The Journal of Urology - Articles in Press

Re: Effect of Suturing Technique and Urethral Plate Characteristics on Complication Rate Following Hypospadias Repair: A Prospective Randomized Study: O. Sarhan, M. Saad, T. Helmy and A. HafezJ Urol 2009; 182: 682–686 - Corrected Proof

Warren T. Snodgrass — 2010-03-04

The authors performed a prospective randomized surgical trial and concluded urethral plate width 8 mm or greater was essential for successful tubularized incised plate (TIP) repair. However, patients were randomized to study the effect of urethroplasty suturing technique (continuous vs interrupted), not urethral plate width, and so it is possible that other factors explain the outcomes attributed to variations in plate width. For example the authors observed a significantly greater complication rate after mid penile than distal repair but did not state if patients with plate widths 8 mm or less were evenly distributed by extent of hypospadias defect.

Re: Effect of Suturing Technique and Urethral Plate Characteristics on Complication Rate Following Hypospadias Repair: A Prospective Randomized Study - Corrected Proof

Emre Huri, Turgay Akgül, Cankon Germiyanoğlu — 2010-03-04

Hypospadias is an important penile deformity and should be treated by an experienced hypospadiologist. The main aim of hypospadias repair should be to provide a regular meatal appearance with excellent functional and cosmetic results without complication. The causes of increased complications following surgery are still controversial.

Diagnostic Urology, Urinary Diversion and Perioperative Care - Corrected Proof

Richard K. Babayan — 2010-02-26

A. J. Gross and T. Bach Abteilung fur Urologie, Asklepios Hospital Barmbek, Hamburg, Germany

Socioeconomic Factors, Urological Epidemiology and Practice Patterns - Corrected Proof

David F. Penson — 2010-02-26

J. M. Hollingsworth, Z. Ye, S. A. Strope, S. L. Krein, A. T. Hollenbeck and B. K. Hollenbeck RWJ Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan

Comparative Effectiveness of Prostate Cancer Surgical Treatments: A Population Based Analysis of Postoperative Outcomes - Corrected Proof

2010-02-25

Purpose: Enthusiasm for laparoscopic surgical approaches to prostate cancer treatment has grown despite limited evidence of improved outcomes compared with open radical prostatectomy. We compared laparoscopic prostatectomy with or without robotic assistance vs open radical prostatectomy in terms of postoperative outcomes and subsequent cancer directed therapy.Materials and Methods: Using a population based cancer registry linked with Medicare claims we identified men 66 years old or older with localized prostate cancer who underwent radical prostatectomy from 2003 to 2005. Outcome measures were general medical/surgical complications and mortality within 90 days after surgery, genitourinary/bowel complications within 365 days, radiation therapy and/or androgen deprivation therapy within 365 days and length of hospital stay.Results: Of the 5,923 men 18% underwent laparoscopic radical prostatectomy. Adjusting for patient and tumor characteristics, there were no differences in the rate of general medical/surgical complications (OR 0.93 95% CI 0.77–1.14) or genitourinary/bowel complications (OR 0.96 95% CI 0.76–1.22), or in postoperative radiation and/or androgen deprivation (OR 0.80 95% CI 0.60–1.08). Laparoscopic prostatectomy was associated with a 35% shorter hospital stay (p <0.0001) and a lower bladder neck/urethral obstruction rate (OR 0.74, 95% CI 0.58–0.94). In laparoscopic cases surgeon volume was inversely associated with hospital stay and the odds of any genitourinary/bowel complication.Conclusions: Laparoscopic prostatectomy and open radical prostatectomy have similar rates of postoperative morbidity and additional treatment. Men considering prostate cancer surgery should understand the expected benefits and risks of each technique to facilitate decision making and set realistic expectations.

Editorial Comment - Corrected Proof

Yair Lotan — 2010-02-25

The introduction of robotics brought great hope for improved outcomes of surgery for prostate cancer. This population based analysis of Medicare patients who underwent surgery for prostate cancer from 2003 to 2005 shows no significant difference in complications or the need for adjuvant therapy between the open and laparoscopic/robotic approaches. While the study suffers from the fact that many surgeons performing robotic assisted laparoscopic prostatectomy may have been in their learning curve since analysis was based on cases from 4 to 6 years ago, findings are supported by a recent meta-analysis showing no advantage in oncological outcomes, continence, potency or complications for laparoscopic or robotic approaches vs open prostatectomy (reference 9 in article). These authors found that the main advantage of laparoscopic approaches is decreased length of stay.

Re: Predictors of Surgical Approach to Repair Pelvic Fracture Urethral Distraction Defects: M. M. Koraitim J Urol 2009; 182: 1435–1439 - Corrected Proof

Sananda Bag, Mayank M. Agarwal, Shrawan K. Singh, Arup K. Mandal — 2010-02-24

We read this article with interest. Koraitim retrospectively analyzed clinicoradiological parameters as predictors of the need for progression during urethroplasty, so that the operation can be planned more objectively. The author devised a gapometry/urethrometry (GU) index. An index of less than 0.35 indicated execution of urethroplasty by simple perineal operation, whereas an index of greater than 0.35 was associated with urethroplasty by an involved perineal or transpubic procedure. Involved perineal and transpubic procedures have different implications in terms of complexity and extent of surgery. The readers might wish to know which category of patients would require transpubic procedures or otherwise. Therefore, it would have been more appropriate to subcategorize cases with a GU index of greater than 0.35 accordingly, to make the data more informative.

Urolithiasis/Endourology - Corrected Proof

Dean Assimos — 2010-02-24

S. Fargue, J. Harambat, M. F. Gagnadoux, M. Tsimaratos, F. Janssen, B. Llanas, J. P. Bertheleme, B. Boudailliez, G. Champion, C. Guyot, M. A. Macher, H. Nivet, B. Ranchin, R. Salomon, S. Taque, M. O. Rolland and P. Cochat

Laparoscopy/New Technology - Corrected Proof

Jeffrey A. Cadeddu, Jeffrey A. Cadeddu — 2010-02-24

S. D. Wu, O. A. Lesani, L. C. Zhao, W. K. Johnston, J. S. Wolf, Jr., R. V. Clayman and R. B. Nadler Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Urological Oncology: Renal, Ureteral and Retroperitoneal Tumors - Corrected Proof

Fray F. Marshall — 2010-02-24

P. L. Crispen, R. Viterbo, S. A. Boorjian, R. E. Greenberg, D. Y. Chen and R. G. Uzzo Section of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Medical Center, Philadelphia, Pennsylvania

Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology - Corrected Proof

James E. Montie — 2010-02-24

V. Serretta, V. Altieri, G. Morgia, R. Allegro, A. Ruggirello, A. Di Lallo, G. Carrieri and D. Melloni; Members of Foundation Gruppo Studi Tumori Urologici (GSTU) Institute of Urology, University of Palermo, Palermo, Italy

Socioeconomic Factors, Urological Epidemiology and Practice Patterns - Corrected Proof

David F. Penson — 2010-02-24

K. M. Christie, B. E. Meyerowitz, A. Giedzinska-Simons, M. Gross and D. B. Agus Department of Psychology, University of Southern California, Los Angeles, California

Imaging - Corrected Proof

Cary Siegel — 2010-02-24

A. M. Hovels, R. A. Heesakkers, E. M. Adang, J. O. Barentsz, G. J. Jager and J. L. Severens Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

Urological Oncology: Testis Cancer - Corrected Proof

Jerome P. Richie — 2010-02-24

H. S. Haugnes, N. Aass, S. D. Fossa, O. Dahl, M. Brydoy, U. Aasebo, T. Wilsgaard and R. M. Bremnes Department of Oncology, Institute of Clinical Medicine, University of Tromso, Tromso, Norway

Should Pelvic Lymph Node Dissection be Performed With Radical Prostatectomy? - Corrected Proof

Urs E. Studer — 2010-02-24

When performing radical prostatectomy for prostate cancer extended pelvic lymph node dissection should be considered for 6 reasons. 1) Histopathological examination of removed pelvic lymph nodes is the most accurate staging procedure. Imaging studies can detect only gross nodal disease with enlarged lymph nodes. Such patients can rarely be cured by surgery alone. Newer technologies, such as diffusion-weighted magnetic resonance imaging enhanced with ultrasmall superparamagnetic particles of iron oxide, which seem to allow detection of metastasis greater than 2 mm in normal sized nodes are still under investigation.

Erratum - Corrected Proof

2010-02-24

Volume 183, No. 1, Pages 43 and 45: In the Abstract and in the Results multivariate analysis for associated risk factors MDRD (Modification of Diet in Renal Disease) is p = 0.03 as listed. In table 3 the Race is African-American.

Errata - Corrected Proof

2010-02-24

Volume 183, Number 2, Page 546: The name of the second author listed is Swati Yalamanchi.

Screening Agents for Preventive Efficacy in a Bladder Cancer Model: Study Design, End Points, and Gefitinib and Naproxen Efficacy - Corrected Proof

Ronald A. Lubet, Vernon E. Steele, M. Margaret Juliana, Clinton J. Grubbs — 2010-02-22

Purpose: We optimized agent testing in an in vivo bladder cancer model and determined the most sensitive, relevant protocol to test efficacy in clinical prevention trials.Materials and Methods: Female Fischer-344 rats (Harlan™) were treated with the bladder carcinogen OH-BBN (TCI America, Portland, Oregon) for 8 weeks. Rats were treated with naproxen (400 mg/kg diet), aspirin (Sigma®) (300 or 3,000 mg/kg diet), Iressa® (10 mg/kg body weight daily) or resveratrol (1,000 mg/kg diet) using 1 of 3 protocols, including treatment beginning 1) 1 week after OH-BBN and continuing for 7 months, 2) 3 months after OH-BBN after microscopic lesions already existed and continuing for 3 months, and 2) 1 week after OH-BBN and continuing for 4 months. In protocols 1 and 2 bladder lesion weight and large tumors were primary end points, and in protocol 3 microscopic cancer was the end point.Results: Using protocol 1 naproxen, Iressa, resveratrol, and low and high dose aspirin altered the formation of large bladder tumors by 87% (decreased), 90% (decreased), 3% (increased), 6% (decreased) and 60% (decreased), respectively. Using protocol 2 Iressa and naproxen were also highly effective. Protocol 3 evaluation revealed that only Iressa caused a significant decrease in microscopic bladder cancers (63%).Conclusions: Initiating treatment after OH-BBN or when bladder lesions already existed showed naproxen and Iressa to be effective in preventing formation of large cancers. Low dose aspirin and resveratrol were ineffective. In protocol 3, in which microscopic lesions were the end point and only Iressa was effective. Thus, an established cancer end point appears preferable. Naproxen, which has an excellent cardiovascular profile, or epidermal growth factor receptor inhibitors may be effective in an adjuvant setting.

Adrenomedullin Increases Renal Nitric Oxide Production and Ameliorates Renal Injury in Mice With Unilateral Ureteral Obstruction - Corrected Proof

2010-02-22

Purpose: We evaluated the effects of adrenomedullin (Peptide Institute, Minoh-shi, Osaka, Japan) on mediators, including nitric oxide and transforming growth factor-β, and parameters of renal injury in a murine unilateral ureteral obstruction model.Materials and Methods: Three study groups of control, adrenomedullin treated and adrenomedullin plus L-NAME treated BALB/C mice, respectively, underwent left unilateral ureteral obstruction. A 24-hour urine sample was collected to measure urinary NO2/NO3 1 day before unilateral ureteral obstruction and kidneys were harvested on postoperative day 14. Tubulointerstitial damage markers were evaluated by immunohistochemistry. Tissue transforming growth factor-β was determined by enzyme-linked immunosorbent assay. Endothelial and inducible nitric oxide synthase immunolocalization was also determined.Results: Urinary NO2/NO3 was significantly higher in the adrenomedullin group than in controls, confirming increased renal nitric oxide production. Immunohistochemistry showed increased endothelial nitric oxide synthase in vascular endothelial cells in the adrenomedullin group but tissue transforming growth factor-β did not significantly differ in controls vs the adrenomedullin group. Interstitial collagen deposition and fibroblasts in the obstructed kidney were significantly decreased in the adrenomedullin group. The number of leukocytes and apoptotic cells in the obstructed kidney were significantly decreased by adrenomedullin. Renal injury amelioration resulting from adrenomedullin was blunted by the nitric oxide synthase inhibitor L-NAME.Conclusions: Adrenomedullin increased renal nitric oxide, and suppressed tubular apoptosis, interstitial fibrosis and inflammatory cell infiltration in mice with unilateral ureteral obstruction. The renoprotective peptide adrenomedullin may be useful for that condition.

Effect of Isocaloric Low Fat Diet on Prostate Cancer Xenograft Progression in a Hormone Deprivation Model - Corrected Proof

2010-02-22

Purpose: Previous mouse studies suggesting that low fat diets slow prostate cancer growth often used corn oil (ω-6), which enhances prostate cancer growth, as the primary fat. Using a saturated fat based diet we previously found no significant difference in tumor growth between low and high fat fed SCID mice (Taconic Farms, Hudson, New York) xenografted with LAPC-4 cells. Whether similar results would hold in a castration model is unclear.Materials and Methods: A total of 80 male SCID mice were fed a Western diet (40% fat and 44% carbohydrate) and injected with LAPC-4 human prostate cancer cells. When tumors were 200 mm3, the mice were castrated and randomized to an isocaloric Western or a low fat diet (12% fat and 72% carbohydrate). Animals were sacrificed when tumors were 1,000 mm3. Serum was collected and assayed for prostate specific antigen, insulin, insulin-like growth factor 1 and insulin-like growth factor binding protein 3. Tumors were assayed for total and phosphorylated Akt.Results: Mouse weight was equivalent in the 2 groups. Overall dietary group was not significantly associated with survival (log rank p = 0.32). There were no statistically significant differences in prostate specific antigen (p = 0.53), insulin-like growth factor axis parameters (each p >0.05) or p-Akt-to-t-Akt ratios (p = 0.22) between the groups at sacrifice.Conclusions: In this xenograft model we found no difference in tumor growth or survival between low fat vs Western fed mice when the fat source was saturated fat. These results conflict with those of other studies in which corn oil was used to show that low fat diets delay prostate cancer growth, suggesting that fat type may be as important as fat amount in the prostate cancer setting.

Comprehensive 5-Year Study of Cytogenetic Aberrations in 668 Infertile Men - Corrected Proof

2010-02-22

Purpose: The causes of male infertility are heterogeneous but more than 50% of cases have a genetic basis. Specific genetic defects have been identified in less than 20% of infertile males and, thus, most causes remain to be elucidated. The most common cytogenetic defects associated with nonobstructive azoospermia are numerical and structural chromosome abnormalities, including Klinefelter syndrome (47,XXY) and Y chromosome microdeletions. To refine the incidence and nature of chromosomal aberrations in males with infertility we reviewed cytogenetic results in 668 infertile men with oligozoospermia and azoospermia.Materials and Methods: High resolution Giemsa banding chromosome analysis and/or fluorescence in situ hybridization were done in 668 infertile males referred for routine cytogenetic analysis between January 2004 and March 2009.Results: The overall incidence of chromosomal abnormalities was about 8.2%. Of the 55 patients with abnormal cytogenetic findings sex chromosome aneuploidies were observed in 29 (53%), including Klinefelter syndrome in 27 (49%). Structural chromosome abnormalities involving autosomes (29%) and sex chromosomes (18%) were detected in 26 infertile men. Abnormal cytogenetic findings were observed in 35 of 264 patients (13.3%) with azoospermia and 19 of 365 (5.2%) with oligozoospermia.Conclusions: Structural chromosomal defects and low level sex chromosome mosaicism are common in oligozoospermia cases. Extensive cytogenetic assessment and fluorescence in situ hybridization may improve the detection rate in males with oligozoospermia. These findings highlight the need for efficient genetic testing in infertile men so that couples may make informed decisions on assisted reproductive technologies to achieve parenthood.

Enhanced Oncolytic Activity of Vesicular Stomatitis Virus Encoding SV5-F Protein Against Prostate Cancer - Corrected Proof

2010-02-22

Purpose: Vesicular stomatitis virus has been investigated as an oncolytic agent for cancer therapy because it preferentially replicates in tumor but not in normal cells due to the lack of a robust interferon antiviral system in transformed cells. However, wild-type vesicular stomatitis virus can induce a strong systemic immunological response and replicate in the central nervous system, potentially limiting its clinical usefulness. We report the construction of the recombinant, replication restricted vesicular stomatitis virus encoding SV5-F, which can induce syncytial formation with enhanced oncolytic properties against TRAMP-C2 tumors in an immunocompetent mouse model of prostate cancer.Materials and Methods: We constructed the SV5-F recombinant restricted virus vector by replacing the vesicular stomatitis virus G gene with that of the SV5-F transgene to generate rVSV-ΔG-SV5-F. Morphological changes and DNA fragmentation induced by rVSV-ΔG-GFP or rVSV-ΔG-SV5-F were determined by phase contrast microscopy and gel electrophoresis. In vitro cytotoxicity by recombinant vesicular stomatitis virus was done by MTT assay. In vivo study of rVSV treatment was done in immunocompetent mice by subcutaneous administration of TRAMP-C2 cells.Results: In vitro characterization of the recombinant fusogenic VSV-ΔG vector on TRAMP-C2 cells showed significantly enhanced apoptotic and cytotoxic effects relative to a similar virus encoding green fluorescent protein, that is rVSV-ΔG-GFP. Regardless of initial tumor size intratumor rVSV-ΔG-SV5-F administration in mice bearing subcutaneous TRAMP-C2 tumors resulted in a significantly reduced tumor load over that of the nonfusogenic green fluorescent control virus and of heat inactivated recombinant vesicular stomatitis virus in treated animals (p <0.01).Conclusions: Results show that G complemented recombinant VSV-ΔG vectors, especially rVSV-ΔG-SV5-F, are an effective oncolytic agent against mouse prostate cancer cells in vitro and in an in vivo immunocompetent mouse model system.

Extracellular Matrix Associated Protein CYR61 is Linked to Prostate Cancer Development - Corrected Proof

2010-02-22

Purpose: The cancer cell microenvironment includes complex interactions between the cell and the extracellular matrix. Expression of the CCN family of extracellular matrix associated proteins is often modified in disease states. Depending on cancer type these changes are linked with enhanced or inhibited tumor growth. We characterized Cyr61 in prostate cancer. Cyr61 is an integrin binding matricellular protein with altered expression in many cancer types.Materials and Methods: Cyr61 expression in prostate cancer, benign prostatic hyperplasia and normal tissues was evaluated by microarray analysis, quantitative real-time polymerase chain reaction and tissue microarray. Immunoblots were analyzed to assess endogenous protein expression in prostate cancer cell lines.Results: On genomic analysis Cyr61 up-regulation was observed in prostate cancer tissue and in normal prostate tissue adjacent to tumor vs that in prostate donor tissue. In 174 matched tumors and normal prostate tissues adjacent to tumor tissue microarray revealed significantly up-regulated Cyr61 protein expression in cancer tissue vs normal prostate tissue adjacent to tumor. Also, increased Cyr61 expression correlated with Gleason sum 8 or greater cancer. Staining in high grade prostatic intraepithelial neoplasia was moderately up-regulated vs that in normal prostate tissue adjacent to tumor but generally less intense than in carcinoma tissue.Conclusions: In addition to the correlation with more advanced disease, the strong association between Cyr61 expression and prostate cancer supports the potential usefulness of Cyr61 as a novel biomarker for prostate cancer. This warrants further analysis to determine the mechanisms by which Cyr61 may contribute to prostate cancer development and progression.

α-Melanocyte Stimulating Hormone Analogue AP214 Protects Against Ischemia Induced Acute Kidney Injury in a Porcine Surgical Model - Corrected Proof

2010-02-22

Purpose: α-Melanocyte stimulating hormone protects kidneys against ischemia and sepsis induced acute kidney injury in rodents. We examined the efficacy of α-melanocyte stimulating hormone analogue AP214 to protect against acute kidney injury in higher vertebrates.Materials and Methods: We performed a prospective, blinded, randomized, placebo controlled study in 26 pigs. Laparoscopic technique was used for left nephrectomy and to induce complete warm ischemia in the right kidney for 120 minutes. AP214 (200 μg/kg intravenously) was administered daily on the day of surgery and for 5 days thereafter. Kidney function was measured for 9 days. We measured changes in serum creatinine, estimated glomerular filtration rate, serum C-reactive protein and urine interleukin-18.Results: In the placebo control and AP214 groups mean peak serum creatinine was 10.2 vs 3.92 mg/dl and the estimated glomerular filtration rate nadir was 22.9 vs 62.6 ml per minute per kg (each p = 0.001). Functional nadir occurred at 72 vs 24 hours in the control vs AP214 groups. Estimated glomerular filtration rate outcome on postoperative day 9 was 118 vs 156 ml per minute per kg in the control vs AP214 groups (p = 0.04).Conclusions: We noted a robust renoprotective effect of AP214. A similar AP214 effect may be observed in humans. Future research includes mechanistic studies in pigs and a phase II human clinical trial of AP214 in kidney transplant and partial nephrectomy populations.

HAMLET Treatment Delays Bladder Cancer Development - Corrected Proof

2010-02-22

Purpose: HAMLET is a protein-lipid complex that kills different types of cancer cells. Recently we observed a rapid reduction in human bladder cancer size after intravesical HAMLET treatment. In this study we evaluated the therapeutic effect of HAMLET in the mouse MB49 bladder carcinoma model.Materials and Methods: Bladder tumors were established by intravesical injection of MB49 cells into poly L-lysine treated bladders of C57BL/6 mice. Treatment groups received repeat intravesical HAMLET instillations and controls received α-lactalbumin or phosphate buffer. Effects of HAMLET on tumor size and putative apoptotic effects were analyzed in bladder tissue sections. Whole body imaging was used to study HAMLET distribution in tumor bearing mice compared to healthy bladder tissue.Results: HAMLET caused a dose dependent decrease in MB49 cell viability in vitro. Five intravesical HAMLET instillations significantly decreased tumor size and delayed development in vivo compared to controls. TUNEL staining revealed selective apoptotic effects in tumor areas but not in adjacent healthy bladder tissue. On in vivo imaging Alexa-HAMLET was retained for more than 24 hours in the bladder of tumor bearing mice but not in tumor-free bladders or in tumor bearing mice that received Alexa-α-lactalbumin.Conclusions: Results show that HAMLET is active as a tumoricidal agent and suggest that topical HAMLET administration may delay bladder cancer development.

Continence Definition After Radical Prostatectomy Using Urinary Quality of Life: Evaluation of Patient Reported Validated Questionnaires - Corrected Proof

2010-02-22

Purpose: After radical prostatectomy continence is commonly defined as no pads except a security pad or 0 to 1 pad. We evaluated the association of pad status and urinary quality of life to determine whether security and 1 pad status differ from pad-free status to better define 0 pads as the post-prostatectomy standard.Materials and Methods: A total of 500 consecutive men underwent robot assisted radical prostatectomy from October 2003 to July 2007. Data were collected prospectively and entered into an electronic database. Postoperatively men completed self-administered validated questionnaires including questions on 1) daily pad use (0, security, 1, or 2 or more), 2) urine leakage (daily, about once weekly, less than once weekly or not at all), 3) urinary control (none, frequent dribbling, occasional dribbling or total control), 4) American Urological Association symptom score and 5) urinary quality of life.Results: Postoperatively men who indicated 0 pad use had a mean ± SE symptom score of 5.8 ± 0.3 and pleased quality of life (1.16 ± 0.08). In contrast, men with a security pad and 1 pad had a symptom score of 7.6 ± 0.7 and 9.2 ± 0.6 but mixed quality of life (2.78 ± 0.18 and 3.41 ± 0.15, respectively, p <0.0005).Conclusions: Results show a significant decrease in quality of life between no pads (1.16 or pleased), a security pad and 0 or 1 pad (2.78 and 3.41 or mixed, respectively). Findings do not support defining continence with a security pad or 0 to 1 pad. Continence should be strictly defined as 0 pads.

Outcomes of Patients Lost to Followup After Mid Urethral Synthetic Slings—Successes or Failures? - Corrected Proof

Katie N. Ballert, Amy E. Rose, Grace Y. Biggs, Nirit Rosenblum, Victor W. Nitti — 2010-02-22

Purpose: We classified patients lost to followup after mid urethral synthetic sling placement as examples of treatment success or failure based on the Patient Global Impression of Improvement, and compared the outcomes of those who followed up to the outcomes of those who did not.Materials and Methods: We reviewed the charts of 217 patients who underwent mid urethral synthetic sling placement. Telephone interviews including the Patient Global Impression of Improvement and the Medical, Epidemiological, and Social Aspects of Aging questionnaires were conducted for patients lacking 3-month followup.Results: Based on the Patient Global Impression of Improvement of the 48 patients who responded 13 (27.1%) were failures. The overall failure rate of patients with at least 3-month followup was 19% (23 of 124).Conclusions: In our study success rates for patients lost to followup were similar to the rates for those who had routine followup. However, it is uncertain if these data can be applied to other study populations, especially in a randomized controlled trial.

Can Advance Transobturator Sling Suspension Cure Male Urinary Postoperative Stress Incontinence? - Corrected Proof

Erik B. Cornel, Henk W. Elzevier, Hein Putter — 2010-02-22

Purpose: In a prospective 2-center study we confirmed and extended published results of the positive effect on post-prostatectomy stress incontinence of transobturator sling suspension using an Advance™ male sling.Materials and Methods: From September 2007 to June 2008 a male sling was placed and evaluated in 36 men according to the Rehder and Gozzi method. Diagnosis was based on 24-hour urine loss measured by a pad test, a 24-hour micturition frequency volume chart and cystoscopy. A visual analog scale for continence and bother, and a pad test were used preoperatively and postoperatively to objectively evaluate operative results.Results: At 1-year followup cure was achieved in 9.0% of patients and improvement was achieved in 45.5%. No effect on incontinence was seen in 36.5% of patients and 9.0% experienced worsening incontinence by pad test. The mean ± SD visual analogue scale score of 6.1 ± 2.2 (range 0 to 10) preoperatively improved significantly to 4.6 ± 3.0 at 3 months (p = 0.024) and not significantly to 4.9 ± 3.1 by 1 year postoperatively (p = 0.39). Improved incontinence did not correlate with patient age or incontinence severity. Complications developed in 2 patients, including sling infection and postoperative urinary retention in 1 each.Conclusions: The transobturator sling suspension operation is a minimally invasive, safe procedure for male postoperative stress incontinence. Significantly improved continence was not observed on pad test but significant improvement in continence and bother was seen on the visual analog scale at 3 months.

Regional Variation in Total Cost per Radical Prostatectomy in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database - Corrected Proof

2010-02-22

Purpose: Surgical treatment for prostate cancer represents a large national health care expenditure. We determined whether state level variation in the cost of radical prostatectomy exists and whether we could explain this variation by adjusting for covariates associated with cost.Materials and Methods: Using the 2004 Healthcare Cost and Utilization Project National Inpatient Sample of 7,978,041 patients we identified 9,917 who were 40 years old or older with a diagnosis of prostate cancer who underwent radical prostatectomy without cystectomy. We used linear regression to examine state level regional variation in radical prostatectomy costs, controlling for the local area wage index, patient demographics, case mix and hospital characteristics.Results: The mean ± SD unadjusted cost was $9,112 ± $4,434 (range $2,001 to $49,922). The unadjusted mean cost ranged from $12,490 in California to $4,650 in Utah, each significantly different from the mean of $8,903 in the median state, Washington (p <0.0001). After adjusting for all potential confounders total cost was highest in Colorado and lowest in New Jersey, which were significantly different from the median, Washington ($10,750 and $5,899, respectively, vs $8,641, p <0.0001). The model explained 85.9% of the variance with regional variation accounting for the greatest incremental proportion of variance (35.1%) and case mix variables accounting for an incremental 32.3%.Conclusions: The total cost of radical prostatectomy varies significantly across states. Controlling for known total cost determinants did not completely explain these differences but altered ordinal cost relationships among states. Cost variation suggests inefficiencies in the health care market. Additional studies are needed to determine whether these variations in total cost translate into differences in quality or outcome and how they may be translated into useful policy measures.

Stone Formation and Pregnancy: Pathophysiological Insights Gained From Morphoconstitutional Stone Analysis - Corrected Proof

2010-02-22

Purpose: We examined whether stone composition in pregnant women reflects peculiar pathophysiological conditions.Materials and Methods: We analyzed in detail the composition of stones from 244 pregnant women 17 to 44 years old and from 5,712 nonpregnant women in the same age range, as recorded between January 1991 and December 2007. Clinical features were also recorded. All stones were analyzed by morphological examination coupled with infrared spectroscopy. The 2 patient groups were compared by clinical and biochemical characteristics.Results: Stone episodes in pregnant women manifested mainly in trimesters 2 and 3 (39% and 46%, respectively). Spontaneous passage was noted in 81% of pregnant vs 47% of nonpregnant women (p <0.0001). Calcium phosphate, mainly in the form of carbapatite, was the main stone component in 65.6% of pregnant vs 31.4% of nonpregnant women (p <0.0001). Octacalcium phosphate pentahydrate, a transition phase in calcium phosphate stone formation, was found in a 5-fold higher proportion in carbapatite stones in pregnant than in nonpregnant women, a finding also suggesting recent stone formation during pregnancy.Conclusions: The composition of stones manifesting during pregnancy clearly differs from that of stones formed in nonpregnant women of childbearing age, suggesting a different pathophysiology specific to the pregnant state. In view of the pH dependency of calcium phosphate stones factors that increase the physiological elevation in maternal urinary calcium excretion and pH are likely to have a role in the preferential formation of calcium phosphate stones during pregnancy.

Photoselective Laser Vaporization Prostatectomy Versus Transurethral Prostate Resection: A Cost Analysis - Corrected Proof

Alvin C. Goh, Ricardo R. Gonzalez — 2010-02-22

Purpose: Laser procedures to treat symptomatic benign prostatic hyperplasia are becoming more common despite concern for potentially increasing cost burdens often associated with new technologies.Materials and Methods: Actual costs associated with photoselective laser vaporization prostatectomy and transurethral prostate resection were measured using the EPSi™ and TSI (Eclipsys®) hospital cost accounting systems at 2 large tertiary referral centers for the first 12 months that GreenLight HPS™ was performed. Only patients who presented for photoselective laser vaporization prostatectomy or transurethral prostate resection as the principal treatment during the hospital visit were included in study.Results: A total of 250 men underwent transurethral prostate resection and 220 underwent photoselective laser vaporization prostatectomy, including 194 (78%) and 209 (95%), respectively, treated on an outpatient basis with less than 23 hours of hospitalization. Overall costs of laser vaporization were lower than those of transurethral prostate resection ($4,266 ± $1,182 vs $5,097 ± $5,003, p = 0.01). Average inpatient length of stay was also longer in the resection group.Conclusions: The actual costs of photoselective laser vaporization prostatectomy at our affiliated hospitals are lower than those of transurethral prostate resection. The primary reason is likely that most patients who undergo laser vaporization are treated on an outpatient basis compared to those who undergo resection. While significant complications are uncommon, those that prolong inpatient hospitalization such as hyponatremia (transurethral resection syndrome), which is associated with transurethral prostate resection but not with photoselective laser vaporization prostatectomy, can add substantial expense. Further studies are warranted to investigate these findings on a broader scale.

A Prospective, Randomized Trial of Management for Asymptomatic Lower Pole Calculi - Corrected Proof

2010-02-22

Purpose: We determined the natural course and compared the deleterious effects in kidneys of shock wave lithotripsy, percutaneous nephrolithotomy and observation for asymptomatic lower caliceal stones.Materials and Methods: Between April 2007 and August 2008 patients with asymptomatic lower caliceal calculi were enrolled in the study. To assess stone status noncontrast abdominal helical computerized tomography was done 3 and 12 months after intervention. All patients were evaluated by dimercapto-succinic acid renal scintigraphy 6 weeks and 12 months after intervention.Results: A total of 94 patients were prospectively randomized to percutaneous nephrolithotomy (31), shock wave lithotripsy (31) and observation (32). Mean ± SD followup was 19.3 ± 5 months (range 12 to 29). In the percutaneous nephrolithotomy group all patients were stone-free at month 12. Scintigraphy revealed a scar in 1 patient (3.2%) on month 3 followup imaging. In the shock wave lithotripsy group the stone-free rate was 54.8%. Scintigraphy revealed scarring in 5 patients (16.1%). In the observation group 7 patients (18.7%) required intervention during followup. Median time to intervention was 22.5 ± 3.7 months (range 18 to 26). One patient (3.1%) had spontaneous stone passage. Scintigraphy did not reveal scarring in any patient.Conclusions: Stone related events were noted in more than 20% of patients with asymptomatic lower caliceal stones observed expectantly. To manage lower caliceal stones percutaneous nephrolithotomy has a significantly higher stone-free rate with less renal scarring than shock wave lithotripsy. Thus, patients with asymptomatic lower caliceal stones must be informed in detail about all management options, especially focusing on percutaneous nephrolithotomy with its outstanding outcome.

The Use of a Novel Reverse Thermosensitive Polymer to Prevent Ureteral Stone Retropulsion During Intracorporeal Lithotripsy: A Randomized, Controlled Trial - Corrected Proof

2010-02-22

Purpose: We present the first randomized clinical study using BackStop™, a novel reverse thermosensitive water-soluble polymer that is dispensed above the stone(s) and temporarily occludes the ureter to prevent retropulsion of stone fragments during ureteroscopic lithotripsy. After fragmentation is completed and concretions are extracted, conventional irrigation with saline dissolves the polymer, which is then flushed out.Materials and Methods: A total of 68 subjects with a single stone in the proximal ureter and an indication for ureteroscopic lithotripsy were enrolled in this prospective, randomized, single-blind, controlled, multisite clinical study. Each subject was randomly assigned to the BackStop group (34) or the control group (34 with no antiretropulsion device). For subjects in the experimental group BackStop was dispensed into the ureter above the stone using a 3Fr or 5Fr catheter. Ureteroscopic lithotripsy was performed in all subjects using pneumatic or laser energy. Measured end points included the retropulsion rate, the need for subsequent procedures, the stone-free rate at followup, the occurrence of adverse events and ureteral occlusion, if any, and post-stone fragmentation and extraction.Results: Subjects randomized to the BackStop group experienced a statistically significant (p = 0.0002) lower rate of retropulsion (8.8%, 3 of 34) vs the control group (52.9%, 18/34). There were no adverse events in the BackStop group and BackStop was successfully dissolved in every subject, resulting in a patent ureter.Conclusions: BackStop appears to be a novel, safe and effective means of preventing stone fragment retropulsion during ureteroscopic lithotripsy for the management of ureteral stones.

Decreasing Electrosurgical Transurethral Resection of the Prostate Surgical Volume During Graduate Medical Education Training is Associated With Increased Surgical Adverse Events - Corrected Proof

2010-02-22

Purpose: In the United States the numbers of electrosurgical transurethral prostate resection procedures have been decreasing. Since electrosurgical transurethral resection of the prostate is a difficult procedure to master, we hypothesized that recent residents are lacking in training for this procedure. We used summary case log information provided by the Accreditation Council for Graduate Medical Education to determine if the number of electrosurgical transurethral prostate resection procedures performed by graduating chief residents has decreased and if there has been an increase in surgical adverse events. In addition, we investigated whether the increased number of laser procedures impacted the rate of adverse events.Materials and Methods: Summary operative data from graduating chief resident case logs were provided by the Accreditation Council for Graduate Medical Education for academic years 2001 to 2007. The numbers of electrosurgical transurethral prostate resection procedures, laser procedures and procedures for adverse events were recorded for each year.Results: The number of electrosurgical transurethral prostate resection procedures performed by graduating chief residents has steadily decreased from 58 in 2001 to 43 in 2007. Conversely the number of laser procedures started increasing in 2004. The rate of procedures for adverse events as a percentage of electrosurgical transurethral resection of the prostate procedures increased during the study period (from 3% in 2001 to 6% in 2007), and as a percentage of electrosurgical transurethral resection of the prostate and laser procedures the rate increased until 2005 and subsequently started decreasing.Conclusions: The rate of surgical adverse events, as measured by the need for subsequent procedures, has increased during the last 7 years. However, when laser procedures are accounted for, it appears that adverse events have recently started trending down as an increasing number of laser procedures started being performed.

Are Sonographic Characteristics Associated With Progression to Surgery in Men With Peyronie's Disease? - Corrected Proof

2010-02-22

Purpose: Traditionally, diagnosis and treatment plans for Peyronie's disease have been based on history and physical examination. Penile ultrasound provides rapid, anatomical information to establish disease severity, and to monitor progression and response to medical therapy. We determined the relationship between ultrasound characteristics and progression to surgical intervention in men with Peyronie's disease.Materials and Methods: We conducted a retrospective cohort study of 518 patients with Peyronie's disease. Patients completed a Peyronie's disease specific questionnaire detailing medical history, health related behaviors and Peyronie's disease characteristics, and underwent sonographic evaluation of the penis. Measurements of subtunical calcifications, septal fibrosis, tunical thickening (tunica thickness greater than 2 mm) and intracavernous fibrosis were made. Progression to surgery was determined from the medical record.Results: In this cohort (mean patient age 53.8 years, range 20 to 78) 31% of patients had calcifications, 50% had tunical thickening, 20% had septal fibrosis and 15% had intracavernous fibrosis. Overall 25% of the cohort progressed to surgical intervention after an average followup of 1.25 years (range 0 to 7.6). Patients who underwent surgery were more likely to have subtunical calcifications present at the first clinic visit (OR 1.75, 95% CI 1.16–2.62). No other sonographic characteristics were associated with progression to surgery. After adjustment for age, marital status, degree of curvature, additional penile deformity, difficulty with penetration, ability to have intercourse and prior treatment for Peyronie's disease, calcifications were strongly associated with progression to surgery (OR 2.75, 95% CI 1.25–3.45).Conclusions: In a large cohort of patients with Peyronie's disease the presence of sonographically detected sub-tunical calcifications during the initial office evaluation was independently associated with subsequent surgical intervention.

Intussusception Vasoepididymostomy With Longitudinal Suture Placement for Idiopathic Obstructive Azoospermia - Corrected Proof

Rajeev Kumar, Satyadip Mukherjee, Narmada P. Gupta — 2010-02-22

Purpose: Surgical reconstruction is an important treatment option for obstructive azoospermia. Vasoepididymostomy results have primarily been described in men with previous vasectomy. We evaluated vaso-epididymal anastomosis outcomes using a 2-suture microsurgical intussusception technique with longitudinal suture placement in men with idiopathic obstructive azoospermia.Materials and Methods: Between April 2007 and May 2009, 24 men with idiopathic obstructive azoospermia underwent 2-layer vaso-epididymal anastomosis using a 2-suture intussusception technique. Two double armed 10-zero polyamide sutures were placed parallel to each other longitudinally along the epididymal tubule to intussuscept the tubule into the lumen of the vas deferens for the inner layer of the anastomosis. Patency was assessed by return of sperm in the semen.Results: A total of 23 men with a mean age of 31 years provided at least 1 postoperative semen sample. All had a mean 67-month history of primary infertility. In 11 men (48%) patency was noted a mean of 6.6 months (range 3 to 15) after surgery. One patient reported pregnancy by natural conception. Men with motile sperm in the epididymal fluid and those with bilateral surgery were more likely to have a patent anastomosis.Conclusions: Within 1 year after surgery approximately half of the men who underwent longitudinal vaso-epididymal anastomosis for idiopathic azoospermia had return of sperm in the ejaculate.

The Urethral Motion Profile Before and After Suburethral Sling Placement - Corrected Proof

Ka Lai Shek, Varisara Chantarasorn, Hans Peter Dietz — 2010-02-22

Purpose: We examined the effect of the Monarc™ suburethral sling on urethral mobility.Materials and Methods: We retrospectively studied the records of 54 consecutive women who received a Monarc suburethral sling between July 2005 and November 2008. All patients were examined by volume ultrasound preoperatively and at followup (average 0.7 years). Volume data sets were analyzed using post-processing software. Urethral mobility was described by vectors of movement from rest to a maximum Valsalva maneuver of 6 equidistant points marked evenly along the urethra from bladder neck (point 1) to external urethral meatus (point 6), as identified in the mid sagittal view. Measurements were made of point coordinates relative to the pubic symphysis dorsocaudal margin at rest and during maximal Valsalva maneuver. To determine the urethral motion profile we calculated mobility vectors of the 6 points using the formula, square root [(xval − xrest)2 + (yval − yrest)2], where val represents the value during the Valsalva maneuver and rest represents the value at rest. We compared values before and after sling placement.Results: The subjective cure rate for stress urinary incontinence was 78% (42 cases). There was a statistically significantly decreased mobility at points 2 to 4, corresponding to the urethral central aspect (p = 0.002 to 0.018). No significant change in mobility was noted at the bladder neck and distal urethra (p = 0.39 to 0.89).Conclusions: Monarc suburethral sling placement decreases mid urethral mobility but does not seem to affect the bladder neck.

Under Treatment of Overactive Bladder Symptoms in Patients With Multiple Sclerosis: An Ancillary Analysis of the NARCOMS Patient Registry - Corrected Proof

S.T. Mahajan, P.B. Patel, R.A. Marrie — 2010-02-22

Purpose: We describe the prevalence of overactive bladder symptoms in patients with multiple sclerosis as well as the rates of evaluation and treatment of urinary complaints.Materials and Methods: Data from the fall 2005 North American Research Committee On Multiple Sclerosis survey were examined, including the Urogenital Distress Inventory plus a nocturia question, the SF-12, and inquiries regarding urological care and treatments. Data were analyzed using descriptive statistics, chi-square and Student's t tests, ANOVA and multivariable logistic regression.Results: Of 16,858 surveys distributed 9,702 (58%) were completed. Participants with a surgically altered bladder were excluded from analysis (21). At least 1 moderate to severe urinary symptom (score of 2 or greater) was reported by 6,263 (65%) respondents. Increasing overactive bladder symptoms were correlated with longer disease duration (r = 0.135) and increasing physical disability (r = 0.291) (both p <0.001). Decreased quality of life was associated with increasing disability (p <0.001) and overactive bladder symptom score (p <0.001). Of patients with moderate to severe overactive bladder symptoms only 2,710 (43.3%) were evaluated by urology and 2,361 (51%) were treated with an anticholinergic medication. Treated patients more frequently reported leakage (p <0.001) and newer treatments were significantly underused (less than 10% total use). Catheter use was reported by 2,309 (36.8%) respondents, and was associated with greater disability, higher overactive bladder symptom score and reduced quality of life (all p <0.001).Conclusions: This large scale study identified high rates of overactive bladder symptoms in patients with MS, and correlations with increasing disease duration and physical disability. Despite an increasing awareness of overactive bladder symptoms and the need for evaluation and treatment, many patients remain underserved.

Correlation of Penile and Bulbospongiosus Measurements: Implications for Artificial Urinary Sphincter Cuff Placement - Corrected Proof

Bruce J. Schlomer, Daniel D. Dugi, Celeste Valadez, Allen F. Morey — 2010-02-22

Purpose: We assessed penile and bulbospongiosus measurements to develop a quantitative guide to select the surgical approach (perineal vs transscrotal vs transcorporeal) to artificial urinary sphincter cuff placement.Materials and Methods: We retrospectively reviewed the intraoperative records of 100 men who underwent artificial urinary sphincter placement (43) or anastomotic urethroplasty (57) from February 2008 to June 2009. Correlations between penile (stretched length and circumference at the shaft base) and bulbospongiosus (distal and proximal circumference) measurements were assessed. Cases were analyzed according to 2 penile circumference groups, including group 1—8.0 cm or less and group 2—8.5 or more.Results: Mean proximal bulbospongiosus circumference was uniformly larger than distal bulbospongiosus circumference (4.5 vs 3.9 cm). It was about 50% of the penile shaft circumference (mean 8.9 cm, r = 0.70). In group 1 men the average distal bulbospongiosus circumference was 3.4 cm. They were more likely to undergo transcorporeal artificial urinary sphincter cuff placement than those in group 2, who had an average distal bulbospongiosus circumference of 4.1 cm (8 of 22 or 36% vs 1 of 21 or 5%, OR 11.4). Penile length correlated less robustly with distal and proximal bulbospongiosus circumference (r = 0.39 and 0.43, respectively). Patients with urethroplasty had significantly larger urethral measurements than those with the artificial urinary sphincter (proximal and distal bulbospongiosus circumference 4.9 vs 3.7 and 4.1 vs 3.2, respectively) but were significantly younger (47 vs 67 years), and less likely to have erectile dysfunction (11 of 57 vs 34 of 43) or to have undergone radical prostatectomy (0 of 57 vs 37 of 43).Conclusions: Bulbospongiosus circumference appears to be proportional to penile circumference. The distal bulbospongiosus is uniformly smaller than the proximal bulbospongiosus. The potential need for a perineal or transcorporeal approach to artificial urinary sphincter placement can be anticipated by penile circumference measurements and a combination of clinical factors, such as older patient age, history of radical prostatectomy and impotence.

The Role of Race in Determining 24-Hour Urine Composition in White and Asian/Pacific Islander Stone Formers - Corrected Proof

Brian H. Eisner, Sima P. Porten, Seth Bechis, Marshall L. Stoller — 2010-02-22

Purpose: We examined differences in 24-hour urine composition between white and Asian/Pacific Islander stone formers.Materials and Methods: We retrospectively reviewed the 24-hour urinalysis database at a metabolic stone clinic. We identified and included in the study patients 18 years old or older who presented for the initial metabolic stone evaluation when race was marked as white or Asian/Pacific Islander in the electronic medical record. Univariate analysis was done to compare 24-hour urine composition between white and Asian/Pacific Islander stone formers. We performed multivariate linear regression adjusted for possible confounders, including age, gender, body mass index, hypertension, diabetes mellitus, thiazide use, potassium citrate use and 24-hour urine chemistry (volume, pH, calcium, citrate, creatinine, oxalate, magnesium, phosphate, potassium, sodium, sulfate and uric acid).Results: Included in analysis were 371 white and 91 Asian/Pacific Islander patients. On univariate analysis Asian/Pacific Islander patients excreted significantly greater uric acid, and significantly less citrate, magnesium, phosphate and creatinine than white patients. On multivariate analysis Asian/Pacific Islander patients excreted significantly greater uric acid, and significantly less urine citrate, phosphate, creatinine and volume than white patients.Conclusions: Significant differences exist in 24-hour urine chemistry between white and Asian/PI stone formers. Knowledge of these differences would be useful to evaluate and treat these patients, and prevent stone recurrence.

How Do You Tell Whether a Change in Surgical Technique Leads to a Change in Outcome? - Corrected Proof

Andrew J. Vickers, Angel M. Cronin, Timothy A. Masterson, James A. Eastham — 2010-02-22

Purpose: Surgeons routinely evaluate and modify their surgical technique to improve patient outcome. It is also common for surgeons to analyze results before and after a change in technique to determine whether the change led to better results. Simple comparison of results before and after surgical modification may be confounded by the surgical learning curve. We developed a statistical method applicable to analyzing before/after surgical studies.Materials and Methods: We used simulation studies to compare different statistical analyses of before/after studies. We evaluated a simple 2-group comparison of results before and after the modification by the chi-square test and a novel bootstrap method that adjusts for the surgical learning curve.Results: In the presence of the learning curve a simple 2-group comparison almost always showed an ineffective surgical modification to be of benefit. When the surgical modification was harmful, leading to a 10% decrease in the success rate, 2-group comparison nonetheless showed a statistically significant improvement in outcome about 80% of the time. The bootstrap method had only moderate power but did not show that ineffective surgical modifications were beneficial more than would be expected by chance.Conclusions: Simplistic approaches to the analysis of before/after surgical studies may lead to grossly erroneous results under the surgical learning curve. A straightforward alternative statistical method allows investigators to separate the effects of the learning curve from those of the surgical modification.

Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Sham Efficacy in the Treatment of Overactive Bladder Syndrome: Results From the SUmiT Trial - Corrected Proof

2010-02-22

Purpose: The Study of Urgent® PC vs Sham Effectiveness in Treatment of Overactive Bladder Symptoms (SUmiT) was a multicenter, double-blind, randomized, controlled trial comparing the efficacy of percutaneous tibial nerve stimulation to sham through 12 weeks of therapy. The improvement in global response assessment, voiding diary parameters, and overactive bladder and quality of life questionnaires was evaluated.Materials and Methods: A total of 220 adults with overactive bladder symptoms were randomized 1:1 to 12 weeks of treatment with weekly percutaneous tibial nerve stimulation or sham therapy. Overactive bladder and quality of life questionnaires as well as 3-day voiding diaries were completed at baseline and at 13 weeks. Subject global response assessments were completed at week 13.Results: The 13-week subject global response assessment for overall bladder symptoms demonstrated that percutaneous tibial nerve stimulation subjects achieved statistically significant improvement in bladder symptoms with 54.5% reporting moderately or markedly improved responses compared to 20.9% of sham subjects from baseline (p <0.001). All individual global response assessment subset symptom components demonstrated statistically significant improvement from baseline to 13 weeks for percutaneous tibial nerve stimulation compared to sham. Voiding diary parameters after 12 weeks of therapy showed percutaneous tibial nerve stimulation subjects had statistically significant improvements in frequency, nighttime voids, voids with moderate to severe urgency and urinary urge incontinence episodes compared to sham. No serious device related adverse events or malfunctions were reported.Conclusions: This pivotal multicenter, double-blind, randomized, sham controlled trial provides level I evidence that percutaneous tibial nerve stimulation therapy is safe and effective in treating overactive bladder symptoms. The compelling efficacy of percutaneous tibial nerve stimulation demonstrated in this trial is consistent with other recently published reports and supports the use of peripheral neuromodulation therapy for overactive bladder.

Resume Fraud: Unverifiable Publications of Urology Training Program Applicants - Corrected Proof

Israel P. Nosnik, Patricia Friedmann, Harris M. Nagler, Caner Z. Dinlenc — 2010-02-22

Purpose: We examined the incidence of resume fraud among urology residency applicants by determining the rate of misrepresented publications listed in applications to a urology residency program.Materials and Methods: Applications from all 147 urology residency applicants to a program from the 2007 application cycle were analyzed. Verification of listed publications was attempted by querying PubMed®, Google™ Scholar and MEDLINE®. Univariate analysis was conducted to assess associations between unverifiable publications and applicant demographics.Results: Of the applicants who submitted publications 19% (14 of 71) had at least 1 unverifiable publication, which represented 9% (14 of 147) of the entire applicant pool. There were no statistically significant associations between misrepresented publications and applicant demographics.Conclusions: Applicants had a low but still unacceptable rate of misrepresented publications and this trend in academic medicine is of great concern.

Durability of Urethral Bulking Agent Injection for Female Stress Urinary Incontinence: 2-Year Multicenter Study Results - Corrected Proof

2010-02-22

Purpose: We evaluated the durability of the urethral bulking agent Macroplastique® for stress urinary incontinence in a 24-month study in women with a previously documented successful outcome 12 months after the last injection.Materials and Methods: In a multicenter study females diagnosed with stress urinary incontinence primarily due to intrinsic sphincter deficiency successfully treated with Macroplastique, defined as 1 or greater Stamey grade improvement 12 months from baseline, were followed for 24 months to assess the sustained therapeutic response. Outcome measures were Stamey grade, Patient Global Impression of Improvement, Physician Assessment of Improvement, 1-hour pad weight, Incontinence Quality of Life scores and safety assessment.Results: At 24 months 56 of 67 patients (84%) had sustained success since 12 months, of whom 45 of 67 (67%) were dry (Stamey grade 0). Of the dry patients at 12 months 33 of 38 (87%) maintained cure at 24 months. Also, 12 of 29 patients (41%) considered improved at 12 months were dry at 24 months. Overall Incontinence Quality of Life scores and all subscales showed statistically significant improvement from baseline (p <0.001). Mean pad weight was 24 gm at baseline, and 4 gm at 12 and 24 months. Patient and physician assessments rated 85% of patients dry or markedly improved 24 months after the last treatment.Conclusions: Substantial, durable results were sustained during 2 years with 84% of patients maintaining significant Stamey grade improvement from the 12-month assessment. Two-thirds of patients were dry at 24 months. The durability of Macroplastique shows its effectiveness as a viable long-term therapy for female stress urinary incontinence primarily due to intrinsic sphincter deficiency.

Risk Factors for Breakthrough Infection in Children With Primary Vesicoureteral Reflux - Corrected Proof

2010-02-22

Purpose: Despite the widespread application of endoscopic therapy and the debate surrounding the use of prophylactic antibiotics to treat children with vesicoureteral reflux, many pediatric urologists still favor medical management. Breakthrough infection is one of the absolute indications for surgery. Data to predict breakthrough infection are warranted to manage cases of primary reflux.Materials and Methods: We reviewed medical records of 72 girls and 138 boys (mean ± SD age at diagnosis 2.66 ± 3.23 years) with primary vesicoureteral reflux who were followed with antibiotic prophylaxis at Aichi Children's Health and Medical Center. We examined multiple factors by univariate/multivariate analysis to elucidate risk factors for breakthrough infection.Results: Breakthrough infection developed in 59 children (28%). On univariate analysis higher reflux grade (p <0.05) and abnormal renal scan determined by 99mtechnetium dimercapto-succinic acid (p <0.0001) were significantly associated with breakthrough infection. On multivariate analysis abnormal renal scan was an independent risk factor for breakthrough infection (OR 11.08, 95% CI 0.76–1.72, p <0.0001).Conclusions: Abnormal renal scan is an independent risk factor for breakthrough infection. Parents and physicians should remain aware that these patients are at high risk for breakthrough infection, which potentially could lead to renal damage.

Melamine Related Bilateral Renal Calculi in 50 Children: Single Center Experience in Clinical Diagnosis and Treatment - Corrected Proof

2010-02-22

Purpose: We investigated the clinical diagnosis and treatment features of bilateral renal calculi in young children who ingested melamine tainted infant milk formula.Materials and Methods: We retrospectively analyzed clinical data on 50 children (mean ± SE age 23.4 ± 3.1 months) with a history of ingesting melamine tainted infant milk formula and suffering from bilateral renal calculi. All patients underwent ultrasound and renal function evaluation. Treatment included cessation of melamine tainted formula consumption, hydration, urine basification and hemodialysis if necessary.Results: Bilateral renal calculi peaked in 6 to 18-month-olds (58% of cases). The male-to-female ratio was 3.1:1.0. Calculi ranged in diameter from 4 to 10 mm in 33 patients (66%) and 2.5 to 4 mm in 17 (34%). Of the 11 patients with renal failure 8 underwent 1 to 4 sessions of hemodialysis. Of the 9 bilateral obstruction cases with renal failure 8 did not require surgical intervention but 1 required ureteral catheterization to drain the renal pelvis. All children experienced a good outcome and were discharged home after a mean ± SE hospitalization of 8.1 ± 0.7 days.Conclusions: Melamine related urinary calculi were most often seen in patients 6 to 18 months old. Conservative management has been sufficient in most cases. However, these children need to be monitored for long-term effects of melamine tainted milk formula consumption.

Urological and Nephrological Findings of Renal Ectopia - Corrected Proof

2010-02-22

Purpose: Urological characteristics of renal ectopia have been addressed previously but little is known about the functional consequences. We sought to study renal function, blood pressure, proteinuria and urological abnormalities in children with renal ectopia. As a secondary objective, we compared these parameters between simple and crossed ectopia.Materials and Methods: For this retrospective, single center, observational study we reviewed case documents and radiological records. We also analyzed longitudinal data on blood pressure, proteinuria and kidney function.Results: Renal ectopia was diagnosed in 41 cases, of which 26 (63%) were simple renal ectopia, ie unilateral pelvic kidney. In 32% of patients the diagnosis was made during prenatal screening. Median patient age was 0.24 years at diagnosis and 7.7 years at the most recent control visit. Associated urological abnormalities were found in 66% of patients. Voiding cystourethrography was performed in all patients, with vesicoureteral reflux shown in 13. In 8 of 10 cases with unilateral reflux the condition manifested in the orthotopic kidney. The relative function of the ectopic kidney on dimercapto-succinic acid scan was 38%, and in 22% of patients glomerular filtration rate was less than 90 ml per minute per 1.73 m2. Albuminuria and proteinuria were absent in most cases. Longitudinal analysis of blood pressure, glomerular filtration rate and albuminuria revealed a stable course for all parameters. No substantial difference was observed between simple and crossed renal ectopia.Conclusions: Our data suggest no adverse effects on blood pressure or kidney function in children with renal ectopia. However, periodic followup seems warranted, at least until young adulthood.

Variation Among Internet Based Calculators in Predicting Spontaneous Resolution of Vesicoureteral Reflux - Corrected Proof

2010-02-22

Purpose: An increasing number of parents and practitioners use the Internet for health related purposes, and an increasing number of models are available on the Internet for predicting spontaneous resolution rates for children with vesicoureteral reflux. We sought to determine whether currently available Internet based calculators for vesicoureteral reflux resolution produce systematically different results.Materials and Methods: Following a systematic Internet search we identified 3 Internet based calculators of spontaneous resolution rates for children with vesicoureteral reflux, of which 2 were academic affiliated and 1 was industry affiliated. We generated a random cohort of 100 hypothetical patients with a wide range of clinical characteristics and entered the data on each patient into each calculator. We then compared the results from the calculators in terms of mean predicted resolution probability and number of cases deemed likely to resolve at various cutoff probabilities.Results: Mean predicted resolution probabilities were 41% and 36% (range 31% to 41%) for the 2 academic affiliated calculators and 33% for the industry affiliated calculator (p = 0.02). For some patients the calculators produced markedly different probabilities of spontaneous resolution, in some instances ranging from 24% to 89% for the same patient. At thresholds greater than 5%, 10% and 25% probability of spontaneous resolution the calculators differed significantly regarding whether cases would resolve (all p <0.0001).Conclusions: Predicted probabilities of spontaneous resolution of vesicoureteral reflux differ significantly among Internet based calculators. For certain patients, particularly those with a lower probability of spontaneous resolution, these differences can significantly influence clinical decision making.

Fentanyl Sparing Effects of Combined Ketorolac and Acetaminophen for Outpatient Inguinal Hernia Repair in Children - Corrected Proof

Jeong-Yeon Hong, Sang Won Han, Won Oak Kim, Hae Keum Kil — 2010-02-22

Purpose: In this prospective, randomized, double-blinded study we sought to evaluate the efficacy and safety of combined use of intravenous ketorolac and acetaminophen in small children undergoing outpatient inguinal hernia repair.Materials and Methods: We studied 55 children 1 to 5 years old who were undergoing elective repair of unilateral inguinal hernia. After induction of general anesthesia children in the experimental group (28 patients) received 1 mg/kg ketorolac and 20 mg/kg acetaminophen intravenously. In the control group (27 patients) the same volume of saline was administered. All patients received 1 μg/kg fentanyl intravenously before incision. We also evaluated the number of patients requiring postoperative rescue fentanyl, total fentanyl consumption, pain scores and side effects.Results: Significantly fewer patients receiving ketorolac-acetaminophen received postoperative rescue fentanyl compared to controls (28.6% vs 81.5%). A significantly lower total dose of fentanyl was administered to patients receiving ketorolac-acetaminophen compared to controls (0.54 vs 1.37 μg/kg). Pain scores were significantly higher in the control group immediately postoperatively but eventually decreased. The incidences of sedation use (55.6% vs 25.0%) and vomiting (33.3% vs 10.7%) were significantly higher in controls.Conclusions: Preoperative intravenous coadministration of ketorolac and acetaminophen is a simple, safe and effective method for relieving postoperative pain, and demonstrates highly significant fentanyl sparing effects in small children after outpatient inguinal hernia repair.

Use of Rectus Abdominis Muscle Flap as Adjunct to Bladder Neck Closure in Patients With Neurogenic Incontinence: Preliminary Experience - Corrected Proof

2010-02-22

Purpose: Vesicoureteral fistula is a well-known potential complication following bladder neck closure for neurogenic incontinence. Various maneuvers, including omental interposition, have been described to prevent this problem. Unfortunately omentum is not always available or feasible for use. We describe the surgical anatomy and use of a rectus abdominis muscle flap as an adjunctive maneuver during bladder neck closure to correct or prevent development of bladder neck fistula.Materials and Methods: We performed a retrospective chart review of all patients at our institution undergoing rectus abdominis muscle flap by a single surgeon (EAS). Patient demographics, indications for surgery, intraoperative and postoperative complications, and long-term efficacy were assessed. Cadaveric dissection was also performed to gain a greater understanding of the surgical anatomy relevant to this procedure.Results: In 6 patients with neurogenic bladder dysfunction a rectus abdominis muscle flap was interposed between the bladder neck and urethral stump at bladder neck closure. There were no intraoperative or postoperative complications associated with this procedure. At a mean followup of 45.5 months (range 18 to 120) all 6 patients were continent of urine. There have been no urinary fistulas related to use of the rectus abdominis muscle flap. Cadaveric dissections confirmed the inferior epigastric artery to be the dominant and readily mobile blood supply of the rectus abdominis muscle flap.Conclusions: The rectus abdominis muscle flap is easily harvested without significant risk of morbidity and offers a well vascularized tissue for coverage of a bladder neck closure when an omental flap is not available.