The Impact of Obesity on Urinary Incontinence and Quality of Life
It is well recognized that obesity can influence urinary incontinence and may even lead to its development. However, the data from which this association is derived are often based on poorly quantified symptoms in the absence of urodynamic data. In a multi-institutional study Richter et al (page 622) retrospectively reviewed the results of the SISTer (Stress Incontinence Surgical Treatment Efficacy Trial) and TOMUS (Trial of Mid Urethral Sling). Based on their criteria, 552 of 1,221 women were considered obese. The authors found by objective and subjective measures that urinary incontinence symptoms were increased in these women compared to the cohort that was not obese. On preoperative urodynamic testing obese women had higher baseline intravesical and abdominal pressures than normal weight women. Curiously, in the obese cohort there was less urethral mobility with straining and the Valsalva leak point pressure was higher, which the authors postulate may be explained by a decreased transmission of pressure to the proximal urethra.
Accuracy of PCA3 for Predicting Short-Term Biopsy Progression
PCA3 is a noncoding mRNA overexpressed in prostatic cancer tissue and found in the urine. This biomarker has been proposed as a tool to determine which patients may benefit from repeat prostate biopsy after a negative result. Tosoian et al (page 534) from Baltimore, Maryland questioned whether PCA3 might also be used as a marker to evaluate which patients would benefit from surveillance. They compared the PCA3 score of patients who did and did not experience prostate biopsy progression. PCA3 was not helpful in determining prognosis, or whether there was progression to an unfavorable biopsy or a higher Gleason score. Thus the search continues for better biomarkers for prostate cancer progression and not merely its detection.
Outcomes After Radical Prostatectomy in Men Eligible for Active Surveillance
Which men should receive therapy for a diagnosis of prostate cancer continues to be debated. Adding to the confusion is the lack of standard criteria for active surveillance. Ploussard et al (page 539) from Creteil, France examined radical prostatectomy specimens from men who were eligible for active surveillance using 3 different criteria. Of these patients 94% were recurrence-free and 91.5% did not have biochemical relapse at 3 years. It should be noted that the authors used a 21 core biopsy. It seems that patients who met their criteria for active surveillance did reasonably well. The question remains which if any men actually needed treatment.
Detrusor Overactivity and Postoperative Outcomes in Patients Undergoing Male Bone Anchored Perineal Sling
A reason for failure of stress urinary incontinence procedures in men may be the presence of detrusor overactivity. In this study by Ballert and Nitti (page 641) from Lexington, Kentucky and New York, New York 85 men underwent a male perineal sling procedure for incontinence. Of these patients 72 were evaluated to determine if postoperative success rates correlated with preoperative detrusor overactivity on urodynamics and 22 (30.6%) had detrusor overactivity. All patients completed a global improvement scale outcome measure. There was no significant difference between success and failure of the procedure with regard to detrusor overactivity, although a higher percentage of patients with preoperative detrusor overactivity required postoperative anticholinergics. There was also no difference in the number of patients using pads in either group. Thus the authors conclude that detrusor overactivity per se is not predictive of success or failure of the procedure, a finding similar to studies in women.
Erythrocyte Polyamine Levels and Renal Cell Carcinoma Mortality After Nephrectomy
Polycationic compounds such as spermine and spermidine are valuable prognostic markers, and high tissue levels are associated with a variety of tumors including prostate cancer, leukemia and glioma. Bigot et al (page 486) from Montreal, Quebec, Canada used univariate and multivariate Cox regression models to test the ability of serum spermine and spermidine to predict cancer specific mortality of patients who had undergone radical or partial nephrectomy for renal cell carcinoma. Levels of these polyamines compared well with TNM stage, Fuhrman grade, tumor size and symptom classification. In multivariate analysis of cancer specific mortality after surgery spermine (p=0.007) and spermidine (p=0.04) were independent predictors of survival. In addition these polyamines improved the accuracy of other predictors. The authors conclude that these serum polyamines have a role in prognosis and possibly indications for adjuvant therapy.
Preoperative C-Reactive Protein Predicts Metastasis and Mortality After Nephrectomy for Clear Cell Renal Cell Carcinoma
C-reactive protein is an inflammatory marker associated with tumor and metastasis of renal cell carcinoma. In a study of 130 patients with clinically localized clear cell renal cell carcinoma Johnson et al (page 480) from Atlanta, Georgia found that disease progression 1 year postoperatively correlated with preoperative C-reactive protein levels. Metastases developed in 24.6% of patients and 10.8% died. C-reactive protein discriminated between those patients and the survivors. In multivariate analysis C-reactive protein appeared as a significant predictor of relapse-free survival. This protein may be a useful predictor of prognosis or need for adjuvant therapy, especially if used in conjunction with other biomarkers.
Multivariate Analysis of Risk Factors for Long-Term Urethroplasty Outcome
Outcomes for urethroplasty are variable and thought to be influenced by operative technique and surgeon experience. However, it is also likely that patient characteristics influence restricture rates. Breyer et al (page 613) from San Francisco, California reported stricture recurrence in 93 of 443 patients who underwent urethroplasty. In multivariate analysis smoking, prior direct vision internal urethrotomy, prior urethroplasty and urethral stricture length greater than 4 cm were predictive of treatment failure even in expert hands. Diabetes was not a significant risk factor.
Periureteral Botulinum Toxin Type A Injection for Ureteral Stent Pain Reduction
Botulinum toxin inhibits neurotransmitter release through a complex interaction with proteins regulating the binding of synaptic vesicles to the nerve terminal. Because certain nerve transmitters contained within vesicles are involved in pain processing, Gupta et al (page 765) from New York, New York postulate that botulinum toxin may be used to treat conditions associated with pain. One such scenario is the use of ureteral stents which can trigger pain. In an innovative randomized study the authors administered 3 injections of botulinum toxin A, 10 units per ml in each injection, to locations around the ureteral orifice in patients receiving a unilateral ureteral stent and compared the results to those of patients receiving a stent and no injection. This double-blind study revealed a decrease in postoperative pain (p=0.02) and postoperative narcotic use (p=0.03) associated with the stent in the botulinum group compared to controls. However, there was no significant difference in postoperative lower urinary tract symptoms between the groups based on the Ureteral Stent Symptom Questionnaire. The authors conclude that periureteral botulinum toxin does improve tolerability of ureteral stents in this small study.
Erectile Dysfunction After Anterior Urethroplasty
Because of the ability of urethroplasty to potentially interrupt cavernous blood flow, Erickson et al (page 657) from Chicago, Illinois retrospectively reviewed the records of 52 men who underwent anterior urethroplasty to ascertain whether the procedure could lead to erectile dysfunction. Bulbar urethroplasty was performed in 35 men and a more distal urethroplasty of the pendulous urethra was performed in 17. Of the bulbar urethroplasty group 20 underwent excision and primary anastomosis, and augmented anastomotic repair was performed in 15. Postoperative erectile dysfunction was noted in 20 men, of whom 18 recovered fully within 6 to 7 months. In patients with normal preoperative erectile function bulbar urethroplasty was more likely than penile urethroplasty to cause erectile dysfunction (76% vs 38%, p=0.05). The authors conclude that anterior urethroplasty can cause erectile dysfunction in nearly 40% of patients but function recovers within 6 months in most. Thus, it is important to inform patients of this potential morbidity before surgery especially if performing a bulbar urethroplasty.
Robotic Radical Cystectomy for Bladder Cancer
Robotic assisted laparoscopic radical cystectomy is rapidly becoming the preferred approach for the treatment of advanced bladder cancer. Justification for robotic cystectomy includes less trauma and blood loss with the potential for more rapid recovery or reduced morbidity. In this single institution retrospective series Pruthi et al (page 510) from Chapel Hill, North Carolina evaluated 100 consecutive patients who had undergone robotic radical cystectomy and urinary diversion. Mean operative time was only 4.6 hours and blood loss was 271 ml. Tumor was pT1 or less in 40% of patients, pT2 in 27%, pT3/4 in 13% and node positive in 20%. Mean number of lymph nodes removed associated with this technique was 19. There were 41 postoperative complications in 36 patients, including Clavien grade 3 or higher major complication in 8%, and the rehospitalization rate was 11%. At a mean followup of 21 months 15 patients had disease recurrence and 6 died. Although this approach is feasible, prospective randomized trials are needed to help clarify whether robotic cystectomy offers advantages or limitations compared to the open procedure.
FULL TEXT