The Journal of Urology
Volume 179, Issue 2 , Pages 395-397, February 2008

This Month in Clinical Urology

published online 14 December 2007.

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Predictors of Success With Postoperative Voiding Trials After Mid Urethral Sling 

Voiding dysfunction, manifested by urinary retention or incomplete bladder emptying, is a potential postoperative complication of mid urethral sling surgery for incontinence. Wheeler et al (page 600) from Birmingham, Alabama evaluated factors that could predict postoperative voiding difficulty in 89 women undergoing mid urethral sling surgery for incontinence. Two-thirds of the women passed the first voiding trial, but of these 16% failed a second voiding trial. Maximum flow rate on preoperative uroflowmetry was the best predictor of success in an initial voiding trial. None of the patients with a maximal flow rate greater than 30 cc per second failed the first or second voiding trial, whereas more than three-fourths of those with a maximal flow rate less than 15 cc per second failed one of these trials. (CME credit article)

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Effects of Urinary Incontinence, Comorbidity and Race on Quality of Life Outcomes in Women 

Ragins et al (page 651) from Oakland, California studied 2,109 women randomly selected from an urban health maintenance organization to evaluate risk factors for urinary incontinence. All patients were 40 to 69 years old and underwent an in person interview. Using a validating questionnaire, decreased quality of life was observed in women with urinary incontinence as well as in those with significant comorbidity. Except in the sickest women, incontinence continued to have a negative impact on quality of life even when comorbidity was controlled. No clear variation in outcomes was established when the women were separated by racial classifications. This study clearly documents the importance and negative impact of incontinence on quality of life in women.

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Urinary Incontinence Prevalence Based on National Health and Nutrition Examination Survey Results 

Dooley et al (page 656) from Maywood, Illinois used the National Health and Nutrition Examination Survey to determine racial differences in urinary incontinence prevalence between 2001 and 2004. Self-reported data and responses were available for 4,229 women older than 20 years. The study sample was 58% white nonHispanic, 22% Mexican-American and 20% black nonHispanic. The odds of stress urinary incontinence in white and Mexican-American women were almost 2.5 times higher than in black women. In contrast, black and Mexican-American women were more likely to report urgency incontinence compared to white women. Since almost half of the women reported stress incontinence, the study also documents the frequency of this problem in women. The authors acknowledge a limitation of racial comparisons is that self-reporting may be influenced by differences among racial and ethnic groups based on accepted racial and cultural norms, and understandings of definitions.

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Study Characteristics of Abstracts Presented at AUA Southeastern Section Annual Meetings 

Section meetings of the American Urological Association provide an important forum for the presentation of scientific studies and educational interchange. Fesperman et al (page 667) from Gainesville, Florida performed an analysis of poster and podium presentations from the AUA Southeastern Section (SESAUA) annual meetings during a 10-year period ending in 2005. A total of 23 academic institutions in the SESAUA contributed abstracts during this period, and 15.6% of the abstracts came from a single institution (Vanderbilt University) while 3 institutions (Vanderbilt, Duke and Tulane) contributed almost a third of the abstracts. The overall publication rate of abstracts presented at the meeting was 33.5% with The Journal of Urology® being the most frequent publishing journal. Women were first authors on 6.2% and senior authors of 5.4% of abstracts, figures which are apparently lower than the proportion of female urology residents in the Section.

The authors acknowledge that presentations at Section meetings are not a surrogate for the academic productivity of individual institutions. Also, these findings cannot necessarily be generalized to other regional meetings which may differ significantly in format and degree of resident participation. However, the authors did conclude that a majority of studies presented at the SESAUA annual meeting may not be well suited to guide clinical decision making.

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Significance of Tertiary Gleason Pattern 5 in Radical Prostatectomy Specimens 

A higher tertiary (third most prevalent) grade is increasingly being reported by pathologists on radical prostatectomy specimens. However, the impact of tertiary pattern 5 cancer is still uncertain. Using the Department of Defense Center for Prostate Disease Research database, Whittemore et al (page 516) performed a repeat pathological review of 214 available radical prostatectomy specimens from Wilford Hall Medical Center. Patients with Gleason score 7 and tertiary pattern 5 cancer had a statistically significant increase in adverse histological findings such as seminal vesicle invasion, extraprostatic extension and lymphovascular invasion compared to Gleason 7 tumors without any tertiary Gleason 5 pattern. Furthermore, patients with tertiary pattern 5 tumors had significantly decreased biochemical recurrence-free survival (p=0.005). These results lend further credence to the idea that any Gleason pattern 5 involvement, even in a small proportion of the specimen, adversely affects outcome after radical prostatectomy. (CME credit article)

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Small Transrectal Ultrasound Prostate Volume Predicts Clinically Significant Gleason Score Upgrading 

It is well recognized that Gleason score upgrading occurs in a substantial proportion of patients with prostate cancer when the entire prostate is evaluated after radical prostatectomy compared to preoperative needle biopsy. Some studies have shown that larger prostate volume is associated with a higher frequency of upgrading simply because of the assumed greater sampling error from the needle biopsy. Turley et al (page 523) from Durham, North Carolina used the SEARCH (Shared Equal Access Regional Cancer Hospital) database to examine the association between transrectal ultrasound volume and upgrading. Of 586 cases evaluated 24% were upgraded, 14% downgraded, and 62% had an identical biopsy and pathological Gleason sum. Larger transrectal ultrasound prostate volume was significantly associated with a decreased likelihood of upgrading. The authors concluded that a greater likelihood of high grade disease in smaller prostates outweighed any association between sampling error and upgrading in larger glands.

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Distribution of Histological Subtypes of Renal Tumors by Decade of Life 

There are known differences in the molecular determinants of the recognized subtypes of renal cell cancers. Furthermore, there is a known association between subtypes and clinical outcomes. Skolarus et al (page 439) from St. Louis, Missouri evaluated the distribution of histological subtypes of renal tumors according to decade of life. Clear cell renal cell carcinoma and angiomyolipoma decreased with increasing decade of life, while the proportions of oncocytoma and papillary renal cell carcinoma increased. Unlike in other studies, in this study younger patients were more likely to have larger tumors and metastatic disease. An association between patient age and histological subtype of renal tumors could potentially have clinical implications. However, as the authors conclude, further studies are warranted to validate these findings. (CME credit article)

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Differences in Organ System of Distant Metastasis by Renal Cell Carcinoma Subtype 

Subtyping of renal cell carcinoma has epidemiological, prognostic and therapeutic complications. The risk of metastatic disease is known to be associated with subtype. Hoffmann et al (page 474) from Rochester, Minnesota retrospectively evaluated 910 patients treated with radical nephrectomy to determine whether there was any association between subtype and site of metastasis. Lung metastasis was more likely in patients with clear cell carcinoma (53%) than in those with papillary (33%) or chromophobe (33%) renal cell carcinoma. However, those with chromophobe tumors were found to have liver metastasis more commonly than those with clear cell cancer. These associations were only noted in patients who had metastasis at the time of presentation. The site of metastasis did not differ significantly among patients who had metastasis during followup. These findings suggest that there are further undefined biological factors in subtypes of renal cell carcinoma and that some have implications for staging evaluation of cases.

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Seasonal Variation in Urinary Calculi Attacks and Their Association With Climate 

It is commonly recognized that ambient air temperature is associated with the frequency of urinary calculi. This seems to account for some of the recognized geographic and seasonal variation in stone incidence. Whether other climatic factors are important has been less well studied. Chen et al (page 564) from Taipei, Taiwan evaluated stone frequency in Taiwan and correlated it with various meteorological conditions. From 1990 to 2003 a total of 270,302 emergency department visits for urinary calculi were documented. There was a peak incidence in July through September and a sharp decrease in October. This seasonal variation was demonstrable across each gender and age group. Although significant associations were found among ambient temperature, atmospheric pressure and hours of sunshine, only ambient temperature was found to be a major factor after adjustment for trends in seasonality. These results would appear to confirm ambient air temperature as the primary contributor to seasonal and geographic variation in stone incidence. (CME credit article)

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Impact of Obesity in Patients With Urolithiasis 

Lee et al (page 570) from Cheongju, South Korea evaluated the influence of obesity on risk factors for stone disease and stone recurrence rates. From a database of 704 consecutive stone formers they identified 163 patients with more than 36 months of followup for inclusion in their recurrence analysis. Obese stone formers excreted increased amounts of sodium, calcium, uric acid and citrate, and had a decreased urine pH in a 24-hour sample compared to nonobese stone formers (p <0.05). Uric acid stones were more frequently found in obese patients. Obesity was the only strong predictor of recurrence by multivariate analysis in first time stone formers. However, no association between obesity and stone recurrence was detected in recurrent stone formers. The authors concluded that weight control may be considered a preventive modality against stone formation especially in first time stone formers.

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Muscle Tenderness in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome 

Myofascial pain has been suggested as a possible etiology for symptoms related to the chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Shoskes et al (page 556) from Cleveland, Ohio studied 384 men with CPPS and compared them to 121 asymptomatic controls. Seven clinical centers contributed to the study and performed unblinded physical examinations. Overall 51% of patients with CPPS and 7% of controls had any tenderness. The most common site of tenderness was the prostate followed by the external and internal pelvic floor. Tenderness did not correlate with identifiable inflammation or infection in the prostatic fluid. Prostate consistency was normal in 79% of patients with CPPS and 95% of controls, and did not correlate with symptom severity. Since neither the patient nor the examiner was blinded during the study, operator or reporter bias may have substantially influenced the study results. However, interestingly the study did not reveal any correlation between a boggy prostate on physical examination and symptoms. The authors concluded that extraprostatic tenderness may identify a group of patients with a neuromuscular source of pain for CPPS. (CME credit article)

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Should Ureteroileal Anastomosis be Stented? 

Stents are often placed through a ureterointestinal anastomosis to help avoid early obstruction from edema and compression of the anastomosis, or to prevent urine leakage from the healing anastomosis. However, stents sometimes become obstructed and there are at least some surgeons who believe they may contribute to late anastomotic stricture because of mechanical irritation of the suture line. Mattei et al (page 582) from Bern, Switzerland performed a randomized prospective study to evaluate the role of stenting the ureteroileal anastomosis. A total of 54 patients undergoing cystectomy with an ileal bladder substitute or ileal conduit were prospectively randomized into 2 groups. The stents were removed after 5 to 10 days. Patients with stents had a significant decrease in early postoperative upper tract dilatation as well as earlier return of bowel function. However, 3 patients in the stented group required surgical or endoscopic treatment of a ureterointestinal anastomotic stricture during the 12 months of followup, while none of those without stents had secondary intervention for stricture. The overall patient numbers are small and the statistical power to detect meaningful differences in this study is limited. Whether stents ultimately prevent or promote anastomotic strictures is not certain.

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Book Review 

On page 792 Siegel reviews CT Urography: An Atlas.

PII: S0022-5347(07)02912-6

doi:10.1016/j.juro.2007.11.004

The Journal of Urology
Volume 179, Issue 2 , Pages 395-397, February 2008

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