This Month in Adult Urology

Article Outline

• Small Incidentally Discovered Testicular Masses in Infertile Men
• Decreased Electrosurgical Transurethral Resection Training is Associated With Increased Surgical Adverse Events
• Outcomes of Patients Lost to Followup After Mid Urethral Synthetic Slings
• [-2]ProPSA is Accurate for Differentiating Prostate Cancer From Benign Disease
• Acitretin for Severe Lichen Sclerosus of Male Genitalia
• Segmental Ureterectomy Can be Performed Safely for Transitional Cell Carcinoma of the Ureter
• A Novel Reverse Thermosensitive Polymer to Prevent Ureteral Stone Retropulsion During Lithotripsy
• Are Sonographic Characteristics Associated With Progression to Surgery for Peyronie's Disease?
• Unverifiable Publications of Urology Training Program Applicants
• Results From the SUmiT Trial
• Copyright

Back to Article Outline

Small Incidentally Discovered Testicular Masses in Infertile Men 

Toren et al (page 1373) from Toronto, Ontario, Canada examined a large database of patients undergoing treatment for infertility for small testicular masses. Of men undergoing scrotal ultrasound during infertility evaluation 46 (1%) had a small nonpalpable testicular mass with a mean diameter of 1.3 mm. The men were followed and 8 subsequently underwent orchiectomy when the doubling time reached 3 to 6 months, of whom 1 had seminoma. The authors suggest that for patients with small nonpalpable testicular masses and negative tumor markers, examination of doubling time may be sufficient to determine if orchiectomy is warranted. This study and the literature suggest that 6 months of surveillance may be adequate.

Back to Article Outline

Decreased Electrosurgical Transurethral Resection Training is Associated With Increased Surgical Adverse Events 

The operative data case logs presented to the Accreditation Council for Graduate Medical Education from graduating chief residents from academic years 2001 to 2007 were reviewed by Sandhu et al (page 1515) from New York, New York. The number of electrosurgical prostatic transurethral resections decreased 26% during this period from an average of 58 to 43 procedures. However, laser procedures began increasing in 2004. The authors also noticed that adverse events associated with electrosurgical procedures increased from 3% in 2001 to 6% in 2007. They infer that the 26% decrease in experience correlates with the increase in adverse events, although the study was not powered to detect such change or controlled for increased reporting of adverse events in recordkeeping during this period.

Back to Article Outline

Outcomes of Patients Lost to Followup After Mid Urethral Synthetic Slings 

Debate continues on the true success rate of stress incontinence surgery in women, especially when patients are lost to followup. In “intent to treat” analyses these cases are considered failures while in “last observation carried forward analysis” outcomes are extrapolated. Ballert et al (page 1455) from Kentucky and New York evaluated 217 patients who underwent mid urethral synthetic sling and used the Patient Impression of Improvement Scale as the outcome measure for those without a 3-month followup. Of 48 patients who responded the failure rate was 27% for 13 without 3 months of followup while the overall failure rate was 19% for patients with 3 months of followup. The authors reported a 73% success rate for patients lost to followup, which was not significantly different although lower than the 81% success rate for patients with 3 months of followup. They conclude that neither the intent to treat or last observation carried forward analysis accurately gauges the outcomes of study populations.

Back to Article Outline

[-2]ProPSA is Accurate for Differentiating Prostate Cancer From Benign Disease 

In the ongoing quest for better biomarkers for prostate cancer, Le et al (page 1355) from Chicago, Illinois performed a prospective study of more than 2,000 men undergoing prostate cancer screening to determine the usefulness of a precursor isoform of PSA, [-2]proPSA, called p2PSA, vs free PSA as well as total PSA to predict a positive biopsy. Of 322 men recommended to undergo biopsy after screening 74 complied with the recommendation for biopsy at the time of reporting. Overall 41% of these men were diagnosed with prostate cancer on biopsy. No significant difference in total PSA was noted when positive biopsies were compared to negative biopsies. Men diagnosed with prostate cancer had a significantly lower median free PSA and a significantly higher p2PSA. The percentage of positive biopsies continuously increased with increasing p2PSA tertiles (p=0.002). In ROC analysis total PSA alone lacked sensitivity and specificity in the 2.5 to 10 ng/ml range (AUC=0.50), while free PSA (AUC=0.68) and p2PSA (AUC=0.77) demonstrated more favorable performance. Setting the level of sensitivity at 88.5%, p2PSA led to substantial improvement in specificity over free or total PSA.

Back to Article Outline

Acitretin for Severe Lichen Sclerosus of Male Genitalia 

Acitretin is a synthetic retinoid used to treat genital lichen sclerosis in women which to my knowledge has not been studied in a randomized controlled setting in men. Ioannides et al (page 1395) from Thessaloniki, Greece performed a prospective randomized study of the effect of acitretin on steroid resistant lichen sclerosis of the penis. The primary outcome measure used was a total clinical score which represented the sum of 6 different rates resulting from the 3 different parameters of symptoms, signs and extent of lesions. Of 51 patients 49 completed the trial and were eligible for statistical analysis. Complete or partial response was achieved in 36.4% and 36% of the acitretin group, and 6.3% and 12% of the controls, respectively. The efficacy of acitretin did not become evident until late in the 36-week study and durability decreased with time, suggesting a longer duration of treatment for this new therapeutic option for lichen sclerosis.

Back to Article Outline

Segmental Ureterectomy Can be Performed Safely for Transitional Cell Carcinoma of the Ureter 

Traditional teaching states that for upper tract transitional cell carcinoma (TCC), nephroureterectomy is the treatment of choice. More controversy exists about lower ureteral tumors, especially if they are higher stage or grade. Jeldres et al (page 1324) from Montreal, Quebec, Canada performed the largest study to date comparing nephroureterectomy to segmental ureterectomy for ureteral TCC. Regardless of T stage (T1 to T4) the cancer specific mortality rates at 30 months were similar after segmental ureterectomy (86.6%) and nephroureterectomy (82%). The authors conclude that segmental ureterectomy can be safely performed in selected patients with ureteral TCC, confirming standard recommendations.

Back to Article Outline

A Novel Reverse Thermosensitive Polymer to Prevent Ureteral Stone Retropulsion During Lithotripsy 

Ureteroscopy with laser lithotripsy is rapidly becoming the treatment of choice for lower ureteral stones. However, during procedures smaller stones can be dislodged into the upper ureter or ureteral pelvis, making treatment more difficult. In a multi-institutional study Rane et al (page 1417) evaluated a novel thermosensitive polymer called BackStop™ which is injected just beyond the stone to form a temporary plug preventing retropulsion. The plug is later dissolved by cool irrigation. Ureteroscopic lithotripsy was associated with a lower rate of retropulsion in the BackStop group (8.8%) compared to the control group (52.9%). The authors suggest that this thermosensitive polymer may be of some benefit to ureteroscopic lithotripsy.

Back to Article Outline

Are Sonographic Characteristics Associated With Progression to Surgery for Peyronie's Disease? 

The diagnosis and treatment of Peyronie's disease have been based on physical examination and history with no prognostic indicators predicting which patients will require surgery. In this retrospective cohort study of 518 patients with Peyronie's disease Breyer et al (page 1484) from San Francisco, California evaluated the use of penile ultrasound to measure sub-tunical calcifications, septal fibrosis, tunical thickening and intracavernosal fibrosis to determine whether any of these factors predict the future need for surgery. Progression to surgery was determined from a retrospective review of the medical records. Overall 25% of the cohort required surgical intervention after an average followup of 1.25 years. In addition to severity of curvature, the only prognostic ultrasound indicator of which patients were most likely to undergo surgery was sub-tunical calcifications on the first visit (OR 1.75, 95% CI 1.16–2.62).

Back to Article Outline

Unverifiable Publications of Urology Training Program Applicants 

Nosnik et al (page 1520) from New York, New York reviewed the applications of 147 applicants to 1 institution in the 2007 cycle to determine the incidence of resume fraud among urology residents. The publications in the resumes were queried on PubMed®, Google™ Scholar and MEDLINE®. Overall 19% of applicants who submitted publications had at least 1 unverifiable publication, representing 9% of the entire applicant pool. There were no significant associations between applicant demographics and misrepresented publications. While the incidence of unverifiable publications was low, it does raise questions about the ethics of applicants. However, the authors assumed PubMed, Google Scholar and MEDLINE capture all publications, which is not the case for some unlisted periodicals.

Back to Article Outline

Results From the SUmiT Trial 

Failure of antimuscarinics for overactive bladder represents a therapeutic challenge. Neuromodulation has been the treatment of choice but implantable devices are costly and subject to reoperation. In the SUmiT (Study of Urgent® PC vs. Sham Effectiveness in Treatment of Overactive Bladder Symptoms) trial 220 adults with overactive bladder symptoms were randomized to 12 weeks of percutaneous tibial nerve stimulation (PTNS) or sham (page 1438). Intent to treat analysis was used, and the primary end point was a global response assessment to identify patients whose symptoms were markedly or moderately improved. Improvement in bladder symptoms (moderately or markedly improved) was seen in 54.5% of the treatment group vs 20.9% of the sham subjects. Voiding diaries after 12 weeks showed the PTNS group had improvements in frequency, nighttime voiding, voiding with moderate to severe urgency and urinary urge incontinence episodes. This multicenter, double-blind, randomized controlled trial provides evidence that PTNS is safe and relatively effective for patients with overactive bladder. It should be noted that antimuscarinics were discontinued 2 weeks before the study and 66% to 69% of patients had used medications within 6 months of the trial.