rich perineal membrane. The membrane was U shaped, wrapping around the anterior aspect of the middle urethra and extending posterior along the distal vagina to end at the lateral extension of the perineal body near the external anal sphincter. Mean estimated blood loss was 965 ml. Of patients who received a neobladder hypercontinence was observed in 14.3% and 57.1% achieved continence. Conclusions: There is topographical variation in the anatomy of tissues surrounding the female urethra. Care should be taken when dissecting the tissues dorsal or lateral to the urethra. The antegrade approach is useful since the urethra can be dissected under direct vision and traction can be applied to these structures.

Risk Stratification of Organ Confined Bladder Cancer After Radical Cystectomy Using Cell Cycle Related Biomarkers

2011-12-15

Purpose: We tested whether assessing the expression of cell cycle related proteins (p53, pRB, p21 and p27) could predict clinical outcomes after radical cystectomy in patients with organ confined urothelial carcinoma of the bladder. Materials and Methods: Our study included a development cohort of 272 patients and an external testing cohort of 52 patients with chemotherapy naïve pT1-2N0M0 urothelial carcinoma of the bladder treated with radical cystectomy. Immunohistochemical staining of p53, p27, p21 and pRB was performed on the development cohort of 272 patients and the external testing cohort of 52 patients. Results: Overall 260 (80.2%) patients had altered expression of at least 1 molecular marker and 105 (32.4%), 95 (29.3%), 44 (13.6%) and 16 (4.9%) had 1 to 4 altered molecular markers, respectively. Addition of the number of altered molecular markers increased the predictive accuracy of the base model for disease recurrence and cancer specific mortality by 15.6% and 14.8%, respectively (p <0.001). The base model included age, gender, pT1 vs pT2 stage, grade, number of lymph nodes removed, lymphovascular invasion and concomitant carcinoma in situ. The combination of molecular markers yielded a predictive accuracy superior to that of any single molecular marker. We developed nomograms for the prediction of recurrence-free and cancer specific survival. Conclusions: Assessment of the number of altered cell cycle regulatory proteins in the cystectomy specimen improves the prediction of urothelial carcinoma of the bladder recurrence and survival in patients with organ confined disease. A combination of multiple markers is needed to capture the complex biological behavior of urothelial carcinoma of the bladder.

Editorial Comment

Bas W.G. van Rhijn — 2011-12-15

Prediction of clinical outcome after radical cystectomy relies heavily on the TNM classification system and lymphovascular invasion. Shariat et al retrospectively analyzed a development cohort (272) and an external testing cohort (52) of pT1-2 pN0 cM0-R0 cases after radical cystectomy. The combination of 4 cell cycle related markers (p53, p21, p27 and pRB) significantly improved the prognostic value of the multivariable models by the highest percentages. Patients with organ confined disease and multiple aberrant molecular markers may benefit from adjuvant therapy and/or intensified followup. New in this report is a testing cohort with external pathology and an external laboratory to analyze the biomarkers. Although the differences between the 2 cohorts are substantial, the number of patients in the external cohort is too small to draw definitive conclusions. Next to molecular work, this study once again shows the importance of an institutional database and collaboration among centers.

Complications and Long-Term Results of Salvage Cystectomy After Failed Bladder Sparing Therapy for Muscle Invasive Bladder Cancer

2011-12-15

Purpose: Radical cystectomy has been the standard treatment for muscle invasive bladder cancer. Combined modality therapy involving transurethral bladder tumor resection, external beam radiation and chemotherapy is an effective alternative to cystectomy in selected patients. Salvage cystectomy is reserved for those in whom combined modality therapy fails. We characterized complications associated with salvage cystectomy. Materials and Methods: From 1986 to 2007 of 348 patients undergoing bladder sparing therapy 102 (29%) underwent salvage cystectomy, 91 of whom were treated at Massachusetts General Hospital after receiving combined modality therapy for T2–T4aNxM0 bladder cancer. Patients underwent transurethral bladder tumor resection followed by chemoradiation (40 Gy). Early assessment was performed by cystoscopy/re-biopsy. Patients with complete response continued with consolidation chemoradiation (total dose 64 Gy). Immediate salvage cystectomy (50 of 91) was performed for persistent disease, while delayed salvage cystectomy (41 of 91) was performed for an invasive recurrence. Complications were classified using the Clavien system. Results: Median patient age was 69.4 years (range 27.5 to 88.9) and median living patient followup was 12 years (range 0 to 23). Of the patients 99% (90 of 91) underwent ileal diversion. Complications of any grade within 90 days occurred in 69% (63 of 91) of patients and 16% (15 of 91) experienced major complications within 90 days. Of the patients 21% (19 of 91) required hospital readmission within 90 days. The 90-day mortality rate was 2.2% (2 of 91). Significant cardiovascular/hematological complications (pulmonary embolism, myocardial infarction, deep vein thrombosis, transfusion) within 90 days were more common in the immediate than in the delayed cystectomy group (37% vs 15%, p = 0.02). Tissue healing complications (fascial dehiscence, wound infection, ureteral stricture, anastomotic stricture, stoma/loop revisions) were more common in the delayed than in the immediate cystectomy group (35% vs 12%, p = 0.05). Conclusions: Salvage cystectomy is associated with acceptable morbidity, although complication rates are slightly higher than for other cystectomy series. Immediate cystectomies have more cardiovascular/hematological complications while delayed cystectomies have more tissue healing complications.

Re: Immunoexpression Status and Prognostic Value of mTOR and Hypoxia-Induced Pathway Members in Primary and Metastatic Clear Cell Renal Cell Carcinomas

Samir S. Taneja — 2011-12-15

L. Schultz, A. Chaux, R. Albadine, J. Hicks, J. J. Kim, A. M. De Marzo, M. E. Allaf, M. A. Carducci, R. Rodriguez, H. J. Hammers, P. Argani, V. E. Reuter and G. J. Netto Departments of Pathology, Oncology and Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York

Re: Tumour Diameter and Decreased Preoperative Estimated Glomerular Filtration Rate are Independently Correlated in Patients With Renal Cell Carcinoma

Samir S. Taneja — 2011-12-15

N. M. Donin, L. K. Suh, L. Barlow, G. W. Hruby, J. Newhouse and J. McKiernan, Department of Urology, Herbert Irving Comprehensive Cancer Center and Department of Radiology, Columbia University College of Physicians and Surgeons, New York, New York

Re: Prognosis and Characteristics of Renal Cell Carcinoma in Hemodialysis Patients: Bilateral Occurrence Does Not Influence Cancer-Specific Survival

Samir S. Taneja — 2011-12-15

T. Takagi, T. Kondo, J. Izuka, H. Kobayashi, E. Tomita, Y. Hashimoto and K. Tanabe Department of Urology, Tokyo Women's Medical University, Tokyo, Japan

Re: Antegrade Perfusion With Bacillus Calmette-Guérin in Patients With Non-Muscle-Invasive Urothelial Carcinoma of the Upper Urinary Tract: Who May Benefit?

Samir S. Taneja — 2011-12-15

G. Giannarini, T. M. Kessler, F. D. Birkhäuser, G. N. Thalmann and U. E. Studer Department of Urology, University of Berne, Inselspital, Berne, Switzerland

Re: Long-Term Outcomes of Immediate Versus Delayed Nephroureterectomy for Upper Tract Urothelial Carcinoma

Samir S. Taneja — 2011-12-15

A. J. Gadzinski, W. W. Roberts, G. J. Faerber and J. S. Wolf Department of Urology, University of Michigan, Ann Arbor, Michigan

Re: International Phase III Trial Assessing Neoadjuvant Cisplatin, Methotrexate, and Vinblastine Chemotherapy for Muscle-Invasive Bladder Cancer: Long-Term Results of the BA06 30894 Trial

David P. Wood — 2011-12-19

International Collaboration of Trialists; Medical Research Council Advanced Bladder Cancer Working Party (now the National Cancer Research Institute Bladder Cancer Clinical Studies Group); European Organisation for Research and Treatment of Cancer Genito-Urinary Tract Cancer Group; Australian Bladder Cancer Study Group; National Cancer Institute of Canada Clinical Trials Group; Finnbladder; Norwegian Bladder Cancer Study Group, and Club Urologico Espanol de Tratamiento Oncologico Group; G. Griffiths, R. Hall, R. Sylvester, D. Raghavan and M. K. Parmar

Re: Bladder Preservation Multimodality Therapy as an Alternative to Radical Cystectomy for Treatment of Muscle Invasive Bladder Cancer

David P. Wood — 2011-12-19

A. M. Maarouf, S. Khalil, E. A. Salem, M. El Adl, N. Nawar and F. Zaiton Department of Urology, Zagazig University, Zagazig, Egypt

Re: Surgery-Related Complications of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion

David P. Wood — 2011-12-19

M. C. Schumacher, M. N. Jonsson, A. Hosseini, T. Nyberg, V. Poulakis, N. P. Pardalidis, H. John and P. N. Wiklund Department of Molecular Medicine and Surgery, Division of Urology, Karolinska Institutet, Stockholm, Sweden

Re: Readaptation of the Peritoneum Following Extended Pelvic Lymphadenectomy and Cystectomy has a Significant Beneficial Impact on Early Postoperative Recovery and Complications: Results of a Prospective Randomized Trial

David P. Wood — 2011-12-19

B. Roth, F. D. Birkhäuser, P. Zehnder, F. C. Burkhard, G. N. Thalmann and U. E. Studer Department of Urology, University of Bern, Bern, Switzerland

Prostate Size Does Not Predict High Grade Cancer

Tin C. Ngo, Simon L. Conti, Rajesh Shinghal, Joseph C. Presti — 2011-12-15

Purpose: Several radical prostatectomy series have linked small prostates with high grade cancer based on the hypothesis that a small prostate results from a low androgen milieu that selects for less hormone dependent, more aggressive tumors. We previously reported that this association resulted from ascertainment bias from the performance characteristics of prostate specific antigen rather than from tumor biology in our radical prostatectomy cohort. In this study we analyzed this association in a more generalized population of men who underwent prostate needle biopsy. Materials and Methods: The prostate needle biopsy database at our institution was queried for all initial biopsies. Included patient characteristics were age, race, family history of prostate cancer, prostate specific antigen, abnormal digital rectal examination and prostate volume in ml on transrectal ultrasound. Multivariate logistic regression was used to determine the influence of prostate volume on the odds of high grade cancer. Results: The study population included 1,295 patients during 2000 to 2010, of whom 582 (44.9%) had prostate cancer and 398 (30.7%) had high grade cancer. When all patients were pooled, the OR for high grade cancer was 0.85 (95% CI 0.78–0.92) for each 10 ml increase in prostate volume. When patients were divided by clinical T stage, the corresponding ORs for those with T1c disease was 0.83 (95% CI 0.74–0.93) and for those with T2 or greater disease it was 0.99 (0.98–1.00). Conclusions: The association between small prostates and high grade cancer exists only in men with clinical T1c (normal digital rectal examination) prostate cancer. It likely resulted from ascertainment bias due to the performance characteristics of prostate specific antigen rather than tumor biology.

Editorial Comment

Daniel A. Barocas — 2011-12-15

The ratio of PSA to prostate size (PSA density) is an important predictor of biopsy results (reference 10 in article), pathological characteristics at radical prostatectomy and biochemical failure (reference 3 in article). Several theories have been postulated to explain this but the most likely is the simplest. If a lot of PSA is produced by a small prostate, it is probably due to relatively aggressive cancer. If a lot of PSA is produced by a large prostate, it is probably due to the bulk of the benign prostate. In this light PSA and prostate size are important to determine risk.

Reply by Author

2011-12-15

Our point was to evaluate the relationship between prostate size and high grade cancer, specifically to address the claim that a small prostate is a surrogate marker for aggressive disease.

Diagnostic Radiation Exposure Risk in a Contemporary Cohort of Male Patients With Germ Cell Tumor

2011-12-15

Purpose: We determined the total amount of diagnostic radiation that a patient with testicular cancer receives during the course of treatment and the associated risk of secondary malignancy. Materials and Methods: At a single institution 119 men with seminomatous and nonseminomatous germ cell tumors of the testis were retrospectively identified. Annual and lifetime exposure to radiation was determined for each histological subtype. Values were assessed for compliance with International Commission of Radiological Protection guidelines. Results: The cohorts included 55 patients with seminomatous and 64 with nonseminomatous germ cell tumor. Between the groups no difference was found in the lifetime (215.5 and 214.1 mSV, p = 0.96) or the annual (104.6 and 104.6 mSV, respectively, p = 1.0) radiation dose. Of the 41 patients with more than 5-year followup 32 (78%) were in violation of guidelines by exceeding 20 mSV per year of radiation. Also, 74 patients (61.7%) received 50 mSV or greater of radiation during a 1-year period. Using the previously calculated excess relative risk for solid cancer and leukemia, excluding chronic lymphocytic leukemia, the RR was 68 and 329, respectively, with a 2.1% lifetime risk of fatal cancer over the baseline risk. Conclusions: At a tertiary care center with experience with managing testicular cancer 78% of patients with more than 5 years of followup exceeded current national and standard safety limits for radiation exposure. Imaging should be done judiciously in this population at high risk for radiation overexposure.

Laparoscopic Retroperitoneal Lymph Node Dissection for Clinical Stage I Nonseminomatous Germ Cell Tumor: A Large Single Institution Experience

2011-12-19

Purpose: Primary laparoscopic retroperitoneal lymph node dissection is done at our institution with therapeutic intent and it technically duplicates the open approach. Controversies associated with the procedure include the thoroughness of dissection, the high rate of chemotherapy exposure and the potential deleterious effects of pneumoperitoneum. We present our experience with laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors. Materials and Methods: We queried the Johns Hopkins minimally invasive surgery database from 1995 to 2010 for patients with a clinical stage I nonseminomatous germ cell tumor undergoing laparoscopic retroperitoneal lymph node dissection. Demographic, perioperative, pathological and followup information was collected and analyzed. Results: Of the 91 patients who underwent extended template laparoscopic retroperitoneal lymph node dissection during the study period 60 (66%) had lymphovascular invasion and 55 (60%) had greater than 40% embryonal carcinoma. Median estimated blood loss was 200 cc and mean length of stay was 2.1 days (range 1 to 4). Four patients (4.3%) experienced intraoperative complications and there were 4 open conversions (4.3%). Nine patients (9.8%) experienced postoperative complications. The mean lymph node count was 26.1 (range 7 to 72) and 28 patients (31%) had retroperitoneal metastasis. Followup was available for 55 patients at a median 38.0 months (range 12 to 168). No pN0 case recurred in the retroperitoneum but there were 5 systemic relapses in pN0 cases. Of the 21 patients with pN1 disease 14 elected chemotherapy and 7 elected surveillance. There was no relapse in either group. Conclusions: Laparoscopic retroperitoneal lymph node dissection appears to be safe, viable and effective for stage I nonseminomatous germ cell tumors. The lack of retroperitoneal recurrence in pN0–N1 cases supports the oncological efficacy of this approach. Its low morbidity and rapid convalescence compare favorably with those in open series.

Editorial Comment

Patrick A. Kenney, Jose A. Karam — 2011-12-19

These authors provide an update of their primary LRPLND series with therapeutic intent in patients with NSGCT. Of the 91 patients in this retrospective study only 55 had more than 1 year of followup and a median followup of just more than 3 years. During this short followup no retroperitoneal recurrence developed in patients with pN0 or pN1 disease. Unfortunately only 7 of 21 patients with pN1 disease were spared postoperative adjuvant chemotherapy, which reflects institutional multidisciplinary practice preferences. Surgical complications were minimal and certainly within acceptable and expected limits.

Prospective Evaluation of 18F-Fluorodeoxyglucose Positron Emission Tomography-Computerized Tomography to Assess Inguinal Lymph Node Status in Invasive Squamous Cell Carcinoma of the Penis

2011-12-15

Purpose: We prospectively evaluated 18F-fluorodeoxyglucose positron emission tomography-computerized tomography to assess inguinal lymph node status, the main prognostic factor in invasive squamous cell carcinoma of the penis. Materials and Methods: From March 2005 to January 2010, 30 patients with invasive squamous cell carcinoma of the penis from the department of urology at our institution were prospectively included in this study. Lymph node status was assessed preoperatively by positron emission tomography-computerized tomography to detect subclinical metastasis in 22 patients with initially cN0 disease and quantify inguinal lymph node invasion in 8 with cN+. Results: In the 22 cN0 cases (total of 44 inguinal lymph node basins analyzed) positron emission tomography-computerized tomography had 75% sensitivity and 87.5% specificity. Positive and negative predictive values were 37.5% and 97.2%, respectively. In the 8 cN+ cases (total of 16 inguinal lymph node basins analyzed) this type of imaging had 100% sensitivity, specificity and positive predictive value. In 3 cases staged clinically as cN1 positron emission tomography-computerized tomography revealed several metabolically active lesions on the same side, which was confirmed by histological examination, up-staging these cases to pN2. Conclusions: 18F-fluorodeoxyglucose positron emission tomography-computerized tomography is a useful staging examination for invasive penile cancer. It confirms inguinal lymph node invasion and can detect subclinical inguinal lymph node invasion.

Re: Should Intervening Benign Tissue be Included in the Measurement of Discontinuous Foci of Cancer on Prostate Needle Biopsy? Correlation With Radical Prostatectomy Findings

Patrick C. Walsh — 2011-12-15

S. Karram, B. J. Trock, G. J. Netto and J. I. Epstein Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland

Re: Suitability of PSA-Detected Localised Prostate Cancers for Focal Therapy: Experience From the ProtecT Study

Patrick C. Walsh — 2011-12-15

J. W. Catto, M. C. Robinson, P. C. Albertsen, J. R. Goepel, M. F. Abbod, D. A. Linkens, M. Davis, D. J. Rosario, A. Y. Warren, M. Varma, D. F. Griffiths, K. M. Grigor, N. J. Mayer, J. D. Oxley, N. S. Deshmukh, J. A. Lane, C. Metcalfe, J. L. Donovan, D. E. Neal and F. C. Hamdy

Re: Stepwise Approach for Nerve Sparing Without Countertraction During Robot-Assisted Radical Prostatectomy: Technique and Outcomes

Patrick C. Walsh — 2011-12-15

K. J. Kowalczyk, A. C. Huang, N. D. Hevelone, S. R. Lipsitz, H. Y. Yu, W. D. Ulmer, J. R. Kaplan, S. Patel, P. L. Nguyen and J. C. Hu Division of Urologic Surgery, Brigham and Women's/Faulkner Hospital, Harvard Medical School, Boston, Massachusetts

Re: Orgasm-Associated Urinary Incontinence and Sexual Life After Radical Prostatectomy

Patrick C. Walsh — 2011-12-15

A. E. Nilsson, S. Carlsson, E. Johansson, M. N. Jonsson, C. Adding, T. Nyberg, G. Steineck and N. P. Wiklund Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden

Re: Presence of Teratoma in Orchiectomy Specimen Increases the Need for Postchemotherapy RPLND

Jerome P. Richie — 2011-12-19

K. Inci, H. S. Dogan, B. Akdogan, D. E. Baydar, A. Ergen and H. Ozen Department of Urology, Hacettepe University, Faculty of Medicine, Ankara, Turkey

Association of Neuropathic Pain With Bladder, Bowel and Catastrophizing Symptoms in Women With Bladder Pain Syndrome

2011-12-15

Purpose: In this study we determined if there is an association of neuropathic pain with urinary, bowel and catastrophizing symptoms in women with bladder pain syndrome. Materials and Methods: Female patients with a diagnosis of bladder pain syndrome completed validated questionnaires to assess neuropathic pain, urinary and bowel symptoms, quality of life and pain catastrophizing. Women were dichotomized into neuropathic pain and nonneuropathic pain groups. Urinary and bowel symptoms, pain catastrophizing and quality of life scores were compared between the 2 groups using parametric and nonparametric tests. Results: Of 150 women with bladder pain syndrome 40 (27%) had features of neuropathic pain while 110 (73%) did not. Women with features of neuropathic pain had significantly worse urinary urgency (mean ± SD 3.1 ± 3.1 vs 2.1 ± 1.7, p <0.001), bladder pain (3.0 ± 1.1 vs 2.0 ± 1.3, p <0.001), bowel pain (8.8 ± 4.0 vs 5.3 ± 3.6, p <0.001), diarrhea (7.8 ± 6.1 vs 4.1 ± 4.3, p <0.001), quality of life (12.2 ± 5.5 vs 9.8 ± 3.8, p <0.001) and higher pain catastrophizing (32.2 ± 12.4 vs 23.1 ± 14.3, p <0.001) scores than those without neuropathic pain. Conclusions: In women with bladder pain syndrome the presence of neuropathic pain is significantly associated with the severity of bladder and bowel pain, urinary urgency and diarrhea. Women with features of neuropathic pain also have worse pain catastrophizing and quality of life than those without features of neuropathic pain.

Comparison of an Interstitial Cystitis/Bladder Pain Syndrome Clinical Cohort With Symptomatic Community Women From the RAND Interstitial Cystitis Epidemiology Study

2011-12-15

Purpose: The RAND Interstitial Cystitis Epidemiology survey estimated that 2.7% to 6.5% of United States women have urinary symptoms consistent with a diagnosis of interstitial cystitis/bladder pain syndrome. We describe the demographic and clinical characteristics of the symptomatic community based RAND Interstitial Cystitis Epidemiology cohort, and compare them with those of a clinically based interstitial cystitis/bladder pain syndrome cohort. Materials and Methods: Subjects included 3,397 community women who met the criteria for the RAND Interstitial Cystitis Epidemiology high sensitivity case definition, and 277 women with an interstitial cystitis/bladder pain syndrome diagnosis recruited from specialist practices across the United States (clinical cohort). Questions focused on demographic information, symptom severity, quality of life indicators, concomitant diagnoses and treatment. Results: Average symptom duration for both groups was approximately 14 years. Women in the clinical cohort reported worse baseline pain and maximum pain, although the absolute differences were small. Mean Interstitial Cystitis Symptom Index scores were approximately 11 for both groups, but mean Interstitial Cystitis Problem Index scores were 9.9 and 13.2 for the clinical cohort and the RAND Interstitial Cystitis Epidemiology cohort, respectively (p <0.001). The RAND Interstitial Cystitis Epidemiology subjects were more likely to be uninsured. Conclusions: The RAND Interstitial Cystitis Epidemiology community cohort was remarkably similar to an interstitial cystitis/bladder pain syndrome clinical cohort with respect to demographics, symptoms and quality of life measures. In contrast to other chronic pain conditions for which clinical cohorts typically report worse symptoms and functional status than population based samples, our data suggest that many measures of symptom severity and functional impact are similar, and sometimes worse, in the RAND Interstitial Cystitis Epidemiology cohort. These findings suggest that interstitial cystitis/bladder pain syndrome is significantly burdensome, and likely to be underdiagnosed and undertreated in the United States.

Re: Population Structure and Uropathogenic Virulence-Associated Genes of Faecal Escherichia coli From Healthy Young and Elderly Adults

Edward M. Schaeffer — 2011-12-15

T. L. Vollmerhausen, N. L. Ramos, A. Gündogdu, W. Robinson, A. Brauner and M. Katouli Faculty of Science, Health and Education, University of Sunshine Coast, Maroochydore, Queensland, Australia

Re: Antimicrobial Resistance in More Than 100,000 Escherichia coli Isolates According to Culture Site and Patient Age, Gender, and Location

Edward M. Schaeffer — 2011-12-15

J. M. Sahuquillo-Arce, M. Selva, H. Perpiñán, M. Gobernado, C. Armero, López-A. Quílez, F. González and H. Vanaclocha Hospital La Fe, Valencia, Spain

Re: Origins of the E. coli Strain Causing an Outbreak of Hemolytic-Uremic Syndrome in Germany

Edward M. Schaeffer — 2011-12-15

D. A. Rasko, D. R. Webster, J. W. Sahl, A. Bashir, N. Boisen, F. Scheutz, E. E. Paxinos, R. Sebra, C. S. Chin, D. Iliopoulos, A. Klammer, P. Peluso, L. Lee, A. O. Kislyuk, J. Bullard, A. Kasarskis, S. Wang, J. Eid, D. Rank, J. C. Redman, S. R. Steyert, J. Frimodt-Møller, C. Struve, A. M. Petersen, K. A. Krogfelt, J. P. Nataro, E. E. Schadt and M. K. Waldor

Urinary Parameters as Predictors of Primary Hyperparathyroidism in Patients With Nephrolithiasis

2011-12-16

Purpose: Serum calcium and parathyroid hormone levels are the primary means of evaluating patients for hyperparathyroidism. Whether there are differences in urinary parameters between stone formers with and those without hyperparathyroidism is controversial. In this study we identify urinary parameters that predict primary hyperparathyroidism. Materials and Methods: From 2001 to 2010 a total of 1,190 adult, noncystine stone forming patients underwent urinary metabolic stone evaluation. Of these patients 34 (3%) underwent parathyroidectomy for primary hyperparathyroidism. Urinary parameters were evaluated as predictors of primary hyperparathyroidism. The most accurate combination of serum and urinary tests and their cutoffs were determined. Results: Stone forming patients with primary hyperparathyroidism were more likely to be women and had higher urinary calcium excretion. Hypercalciuria (aOR 4.38), supersaturation calcium oxalate greater than 10 (aOR 4.27), supersaturation calcium phosphate greater than 2 (aOR 3.64), calcium per kg greater than 4 mg/kg (aOR 8.03) and calcium-to-creatinine ratio greater than 150 mg/gm (aOR 7.07) were significant predictors of primary hyperparathyroidism in separate multivariate models after adjustment. The best accuracy was determined using serum calcium and parathyroid hormone levels with our laboratory cutoffs (AUC 0.984) with a sensitivity of 87%, specificity of 99%, positive predictive value of 79% and negative predictive value of 99.5%. No other factor(s) improved diagnostic accuracy or could replace parathyroid hormone level. Conclusions: Greater urinary calcium excretion predicted primary hyperparathyroidism. Serum calcium with parathyroid hormone level was the most accurate test for primary hyperparathyroidism. No other serum or urinary parameter improved diagnostic accuracy or could replace parathyroid hormone. There were no obvious cutoffs for any of the urinary parameters that reliably differentiated cases of hyperparathyroidism.

Factors That Impact the Outcome of Minimally Invasive Pyeloplasty: Results of the Multi-Institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group

2011-12-16

Purpose: We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy. Materials and Methods: We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures. Results: Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures. Conclusions: Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures.

Medical Malpractice in Endourology: Analysis of Closed Cases From the State of New York

Brian Duty, Zhamshid Okhunov, Zeph Okeke, Arthur Smith — 2011-12-16

Purpose: Medical malpractice indemnity payments continue to rise, resulting in increased insurance premiums. We reviewed closed malpractice claims pertaining to endourological procedures with the goal of helping urologists mitigate their risk of lawsuit. Materials and Methods: All closed malpractice claims from 2005 to 2010 pertaining to endourological procedures filed against urologists insured by the Medical Liability Mutual Insurance Company of New York were examined. Claims were reviewed for plaintiff demographics, medical history, operative details, alleged complication, clinical outcome and lawsuit disposition. Results: A total of 25 closed claims involved endourological operations and of these cases 10 were closed with an indemnity payment. The average payout was $346,722 (range $25,000 to $995,000). Of the plaintiffs 16 were women and mean plaintiff age was 51.4 years. Cystoscopy with ureteral stent placement/exchange resulted in 13 lawsuits, ureteroscopic lithotripsy 8, percutaneous stone extraction 2 and shock wave lithotripsy 2. There were 17 malpractice suits brought for alleged operative complications. Failure to arrange adequate followup was implicated in 4 cases. Error in diagnosis and delay in treatment was alleged in 3 claims. Conclusions: Urologists are not immune to the current medical malpractice crisis. Endourology and urological oncology generate the greatest number of lawsuits against urologists. Most malpractice claims involving endourological procedures result from urolithiasis and alleged technical errors. Therefore, careful attention to surgical technique is essential during stone procedures to reduce the risk of malpractice litigation.

Re: Anatomical Variation Between the Prone, Supine, and Supine Oblique Positions on Computed Tomography: Implications for Percutaneous Nephrolithotomy Access

Dean Assimos — 2011-12-19

B. Duty, N. Waingankar, Z. Okhunov, E. B. Levi, A. Smith and Z. Okeke Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, New York

Re: Outcomes of Long-Term Follow-Up of Patients With Conservative Management of Asymptomatic Renal Calculi

Dean Assimos — 2011-12-19

L. T. Koh, F. C. Ng and K. K. Ng Department of Urology, Changi General Hospital, Singapore

Re: Tamsulosin and Doxazosin as Adjunctive Therapy Following Shock-Wave Lithotripsy of Renal Calculi: Randomized Controlled Trial

Dean Assimos — 2011-12-19

O. M. Zaytoun, R. Yakoubi, A. R. Zahran, K. Fouda, E. Marzouk, S. Gaafar and K. Fareed Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio

Re: Twenty-Year Prevalence of Diabetes Mellitus and Hypertension in Patients Receiving Shock-Wave Lithotripsy for Urolithiasis

Dean Assimos — 2011-12-19

B. H. Chew, B. Zavaglia, C. Sutton, R. K. Masson, S. H. Chan, R. Hamidizadeh, J. K. Lee, O. Arsovska, V. A. Rowley, C. Zwirewich, K. Afshar and R. F. Paterson Department of Urologic Sciences, Gordon and Leslie Diamond Health Care Centre, Vancouver UBC Faculty of Medicine and Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada

A National Study of Trauma Level Designation and Renal Trauma Outcomes

2011-12-16

Purpose: We examined the initial management of renal trauma and assessed patterns of management based on hospital trauma level designation. Materials and Methods: The National Trauma Data Bank is a comprehensive trauma registry with records from hospitals in the United States and Puerto Rico. Renal injuries treated at a member hospital from 2002 to 2007 were identified. We classified initial management as expectant, minimally invasive (angiography, embolization, ureteral stent or nephrostomy) or open surgical management based on ICD-9 procedure codes. The primary outcome was use of secondary therapies. Results: Of 3,247,955 trauma injuries in the National Trauma Data Bank 9,002 were renal injuries (0.3%). High grade injuries demonstrated significantly higher rates of definitive success with the first urological intervention at level I trauma centers vs other trauma centers (minimally invasive 52% vs 26%, p <0.001), and were more likely treated successfully with conservative management (89% vs 82%, p <0.001). When adjusting for other known indices of injury severity, and examining low and high grade injuries, level I trauma centers were 90% more likely to offer an initial trial of conservative management (OR 1.90; 95% CI 1.19, 3.05) and had a 30% lower chance of patients requiring multiple procedures (OR 0.70; 95% CI 0.52, 0.95). Conclusions: Following multivariate analysis conservative therapy was more common at level I trauma centers despite the patient population being more severely injured. Initial intervention strategies were also more definitive at level I trauma centers, providing additional support for tiered delivery of trauma care.

Ureteral Substitution With Reconfigured Colon: Long-Term Followup

D.A. Lazica, B. Ubrig, A.S. Brandt, F.C. von Rundstedt, S. Roth — 2011-12-16

Purpose: Long defects in the mid and upper ureter are not amenable to end-to-end reconstruction. Therefore, we present the long-term results of our technique with reconfigured colon segments. Materials and Methods: Between June 1998 and July 2008, 14 patients underwent ureteral replacement at our institution with reconfigured colon. In 4 patients the substitute was anastomosed to the skin as a modified colon conduit. In 10 patients it was interposed with anastomosis to the ureter in 4, to the bladder in 5 and to the afferent loop of an ileal bladder substitute in 1. Results: At a median followup of 52.4 months (range 7 to 136) excellent renal function was confirmed in 10 of 14 patients. Now at a median followup of 95.8 months (range 38 to 136) 6 patients are alive, all without an indwelling stent and with no sign of obstruction of the ureteral replacement. Metabolic disorders, mucus obstruction and stricture or adhesive ileus were absent during followup. In this series death was unrelated to the procedure. In 7 patients 11 specific reinterventions were necessary including 4 cases of prolonged stenting after surgery, 3 which required secondary drainage, 3 cases of urinary tract infection at 4 weeks and 3 and 112 months, and 1 acute bowel obstruction due to peritoneal carcinosis. Conclusions: Reconfigured colon segments can be used successfully to replace long ureteral defects. The advantages are use in patients with impaired renal function and lack of small intestine, proximity of the colon to the ureter, optimal cross-sectional diameter of the graft and less intraperitoneal surgical trauma than with ileal substitutes.

Re: Repeat Retrourethral Transobturator Sling in the Management of Recurrent Postprostatectomy Stress Urinary Incontinence After Failed First Male Sling

Allen F. Morey — 2011-12-16

I. Soljanik, A. J. Becker, C. G. Stief, C. Gozzi and R. M. Bauer Department of Urology, Klinikum Grosshadern, Ludwig-Maximilian-University Munich, Munich, Germany

Re: Buccal Mucosal Graft Urethroplasty for Penile Stricture: Only Dorsal or Combined Dorsal and Ventral Graft Placement?

Allen F. Morey — 2011-12-16

A. Goel, A. Goel and A. Jain Department of Urology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, India

Re: Urethral Rest: Role and Rationale in Preparation for Anterior Urethroplasty

Allen F. Morey — 2011-12-16

R. P. Terlecki, M. C. Steele, C. Valadez and A. F. Morey Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Re: The “7-Flap” Perineal Urethrostomy

Allen F. Morey — 2011-12-16

D. French, S. J. Hudak and A. F. Morey Department of Urology, UT Southwestern Medical Center, Dallas, Texas

Re: Radiological Treatment of Renal Artery Occlusion After Blunt Abdominal Trauma in a Pediatric Patient: Is it Never Too Late?

Allen F. Morey — 2011-12-16

E. Vidal, G. Marrone, D. Gasparini and P. Pecile Department of Pediatrics, DPMSC, University of Udine School of Medicine, Udine, Italy

Re: Intermediate-Term Follow-Up of Patients Treated With Percutaneous Embolization for Grade 5 Blunt Renal Trauma

Allen F. Morey — 2011-12-16

A. F. Stewart, M. E. Brewer, Jr., B. J. Daley, F. A. Klein and E. D. Kim Division of Urology, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee

Re: What are the Specific Computed Tomography Scan Criteria That Can Predict or Exclude the Need for Renal Angioembolization After High-Grade Renal Trauma in a Conservative Management Strategy?

Allen F. Morey — 2011-12-16

J. Charbit, J. Manzanera, I. Millet, J. P. Roustan, P. Chardon, P. Taourel and X. Capdevila Department of Anesthesiology and Critical Care, Montpellier University Hospital and Department of Radiology, Montpellier I University, Montpellier, France

Re: Routine Follow-Up Imaging of Kidney Injuries May Not be Justified

Allen F. Morey — 2011-12-16

M. Bukur, K. Inaba, G. Barmparas, C. Paquet, C. Best, L. Lam, D. Plurad and D. Demetriades Division of Trauma Surgery and Surgical Critical Care, Los Angeles County Medical Center, University of Southern California, Los Angeles, California

Re: Complications of Hand-Assisted Laparoscopic Renal Surgery: Single-Center Ten-Year Experience

Jeffrey A. Cadeddu — 2011-12-16

N. W. Moore, S. Y. Nakada, S. P. Hedican and T. D. Moon Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Re: Management of Intraoperative Splenic Injury During Laparoscopic Urological Surgery

Jeffrey A. Cadeddu — 2011-12-16

B. I. Chung, M. M. Desai and I. S. Gill Department of Urology, Stanford University School of Medicine, Stanford, California

Re: Relationship Between Penile Fracture and Peyronie's Disease: A Prospective Study

Allen D. Seftel — 2011-12-19

A. Acikgoz, E. Gokce, R. Asci, R. Buyukalpelli, A. F. Yilmaz and S. Sarikaya Department of Urology, Gazi State Hospital, Samsun, Turkey

Re: A Small-Scale Clinical Trial to Determine the Safety and Efficacy of Testosterone Replacement Therapy in Hypogonadal Men With Spinal Cord Injury

Allen D. Seftel — 2011-12-19

W. A. Bauman, C. M. Cirnigliaro, M. F. La Fountaine, A. M. Jensen, J. M. Wecht, S. C. Kirshblum and A. M. Spungen National Center of Excellence for Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York

Presenting Symptoms of Anterior Urethral Stricture Disease: A Disease Specific, Patient Reported Questionnaire to Measure Outcomes

2011-12-16

Purpose: We evaluated the spectrum of symptoms in men with urethral stricture presenting for urethroplasty. Materials and Methods: We identified 214 men who underwent anterior urethroplasty by a single surgeon (CMG) from March 2001 to June 2010. We retrospectively reviewed the initial patient history. All voiding and sexual dysfunction symptoms were recorded. Results: The most common presenting voiding complaints were weak stream in 49% of cases and incomplete emptying in 27%. Overall 21% of men did not present with voiding symptoms specifically addressed by the American Urological Association symptom index. The most common of these symptoms were spraying of urinary stream in 13% of men and dysuria in 10%. No symptoms were reported in 10% of men. Men with lichen sclerosus were more likely to present with obstructive symptoms (76% vs 55%) while men with penile urethral stricture were more likely to present with urinary stream spraying (17% vs 6%, each p <0.05). Sexual dysfunction was reported by 11% of men, most commonly in those with failed hypospadias repair (23% vs 9%) and lichen sclerosus (24% vs 10%, each p <0.05). Conclusions: While the American Urological Association symptom index captures the most common voiding complaints of men with urethral stricture, 21% of those who presented for urethroplasty did not have voiding symptoms assessed by the index. A validated, disease specific instrument is needed to fully capture the presenting voiding symptoms and sexual dysfunction complaints of men with urethral stricture disease.

A New Quadratic Sling for Male Stress Incontinence: Retrograde Leak Point Pressure as a Measure of Urethral Resistance

Craig V. Comiter, Victor Nitti, Christopher Elliot, Eugene Rhee — 2011-12-16

Purpose: Objective methods are essential for evaluating post-prostatectomy incontinence. While symptom score and pad weight may be the most useful methods to evaluate preoperative vs postoperative continence, neither is useful for guiding intraoperative sling tension. The Virtue quadratic sling (Coloplast, Humlebaek, Denmark) is a new device for treating post-prostatectomy incontinence that combines a transobturator and prepubic surgical approach. We examined urethral resistance by measuring retrograde leak point pressure during key portions of the surgery. Materials and Methods: A total of 22 consecutive men who elected to undergo Virtue sling surgery were evaluated with retrograde leak point pressure before and during the surgery. Retrograde leak point pressure was measured via perfusion sphincterometry at baseline, after transobturator tensioning, after prepubic tensioning, and after transobturator and prepubic arms were secured in place. Results: Mean patient age was 70 years. Mean baseline retrograde leak point pressure was 33.4 ± 8.8 cm water. After transobturator tensioning, mean retrograde leak point pressure increased to 43.3 ± 6.8 cm water. After prepubic tensioning mean retrograde leak point pressure was 55.8 ± 8.7, and final retrograde leak point pressure after transobturator and prepubic fixation increased to 68.8 ± 6.0 cm water. Each mean retrograde leak point pressure value was significantly higher than the preceding value. Conclusions: The Virtue sling provides ventral urethral elevation using a transobturator approach, and a long segment of urethral compression against the genitourinary diaphragm via a straightforward prepubic technique without the risks of bone screws or retropubic needle passage. Transobturator and prepubic components of the quadratic fixation contributed to increasing urethral resistance as measured by intraoperative retrograde leak point pressure. This quadratic technique has a potentially greater ability to provide urethral compression than does a purely perineal or transobturator sling.

Preoperative Erectile Function Represents a Significant Predictor of Postoperative Urinary Continence Recovery in Patients Treated With Bilateral Nerve Sparing Radical Prostatectomy

2011-12-16

Purpose: The association between baseline functional status and urinary continence recovery after radical prostatectomy remains controversial. We tested the hypothesis that baseline erectile and urinary function predicts urinary continence recovery after bilateral nerve sparing radical prostatectomy. Materials and Methods: The study included 752 patients with prostate cancer treated with bilateral nerve sparing radical prostatectomy between 2003 and 2009. All patients had preoperative functional and oncological data available, including age at surgery, body mass index, prostate specific antigen, and erectile and urinary function. Preoperatively erectile and urinary function was assessed by the erectile function domain of the International Index of Erectile Function and the International Prostatic Symptoms Score. Urinary continence was defined as wearing no pads. Univariate and multivariate Cox regression models were used to test the association between predictors and urinary continence recovery after surgery. Results: At a mean postoperative followup of 30.7 months (median 29, range 1 to 80) 611 patients (81.3%) had recovered urinary continence. Overall the urinary continence recovery rate at 1 and 3 years was 73.9% and 82.2%, respectively. On univariate Cox regression analysis patient age and the preoperative score on the erectile function domain of the International Index of Erectile Function were significantly associated with urinary continence recovery (each p ≤0.04). On multivariate analysis age at surgery and the preoperative erectile function domain of the International Index of Erectile Function were the only independent predictors of urinary continence recovery after bilateral nerve sparing radical prostatectomy (each p ≤0.04). Conclusions: Age and preoperative erectile function should be considered for urinary continence predictions after bilateral nerve sparing radical prostatectomy and for accurate patient counseling before surgery. Preoperative erectile function might be a marker of pelvic vascular disease, which may affect the status of the external urinary sphincter.

Quartz Head Contact Laser Fiber: A Novel Fiber for Laser Ablation of the Prostate Using the 980 nm High Power Diode Laser

Hassan S. Shaker, Mohammed S. Shoeb, Mohammed M. Yassin, Sayed H. Shaker — 2011-12-16

Purpose: High power 980 nm diode laser ablation of the prostate using the side firing fiber has proven its efficiency and safety in treating lower urinary tract symptoms secondary to benign prostatic hyperplasia. Nevertheless, this procedure is associated with some drawbacks such as prolonged irritative symptoms and tissue sloughing. In this study we evaluated the clinical outcome of high power 980 nm diode laser ablation of the prostate using a new quartz head contact fiber, and compared it to the standard side firing fiber in a randomized fashion. Materials and Methods: A total of 120 patients with benign prostatic hyperplasia scheduled for high power 980 nm diode laser ablation of the prostate were randomized to receive treatment with the standard side firing fiber or the novel quartz head contact fiber between April 2009 and April 2010. Patients were followed for at least 6 months, although 7 were lost to followup. Results: The side firing fiber and quartz head contact fiber groups demonstrated significant improvement in International Prostate Symptom Score (from 20 to 8.39 vs 21.63 to 9.91), International Prostate Symptom Score-quality of life (from 4.47 to 1.94 vs 4.57 to 1.98) and maximum flow rate (from 7.79 to 22.22 vs 8.93 to 29.63 ml per second), and decreased prostate volume (47.79% vs 55.54%) and prostate specific antigen (59.69% to 60.61%), respectively. Complications, postoperative passage of tissue remnants and irritative symptoms were significantly less in the quartz head contact fiber group, as was the number of fibers per case. Conclusions: The quartz head contact fiber can produce similarly good outcomes in ablating the prostate using the high power 980 nm diode laser compared to the side firing fiber, and with fewer complications and side effects.

Re: Mixed Incontinence: Comparing Definitions in Non-Surgical Patients

Alan J. Wein — 2011-12-16

L. Brubaker, E. S. Lukacz, K. Burgio, P. Zimmern, P. Norton, W. Leng, H. Johnson, S. Kraus and A. Stoddard Departments of Obstetrics and Gynecology, and Urology, Loyola University, Chicago, Illinois

Re: National Community Prevalence of Overactive Bladder in the United States Stratified by Sex and Age

Alan J. Wein — 2011-12-16

K. S. Coyne, C. C. Sexton, V. Vats, C. Thompson, Z. S. Kopp and I. Milsom United BioSource Corporation, Center for Health Outcomes Research, Bethesda, Maryland

Re: Patient Satisfaction With the Benefits of Overactive Bladder Treatment: Exploration of Influencing Factors and Development of a Satisfaction Assessment Instrument

Alan J. Wein — 2011-12-16

N. Zinner, K. Kobashi, P. Koochaki, D. Fix and M. Egermark Western Clinical Research, Inc., Torrance, California

Re: Clinical Outcomes After Combined Therapy With Dutasteride Plus Tamsulosin or Either Monotherapy in Men With Benign Prostatic Hyperplasia (BPH) by Baseline Characteristics: 4-Year Results From the Randomized, Double-Blind Combination of Avodart and Tamsulosin (CombAT) Trial

Steven A. Kaplan — 2011-12-19

C. G. Roehrborn, J. Barkin, P. Siami, A. Tubaro, T. H. Wilson, B. B. Morrill and R. P. Gagnier Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas

Re: Comparison of Dutasteride and Finasteride for Treating Benign Prostatic Hyperplasia: the Enlarged Prostate International Comparator Study (EPICS)

Steven A. Kaplan — 2011-12-19

J. C. Nickel, P. Gilling, T. L. Tammela, B. Morrill, T. H. Wilson and R. S. Rittmaster Department of Urology, Queen's University, Kingston, Ontario, Canada

Re: Progression of Null or Mild Lower Urinary Tract Symptoms Indicative of Benign Prostatic Hyperplasia After 2 Years of Follow-Up in Non-Treated Men Aged 40 Years or Older

Steven A. Kaplan — 2011-12-19

J. Moreno Sierra, C. Fernandez Pérez, S. Cano Escudero, M. Fuentes Ferrer, L. Barreales Tolosa and A. Silmi Moyano Department of Urology, Research Unit, Hospital Clínico, San Carlos, Madrid, Spain

Re: Effect of Obesity on the Outcome of Kidney Transplantation: A 20-Year Follow-Up

David A. Goldfarb — 2011-12-19

E. K. Hoogeveen, J. Aalten, K. J. Rothman, J. I. Roodnat, M. J. Mallat, G. Borm, W. Weimar, A. J. Hoitsma and J. W. de Fijter Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands

Re: Laparoscopic Kidney Transplantation: An Initial Experience

David A. Goldfarb — 2011-12-16

P. Modi, J. Rizvi, B. Pal, R. Bharadwaj, P. Trivedi, A. Trivedi, K. Patel, K. Shah, J. Vyas, S. Sharma, K. Shah, R. Chauhan and H. Trivedi Department of Urology and Transplantation Surgery, Smt G R Doshi and Smt K M Mehta Institute of Kidney Diseases and Research Centre and Dr H L Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India

Corpus Cavernosum Electromyography Revisited: Defining the Origin of the Signal

Laura S. Leddy, Xiaogang Jiang, Henry P. Gottsch, Claire C. Yang — 2011-12-16

Purpose: We performed this study to identify the source of complexes recorded during corpus cavernosum electromyography. Materials and Methods: A total of 10 healthy male volunteers 19 to 54 years old (mean age 36) with normal erectile function, participated in the study. A Porti electrodiagnostic system (TMS International, Enschede, The Netherlands) connected to a notebook computer recorded low frequency corpus cavernosum electromyography complexes via penile surface electrodes in 3 phases. In phase 1 baseline corpus cavernosum electromyography was recorded for 30 minutes. In phase 2 penile skin block was performed followed by 30 minutes of corpus cavernosum electromyography recording. Phase 3 consisted of intracavernous block followed by corpus cavernosum electromyography recording for 30 minutes. During all 3 phases startling auditory stimuli and median nerve stimulation were used at random intervals to evoke a sympathetic nervous system response. A suprapubic electrode was used as a control to record sympathetic electrodermal activity. Results: In phase 1 all subjects had spontaneous and evoked corpus cavernosum complexes. The penile skin block used in phase 2 did not affect the presence of these complexes, which remained present in all subjects. During phase 3 no spontaneous or evoked corpus cavernosum complexes were recorded in any subjects, indicating that the intracavernous block eliminated the corporally generated signal. All subjects in all 3 phases demonstrated a sympathetic electrodermal response in the suprapubic electrode in response to evoking stimuli. Conclusions: This study confirms the penile cavernous tissue, and not the penile skin or surrounding tissue, as the origin of the corpus cavernosum electromyography complex. Further refinement of this technique may render it useful in the evaluation of neurogenic and myogenic erectile dysfunction.

The Relationship Between Anogenital Distance and Reproductive Hormone Levels in Adult Men

2011-12-16

Purpose: Anogenital distance is a marker for endocrine disruption in animal studies in which decreased distance has been associated with testicular dysfunction. In this study we investigated whether anogenital distance was associated with reproductive hormone levels in adult men. Materials and Methods: A total of 116 men (mean age 36.1 ± 8.0 years) were evaluated at an andrology clinic in Houston. Anogenital distance (the distance from the posterior aspect of the scrotum to the anal verge) and penile length were measured using digital calipers. Testis size was estimated by physical examination. Linear regression was used to determine correlations between genital measurements and hormone levels. Results: Anogenital distance (r = 0.20, p = 0.03) and penile length (r = 0.20, p = 0.03) were significantly associated with serum testosterone levels while total testis size was not (r = 0.17, p = 0.07). No relationship between genital length and luteinizing hormone, follicle-stimulating hormone or estradiol was identified. After adjusting for age the serum testosterone increased by 20.1 ng/dl (95% CI 1.8, 38.4; p = 0.03) for each 1 cm increase in anogenital distance. On multivariable models no statistically significant relationship existed between penile length and testosterone levels. Moreover men with hypogonadal testosterone levels (less than 300 ng/dl) had a significantly shorter anogenital distance compared to men with higher testosterone levels (31.6 vs 37.3 mm, p = 0.02). Conclusions: Anogenital distance may provide a novel metric to assess testicular function in men. Assuming that anogenital distance at birth predicts adult anogenital distance, our findings suggest a fetal origin for adult testicular function.

Lower Prevalence of Varicoceles in Obese Patients Found on Routine Scrotal Ultrasound

R. Chanc Walters, Charles G. Marguet, Donald S. Crain — 2011-12-16

Purpose: Research shows that obese patients have a lower incidence of varicoceles. Increased adipose tissue, which makes physical examination difficult, was hypothesized to be the cause. We evaluated the varicocele incidence on routine scrotal ultrasound to see whether difficult physical examination was causative. Materials and Methods: We reviewed all scrotal ultrasounds from the last 2 years for men 18 to 40 years old who had a recorded body mass index. Physical examination findings and the indication for ultrasound were included. We used standard criteria for ultrasound detected varicoceles. National Institutes of Health criteria was used to classify patients as normal—body mass index less than 25 kg/m2, overweight—25 to 30 or obese—greater than 30. Results: Of the 1,079 patients 330 (30.6%) had an ultrasound detected varicocele. Mean ± SD body mass index in those with vs without a varicocele was 26.7 ± 3.8 vs 26.0 ± 3.7 kg/m2 (p = 0.04). On physical examination 171 patients (16.0%) had a varicocele. Mean body mass index in those with vs without a varicocele on physical examination was 26.6 ± 3.7 vs 26.4 ± 3.9 kg/m2 (p = 0.09). We calculated varicocele frequency by body mass index for ultrasound detected varicoceles only. Of 374 normal weight patients 129 (34.5%) had a varicocele while in the overweight and obese groups 163 of 535 (30.6%) and 43 of 170 (25.6%), respectively, had a varicocele. The difference between normal and obese patients was statistically significant (p = 0.04). Conclusions: Obese patients have a lower prevalence of varicoceles detected by ultrasound. The lower prevalence is independent of physical examination and more likely due to another factor.

Is Intracytoplasmic Sperm Injection Overused?

2011-12-16

Purpose: We determined whether the use of intracytoplasmic sperm injection in couples who previously underwent intracytoplasmic sperm injection cycles elsewhere could be decreased without compromising the pregnancy rate. Materials and Methods: At our university in vitro fertilization-embryo transfer center we retrospectively analyzed the records of 149 fresh, in vitro fertilization-embryo transfer cycles in patients who underwent intracytoplasmic sperm injection elsewhere and subsequent fertilization by insemination only (all insemination group) or half insemination and half intracytoplasmic sperm injection at our center. We compared fertilization, implantation, clinical pregnancy and live birth rates. Results: The fertilization rate was 74% and 73% for the all insemination and the half intracytoplasmic sperm injection groups, respectively. In the latter group 69% of inseminated and 78% of intracytoplasmic sperm injected oocytes were fertilized. No cycle showed complete fertilization failure. No statistically significant difference in the live birth rate was found between the 2 groups. Conclusions: More stringent criteria for intracytoplasmic sperm injection do not compromise the clinical outcome and reasonable fertilization can be achieved whether or not intracytoplasmic sperm injection is performed. Thus, although intracytoplasmic sperm injection is one of the greatest advances in our field, it is overused and should only be done for clinically proven indications.

Nomograms to Predict Patency After Microsurgical Vasectomy Reversal

2011-12-16

Purpose: After undergoing vasectomy up to 6% of men will elect to undergo vasectomy reversal. For these men paternity can be achieved with vasectomy reversal or surgical sperm retrieval coupled with assisted reproduction. Nevertheless, it remains difficult for surgeons to accurately counsel men on the chance of patency after vasectomy reversal. Materials and Methods: A retrospective review was conducted of 548 patients who underwent microsurgical vasectomy reversal. Surgery was considered successful if sperm concentration was 100,000 or more sperm per ml, total count was 100,000 or more sperm per ejaculate, motile sperm were present and there was no evidence of subsequent failure. A multivariate logistic regression model was constructed to calculate the probability of having a successful vasectomy reversal and nomograms for patency were generated from this model. Results: A total of 548 patients met the inclusion criteria for this study. Mean followup was 1.8 ± 0.10 years. Mean patient age was 43.4 ± 0.3 years and mean duration of obstruction was 10.4 ± 0.2 years. Two nomograms to predict patency were generated, one for preoperative counseling and a second for postoperative counseling. The factors with the largest effect on patency were average testicular volume and obstruction duration. The factor with the least effect was the presence of sperm granuloma. The concordance index for the preoperative and the postoperative nomograms was 0.64 and 0.66, respectively. Conclusions: To our knowledge this represents the first use of nomograms to predict the likelihood of patency after microsurgical vasectomy reversal. These nomograms may prove useful to guide further treatment decisions.

Vasectomy Reversal Provides Long-Term Pain Relief for Men With the Post-Vasectomy Pain Syndrome

2011-12-16

Purpose: The post-vasectomy pain syndrome is a rare but serious and debilitating complication of vasectomy. For men with the post-vasectomy pain syndrome vasectomy reversal is a surgical option after medical management has failed. However, there is a paucity of data in the literature defining its therapeutic efficacy. In this study we better define the role and effect of vasectomy reversal in the treatment of men with the post-vasectomy pain syndrome. Materials and Methods: Three urologists in Toronto, Ontario performed 149 publically funded vasectomy reversals between January 2000 and September 2010. The electronic health records were reviewed and 23 of the 149 (15%) procedures were performed for the post-vasectomy pain syndrome. Of these men who underwent 14 vasovasostomies 13 completed a telephone conducted questionnaire (response rate 56%). Patient demographics, preoperative and postoperative pain scores, and quality of life were retrospectively assessed. Results: Orchialgia occurred a mean ± SD of 19 ± 42.5 months after vasectomy and the men (mean age 43.8 ± 5.2 years) experienced pain for 50.3 ± 34.9 months before vasovasostomy. After vasovasostomy improvement of pain occurred in 93% (13 of 14) and 50% were rendered pain-free with an average improvement in pain intensity scores of 65% (p <0.005). Of the men 15% (2 of 13) had a recurrence of pain to baseline but overall 79% (11 of 14) had a durable positive response. Quality of life was significantly improved after vasovasostomy (p <0.005) and 93% (13 of 14) of the patients said they would undergo the same operation again. Conclusions: Vasovasostomy is an effective treatment modality for the post-vasectomy pain syndrome, and it can achieve robust and durable long-term improvement in pain intensity and quality of life.

Re: Association Between Smoking Cessation and Sexual Health in Men

Allen D. Seftel — 2011-12-16

C. B. Harte and C. M. Meston Department of Psychology, University of Texas at Austin, Austin, Texas

Re: The Relationships Between Sex Hormones and Sexual Function in Middle-Aged and Older European Men

Allen D. Seftel — 2011-12-16

D. B. O'Connor, D. M. Lee, G. Corona, G. Forti, A. Tajar, T. W. O'Neill, N. Pendleton, G. Bartfai, S. Boonen, F. F. Casanueva, J. D. Finn, A. Giwercman, T. S. Han, I. T. Huhtaniemi, K. Kula, F. Labrie, M. E. Lean, M. Punab, A. J. Silman, D. Vanderschueren and F. C. Wu; European Male Ageing Study Group

Re: Total and Free Testosterone Concentrations are Strongly Influenced by Age and Central Obesity in Men With Type 1 and Type 2 Diabetes but Correlate Weakly With Symptoms of Androgen Deficiency and Diabetes-Related Quality of Life

Allen D. Seftel — 2011-12-16

M. Biswas, D. Hampton, R. G. Newcombe and D. A. Rees Department of Medicine and Medical Biochemistry, Royal Gwent Hospital, Newport, and Department of Primary Care and Public Health, and Centre for Endocrine and Diabetes Sciences, School of Medicine, Cardiff University, Cardiff, United Kingdom

Re: Pharmacokinetics of Modified Slow-Release Oral Testosterone Over Nine Days in Normal Men With Experimental Hypogonadism

Allen D. Seftel — 2011-12-16

A. Lee, K. Rubinow, R. V. Clark, R. B. Caricofe, M. A. Bush, H. Zhi, M. Y. Roth, S. T. Page, W. J. Bremner and J. K. Amory J Androl 2011; Epub ahead of print.

Re: Does Metabolic Syndrome Impair Sexual Function in Middle- to Old-Aged Women?

Tomas L. Griebling — 2011-12-16

Y. H. Kim, S. M. Kim, J. J. Kim, I. S. Cho and M. J. Jeon Department of Obstetrics and Gynecology, and Medical Research Institute, School of Medicine, Ewha Womans University, Seoul, Korea

Re: Do the Effects of Testosterone on Muscle Strength, Physical Function, Body Composition, and Quality of Life Persist Six Months After Treatment in Intermediate-Frail and Frail Elderly Men?

Tomas L. Griebling — 2011-12-16

M. D. O'Connell, S. A. Roberts, U. Srinivas-Shankar, A. Tajar, M. J. Connolly, J. E. Adams, J. A. Oldham and F. C. Wu Andrology Research Unit, Manchester Academic Health Science Centre, Manchester Royal Infirmary, University of Manchester, Manchester, United Kingdom

Re: Frailty in Relation to Variations in Hormone Levels of the Hypothalamic-Pituitary-Testicular Axis in Older Men: Results From the European Male Aging Study

Tomas L. Griebling — 2011-12-16

A. Tajar, M. D. O'Connell, A. B. Mitnitski, T. W. O'Neill, S. D. Searle, I. T. Huhtaniemi, J. D. Finn, G. Bartfai, S. Boonen, F. F. Casanueva, G. Forti, A. Giwercman, T. S. Han, K. Kula, F. Labrie, M. E. Lean, N. Pendleton, M. Punab, A. J. Silman, D. Vanderschueren, K. Rockwood and F. C. Wu; European Male Aging Study Group

Re: Low Testosterone Concentrations and the Symptoms of Testosterone Deficiency According to the Androgen Deficiency in Ageing Males (ADAM) and Ageing Males' Symptoms Rating Scale (AMS) Questionnaires

Tomas L. Griebling — 2011-12-16

M. H. Emmelot-Vonk, H. J. Verhaar, H. R. Nakhai-Pour, D. E. Grobbee and Y. T. van der Schouw Department of Geriatrics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands

Re: Varicocele Repair: Does it Still Have a Role in Infertility Treatment?