Search

Background The artificial urinary sphincter (AUS) is a well-established treatment for male stress urinary incontinence. Objective We aimed to characterize the surgical learning curve for reoperation rates after AUS implantation. Design, setting, and participants The study cohort consisted of 65 602 adult males who received an AUS between 1988 and 2008, constituting close to 90% of all operations conducted during that time. Data on reoperations were obtained from the manufacturer, which requires documentation for warranty coverage. Measurements Surgeon experience was calculated as the number of original AUS implants performed prior to the index patient's surgery. Multivariable logistic regression models were used to examine the association between experience and reoperative rates, adjusted for case mix. Results and limitations There was a slow but steady decrease in reoperative rates with increasing surgeon experience ( p =0.020), showing no plateau through 200 procedures. The risk of reoperation for a surgeon with five prior cases was 24.0%, which decreased to 18.1% for a surgeon with 100 prior implants (absolute risk difference [ARD]: 5.9%; 95% confidence interval [CI], 1.3–10.1%) and to 13.2% for a surgeon with 200 prior implants (ARD: 10.7%; 95% CI, 2.6–16.6%). Two-thirds of contemporary patients (having AUS procedure between years 2000 and 2008) saw a surgeon who had done ≤25 prior AUS implants; only 9% saw a surgeon with ≥100 prior procedures. Conclusions The learning curve for AUS surgery appears to be very long and without an obvious plateau. This is in contrast to typical surgeon experience, suggesting a considerable burden of avoidable reoperations. Efforts to flatten the learning are urgently needed.

Anastomotic strictures are relatively common after radical prostatectomy and are associated with significant morbidity, often requiring multiple surgical interventions. There is controversy in the literature regarding which factors predict the development of anastomotic strictures. In this study we determined predictors of symptomatic anastomotic strictures following contemporary radical prostatectomy.Between 1999 and 2007, 4,592 consecutive patients underwent radical prostatectomy without prior radiotherapy at our institution. Data were collected from prospective surgical and institutional morbidity databases, and retrospectively from inpatient and outpatient medical and billing records. Cases were assigned a Charlson score to account for comorbidities. Complications were graded according to the modified Clavien classification.Open radical prostatectomy was performed in 3,458 men (75%) and laparoscopic radical prostatectomy was performed in 1,134 (25%). The laparoscopic radical prostatectomy group included 97 robotic-assisted cases. Median patient age was 59.5 years (IQR 54.7, 64.2). Symptomatic anastomotic strictures developed in 198 patients (4%) after a median postoperative followup of 3.5 months (IQR 2.1, 6.1). On multivariate analysis significant predictors included patient age, body mass index, Charlson score, renal insufficiency, individual surgeon, surgical approach and the presence of postoperative urine leak or hematoma.Patient factors as well as technical factors influence the development of symptomatic anastomotic strictures following contemporary radical prostatectomy. The impact of these factors is influenced by the individual surgeon and the approach used.

Context: In recent years, despite improvement in the surgical technique, the prevalence of postprostatectomy incontinence has increased due to a rise in the number of radical prostatectomies performed annually. Objective: The aim of this review is to evaluate contemporary noninvasive and invasive treatment options for postprostatectomy incontinence. Evidence acquisition: In August 2010, a review of the literature was performed using the Medline database. Evidence synthesis: All articles concerning noninvasive and invasive treatment for postprostatectomy incontinence were included. Conclusions: No randomised controlled trials exist to compare currently used noninvasive and invasive treatments for postprostatectomy incontinence. Pelvic floor muscle training is recommended for the initial treatment of stress urinary incontinence (SUI). Additionally, antimuscarinic therapy should be applied for urgency or urge incontinence. For decades, the artificial urinary sphincter was the reference standard for persistent SUI. Nowadays, male slings are an alternative for men with mild to moderate postprostatectomy SUI.

The diagnosis and management of male stress urinary incontinence (SUI) is complex. Various etiologies exist, with radical prostatectomy being the most common cause in men seeking treatment. SUI in this setting is often temporary and resolves within the first postoperative year. Therefore, it is important to understand the natural history of male SUI before initiating treatment. Generally, the initial management of SUI that persists after 12 months consists of conservative measures, such as pelvic floor muscle exercises. Several treatments are available for men whose continence does not improve after pelvic floor muscle exercises. In order of increasing complexity they are urethral bulking agents, male slings, and the artificial urinary sphincter (AUS). With over 30 years of published data suggesting excellent long-term outcomes, the AUS is considered the gold standard treatment of male SUI. Male slings have recently demonstrated efficacy for selected patients and are likely to be used more often in the future as experience with these devices grows.

Postprostatectomy incontinence is a bothersome complication of radical prostatectomy. Although most men recover from initial postprostatectomy incontinence, some do not. It is important to understand the natural history of postprostatectomy incontinence as well as conservative measures to hasten continence. This article reviews our current understanding of postprostatectomy incontinence with an emphasis on diagnosis and management.

We assessed the impact of prostate size on operative difficulty as measured by estimated blood loss, operating room time and positive surgical margins. In addition, we assessed the impact on biochemical recurrence and the functional outcomes of potency and continence at 1 year after radical prostatectomy as well as postoperative bladder neck contracture.From 1998 to 2007, 3,067 men underwent radical prostatectomy by 1 of 5 dedicated prostate surgeons with no neoadjuvant or adjuvant therapy. Pathological specimen weight was used as a measure of prostate size. Cox proportional hazards and logistic regression analysis was used to study the association between specimen weight, and biochemical recurrence and surgical margin status, respectively, controlling for adverse pathological features. Continence and potency were analyzed controlling for age, nerve sparing status and surgical approach.With increasing prostate size there was increased estimated blood loss (p = 0.013) and operative time (p = 0.004), and a decrease in positive surgical margins (84 of 632 [14%] for 40 gm or less, 99 of 862 [12%] for 41 to 50 gm, 78 of 842 [10%] for 51 to 65 gm, 68 of 731 [10%] for more than 65 gm, p0.001). Biochemical recurrence was observed in 186 of 2,882 patients followed postoperatively and was not significantly associated with specimen weight (p = 0.3). Complete continence was observed in 1,165 of 1,422 patients (82%) and potency in 425 of 827 (51%) at 1 year. Specimen weight was not significantly associated with potency (p = 0.8), continence (p = 0.08) or bladder neck contracture (p = 0.22).Prostate size does not appear to affect biochemical recurrence or 1-year functional results. However, estimated blood loss and operative time increased with larger prostate size, and positive surgical margins are more often observed in smaller glands.

The introduction of the artificial urinary sphincter represented a significant advance in treating urinary incontinence. We examined temporal trends in artificial urinary sphincter use, focusing on adoption of the device with time, individual surgeon volume, indications for placement and differences in application by gender.Data on artificial urinary sphincter related operations performed in the United States from 1975 and thereafter were provided by the manufacturer. Surgical and demographic data on each patient were recorded and analyzed on an annual basis at 5-year intervals to determine the number of procedures performed as well as individual surgeon volume. Indications for implantation or revision were also studied and recorded in 5-year increments.Artificial urinary sphincter use increased dramatically from 11 cases in 1975 to 3,762 in 2005. Most increased volume was due to an increase in device use in men with little growth in use in women. More than 90% of surgeons who participated in artificial urinary sphincter surgery performed 5 or fewer related cases per year (median 1 to 2) in most years. The annual proportion of revision surgeries stabilized after an initial increase. The most prevalent indication for initial implantation in men from 1985 and thereafter was incontinence after radical prostatectomy. In women neurogenic disease was consistently the most common indication for placement.Artificial urinary sphincter use has increased dramatically in the United States since 1975 and it now appears to be stable. Placement is primarily performed in men with incontinence after radical prostatectomy. Only a small minority of surgeons perform a high volume of artificial urinary sphincter cases.

Background Limited data on endorectal magnetic resonance imaging (MRI) features and urinary continence after radical prostatectomy (RP) are available. Objective To assess whether recovery of urinary continence after RP is associated with endorectal MRI findings regarding preoperative and postoperative membranous urethral length (MUL), percent change in MUL, and postoperative urethral and periurethral fibrosis. Design, setting, and participants Sixty-four patients who received an MRI scan before and after RP for localized prostate cancer were evaluated in a retrospective study at a single institution. Intervention All patients underwent RP. Measurements The postoperative scan was performed to detect local recurrence in patients with rising levels of prostate-specific antigen. Urinary continence was graded on a five-point scale. MUL was measured on T2-weighted images. Urethral and periurethral fibrosis was graded from 0 to III based on axial T2-weighted images. Univariate Cox proportional hazards regression was performed to assess variables associated with continence. Results and limitations Forty-eight patients regained continence following surgery. The median follow-up for patient who were incontinent at their last assessment was 7 mo. The median interval from RP to postoperative endorectal MRI was 10 mo. A longer preoperative or postoperative MUL was associated with superior continence (both p p =0.02). Patients with a high grade of postoperative periurethral fibrosis tended to have worse postoperative continence; nevertheless a statistical correlation was not reached (hazard ratio: 0.64, p =0.16). This is a retrospective study. Conclusions Preoperative and postoperative MUL and the MUL loss ratio are related to the recovery time and level of urinary continence after RP. Therefore, preservation of urethral length during surgery is recommended. Periurethral fibrosis might impede the recovery of continence after RP by altering the elasticity of the external sphincter.

We describe the pathophysiology, differential diagnosis and urodynamic findings in patients with a large capacity bladder.This was a retrospective, observational study of 100 consecutive patients with voiding dysfunction and a cystometric bladder capacity of greater than 700 ml. Clinical data, cystometric bladder capacity and other urodynamic findings were evaluated. Bladder outlet obstruction and impaired detrusor contractility were defined by the Schaefer nomogram in men and the Blaivas-Groutz nomogram in women.A total of 56 men and 44 women 36 to 97 years old (median age 75, mean 71.2) with a bladder capacity of 700 to 5,013 ml (median 931, mean 1,091) were studied. The primary pathophysiological diagnoses were bladder outlet obstruction in 48% of cases, impaired detrusor contractility in 11%, absent detrusor contractility in 24% and normal detrusor pressure/uroflow study in 17%. Bladder outlet obstruction was attributable to anatomical obstruction in 34% of patients, acquired voiding dysfunction in 11% and detrusor-external sphincter dyssynergia in 3%. In patients with detrusor contractions the initial contraction occurred at a median of 1,000 ml (mean 1,154, range 86 to 5,000). Associated diagnoses in men included benign prostatic enlargement in 52% and neurological disease in 14%, and in women they were pelvic organ prolapse in 27%, stress incontinence in 18% and neurological disorders in 9%.The etiology of large capacity bladder is multifactorial and often a potentially remediable underlying condition exists. A large capacity bladder may be accompanied by bladder outlet obstruction, impaired or absent detrusor contractions, or normal detrusor pressure/uroflow studies. When detrusor contractions are present, they usually occur only at large bladder volumes. Therefore, it is important during cystometry to fill the bladder until capacity is achieved.

There is a well-known link between treatment for lower urinary tract symptoms (LUTS) and erectile dysfunction. Surgical and medical management of LUTS all have side effect profiles which may affect erectile dysfunction, ejaculatory dysfunction, or libido. These should be taken into consideration during patient counseling. This article reviews the common side effects of the medical and surgical treatments of LUTS.

Objective To build a predictive model of urinary continence recovery after radical prostatectomy (RP) that incorporates magnetic resonance imaging (MRI) parameters and clinical data. Patients and Methods We conducted a retrospective review of data from 2 849 patients who underwent pelvic staging MRI before RP from November 2001 to June 2010. We used logistic regression to evaluate the association between each MRI variable and continence at 6 or 12 months, adjusting for age, body mass index (BMI) and American Society of Anesthesiologists (ASA) score, and then used multivariable logistic regression to create our model. A nomogram was constructed using the multivariable logistic regression models. Results In all, 68% (1 742/2 559) and 82% (2 205/2 689) regained function at 6 and 12 months, respectively. In the base model, age, BMI and ASA score were significant predictors of continence at 6 or 12 months on univariate analysis (P

Objectives To determine whether preoperative urodynamic parameters can predict the outcome in men in urinary retention and aid in counseling these men. Methods Forty men in urinary retention due to benign prostatic hyperplasia underwent photoselective laser vaporization prostatectomy (PVP). Preoperative urodynamic studies were used to identify the men with detrusor overactivity (DO) and impaired detrusor contractility (IDC). The International Prostate Symptom Score (IPSS), maximal flow rate, and postvoid residual urine volume were collected at 1, 3, 6, and 12 months after PVP. Results Of the 40 men, 8 (20%) had IDC and 30 had DO (75%) preoperatively. The men without preoperative DO had a significantly lower IPSS than those with preoperative DO at 1 month of follow-up. Men without preoperative IDC had a significantly lower IPSS and postvoid residual urine volume at the same point compared with men with preoperative IDC. The flow rate in men with preoperative IDC 1 and 6 months postoperatively was significantly lower than in men without preoperative IDC. Conclusions Preoperative urodynamic parameters predict for outcome in men in urinary retention undergoing PVP. Men in urinary retention benefit from PVP with an improvement in both subjective and objective voiding function, regardless of the presence of DO or IDC. Postoperatively, patients with DO have more voiding symptoms than those without DO, and are almost twice as likely to require anticholinergics. Men without IDC have better IPSS, flow rates, and postvoid residual urine volumes compared with men with IDC. Of the 8 men with IDC, 3 required reoperation within the first year.

To report the characteristics and anti-incontinence outcomes of men who fail to demonstrate incontinence on intubated urodynamics (UDS).From 2005 to 2013, the records of men who underwent UDS prior to artificial urinary sphincter (AUS) were reviewed. The histories, UDS, endoscopies, and anti-incontinence outcomes of men who failed to demonstrate incontinence on intubated UDS were recorded. In our UDS protocol, the urodynamic urethral catheter was removed and the UDS was repeated to elicit incontinence without the urethral catheter. The valsalva leak point pressure (VLPP) was obtained via the rectal catheter in these men.All men were status post radical prostatectomy for prostate cancer. Nineteen percent (32) of the study population (169) had non-demonstrable incontinence on intubated UDS. Mean age at the time of UDS was 62 (range 48-81). All patients demonstrated incontinence on UDS upon removal of the urethral catheter. Their mean VLPP was 79.3 (SD 36.7). Fifty-six percent (18) of these men had an anastomotic stricture (AS) and 37.5% (12) had a history of radiotherapy treatment, of which six also had an AS. Mean pads per day at the time of UDS was 4.6 (SD 2.9). At a mean follow up of 40.7 months (SD 24.7) from AUS placement, mean pads per day was 0.87 (SD 1.2).Men who fail to demonstrate incontinence on intubated UDS have a high rate of AS and history of radiotherapy treatment, which is a known cause for urethra fibrosis and scarring. Regardless, these men can achieve excellent anti-incontinence outcomes.

Objectives To study the safety and efficacy of high-power potassium-titanyl-phosphate photoselective laser vaporization of the prostate in men with prostate volumes greater than 60 cm 3 . Methods A total of 64 men with symptomatic benign prostatic hyperplasia and large-volume prostates underwent photoselective laser vaporization of the prostate between May 2002 and September 2003. Medical therapy had failed in all men, and 18 presented with urinary retention. The preoperative evaluation included the maximal flow rate, postvoid residual urine volume, prostate volume, serum sodium, creatinine, and hematocrit, and International Prostate Symptom Score. Transurethral prostatectomy was performed with an 80 W potassium-titanyl-phosphate (KTP) side-firing laser system through a 23F continuous-flow cystoscope with normal saline as the irrigant. The operative time, anesthesia type, length of stay, and postoperative serum sodium, creatinine, and hematocrit were recorded. The International Prostate Symptom Score, maximal flow rate, and postvoid residual urine volume were measured at each follow-up visit. Results The mean preoperative prostate volume was 101 ± 40 cm 3 . The mean operative time was 123 ± 70 minutes. No transfusions were required. Of the 64 patients, 62 were discharged within 23 hours. The serum sodium level did not change significantly. The International Prostate Symptom Score decreased from 18.4 preoperatively to 9.9, 8.6, 7.2, and 6.7 at 1, 3, 6, and 12 months postoperatively, and the maximal flow rate increased from 7.9 mL/s preoperatively to 16.4, 16.2, 20.0, and 18.9 mL/s at 1, 3, 6, and 12 months postoperatively. The postvoid residual urine volume also decreased from 189 mL preoperatively to 78, 78, 67, and 109 mL at 1, 3, 6, and 12 months postoperatively. Conclusions Photoselective laser vaporization of the prostate is safe and efficacious, with durable results for men with symptomatic benign prostatic hyperplasia and large-volume prostates.

The purpose of this review is to summarize the recent peer review literature and provide expert opinion about the diagnosis and treatment of sling erosions.The incidence of sling erosion depends partly on the composition of the sling. Synthetic slings, particularly those made of woven polyester and other tightly woven material erode 15 times more often than autologous, allograft and zenograft slings. The presenting symptoms for all types of sling erosions include urinary retention, urge and mixed incontinence, but synthetic sling erosions often present with additional symptoms, including vaginal discharge, vaginal pain/pressure, suprapubic pain, and recurrent urinary tract infection. The diagnosis is made by cystoscopy. For synthetic sling erosions, it is generally agreed that the entire sling and as much foreign material (bone anchors, screws and sutures) as possible should be removed and the urethra repaired. For non-synthetic sling erosions, incision or partial excision of the sling and urethral closure suffices. The success rate for urethral repair ranges from 89 to 100%, but unless an anti-incontinence procedure is performed concomitantly, the likelihood of postoperative incontinence ranges from 44 to 83%. When synchronous anti-incontinence surgery was performed the anatomical success rate was 96% and the continence rate 87%.Erosions of urinary slings are rare, but synthetic slings erode 15 times more often than non-synthetic slings. The anatomical success rate is very high after a single operation, but unless a concomitant anti-incontinence operation is performed, the likelihood of postoperative sphincteric incontinence is very high.

Background It is generally assumed that if a man does not regain urinary continence or erectile function within 12 mo of radical prostatectomy (RP), then the chance of subsequent recovery is low. Objective To determine the probability of achieving good urinary function (UF) or erectile function (EF) up to 48 mo postoperatively in men who reported poor UF or EF at 12 mo after RP. Design, setting, and participants We identified 3187 patients who underwent RP from 2007 through 2013 at a tertiary institution and had extended multidisciplinary follow-up with patient-reported UF and EF scores at ≥12 mo. Intervention Open or minimally invasive RP. Outcome measurements and statistical analysis Primary outcome was good UF as defined by a urinary score ≥17 (range: 0–21) or good EF as defined by a modified International Index of Erectile Function-6 score ≥22 (range: 1–30). The probability of functional recovery beyond 12 mo was determined by Kaplan-Meier analyses. Results and limitations Among patients incontinent at 12 mo, the probability of achieving good UF at 24, 36, and 48 mo was 30%, 49%, and 59%. In patients experiencing erectile dysfunction at 12 mo, the probability of recovering EF at 24, 36, and 48 mo was 22%, 32%, and 40%. On multivariable analyses, 12-mo functional score and age were associated with recovery, but only score was consistently significant. Conclusions Men with incontinence or erectile dysfunction at 12 mo have higher than anticipated rates of subsequent functional improvement. Probability of recovery is strongly influenced by score at 12 mo. Further research should address the impact of ongoing multidisciplinary follow-up care on our observed rates of recovery. Patient summary Many prostate cancer patients continue to recover urinary and erectile function after 12 mo. The level of functional recovery by 12 mo is associated with long-term recovery and should be discussed by the physician and patient when deciding on rehabilitative interventions.

Clinical characterization of a family with a mutation in the uromodulin (Tamm-Horsfall glycoprotein) gene. Background We have recently identified a mutation in the uromodulin gene in a large family affected with hyperuricemia, gout, and renal failure. The purpose of this investigation is to provide a comprehensive characterization of the clinical findings of this syndrome in family members who had a mutation in the uromodulin gene. Methods An extended family suffering from hyperuricemia and gout was identified by a local practitioner. After consent was obtained, patients provided a directed clinical history and blood and urine specimens for chemical and genetic testing. All family members were tested for the presence of uromodulin gene mutations by direct DNA sequence analysis. The clinical and biochemical characteristics of family members carrying the affected mutation were then investigated. Results Thirty-nine family members were found to have an exon 5 uromodulin gene mutation (g.1966 1922 del), and 29 unaffected family members were identified. The cardinal clinical features in individuals with the uromodulin mutation included hyperuricemia, decreased fractional excretion of uric acid, and chronic interstitial renal disease leading to end-stage renal disease (ESRD) in the fifth through seventh decade. Women did not always develop hyperuricemia or gout, but still developed progressive chronic renal failure. Conclusion Mutation of the uromodulin gene resulted in hyperuricemia, reduced fractional excretion of uric acid, and renal failure. Genetic testing will be required to definitively identify individuals suffering from this condition. We are interested in studying other families that may suffer from this condition and would appreciate any such referrals.

Objective To examine the cost-effectiveness of endoscopic treatment of low-risk non–muscle-invasive bladder cancer (NMIBC) via office-based fulguration vs operating room–based transurethral resection of the bladder (TURB). Methods A Markov state-transition model was created to simulate and compare the economic burden of managing patients with office-based fulguration vs TURB. Direct procedural and hospitalization costs were queried from our institution. Patients were modeled as being followed up routinely with flexible cystoscopy, whereas tumor recurrences were treated with either fulguration or TURB. Results A strategy of office-based fulguration was more cost-effective than TURB ($1171 per quality-adjusted life year [QALY] vs $1208 per QALY) to treat recurrent NMIBC over a 5-year period. Fulguration was both more effective (14.94 vs 14.91 QALYs) as well as less expensive ($17,494 vs $18,005), thus dominating TURB. The incremental cost-effectiveness ratio was −$18,440 per QALY. Sensitivity analysis demonstrates that the relative costs of the procedures are more significant in determining cost-effectiveness than their respective utilities. Conclusion Office-based cystoscopy and fulguration was more cost-effective than TURB for treating recurrent low-risk NMIBC. Adherence to an office-based treatment plan can lead to significant cost savings with a decreased therapeutic burden over the lifetime of a patient with NMIBC.

In the year following a radical prostatectomy, most men recover from any initial urinary incontinence. Nonetheless, incontinence greatly affects a man's quality of life during that time, as it does for those who have persistent incontinence thereafter. Urological assessment should be thorough in order to ensure that no treatable etiology exists aside from stress incontinence. Conservative measures can then be applied from the earliest stages, and offer benefit for those with mild to moderate symptoms. Failing this, a wide variety of surgical options can be considered. For effective outcomes, a clinician must ensure that surgical decision-making is based on current evidence and patient preference, and that it considers possible morbidities.

More than half of the men who receive treatment for prostate cancer elect radiotherapy. After radiotherapy recurrence is determined by an increase in prostate specific antigen and not usually by pathological confirmation. We describe the prevalence of persistent gradable prostate cancer in men treated with radiotherapy for prostate cancer at radical cystoprostatectomy for bladder cancer.A total of 78 patients underwent radiotherapy (brachytherapy and/or external beam radiation) before the development of bladder cancer requiring radical cystectomy at our institution. All tissues were evaluated by a specialized genitourinary pathologist.Median time from radiotherapy to radical cystoprostatectomy was 77 months. Gradable prostate cancer was identified in 45% of patients. Of the tumors 69% were Gleason score 7 or greater, 17% were pT3 or greater and 5% showed positive lymph nodes. Men treated more recently were less likely to have gradable prostate cancer, including 100% before 1980, 49% between 1980 and 2000 and 10% from 2000 to the present (p=0.002) as were those who received external beam radiation alone compared to brachytherapy and combined brachytherapy/external beam radiation (58% vs 27% and 14%, respectively, p=0.005).After radiotherapy 45% of men had persistent prostate cancer (37% of men with no evidence of disease). A decreased prostate cancer rate was associated with later treatment year and combined brachytherapy/external beam radiation regimens. Similar to men treated with radical cystoprostatectomy for muscle invasive bladder cancer, meticulous attention should be paid during prostate removal in men treated with radiotherapy because many may have persistent prostate cancer. In addition, markers other than prostate specific antigen should be studied in men treated with radiotherapy to better identify those with biochemical recurrence.

Photoselective laser vaporization prostatectomy (PVP) with a high-power KTP laser is a hemostatic procedure for men with symptomatic benign prostatic hyperplasia (BPH). This study demonstrates the feasibility of PVP in men who are receiving anticoagulants.Men treated with PVP for symptomatic BPH between July 2002 and September 2003 who were receiving anticoagulants (N=24) were reviewed retrospectively. Their mean age was 75 years, and the mean prostate volume was 82 cc (range 34-164 cc). Nine men (38%) were in retention, eight (33%) had had a myocardial infarction, seven (29%) had had a cerebrovascular accident, and seven had peripheral vascular disease. Of these men, 8 were on warfarin, 2 on clopidogrel, and 14 on aspirin. Men on warfarin discontinued the drug 2 days prior to surgery and restarted it the day after. The other two drugs were not discontinued. The PVP was performed with an 80 W KTP side-firing laser (Laserscope Greenlight PV) through a 23F continuous-flow cystoscope with normal saline as the irrigant.The mean operative time was 101 minutes. No transfusions were required. Most (22; 92%) of the men were discharged without a catheter. The serum hematocrit did not change significantly (40.0% to 38.3%). The International Prostate Symptom Score decreased to 13.6, 10.9, 9.7, and 9.5 at 1, 3, 6, and 12 months from a mean of 18.7 preoperatively. The Qmax increased from 9.0 mL/sec preoperatively to 15.1, 16.3, 20.9, and 20.1 mL/sec at 1, 3, 6, and 12 months. No patients had clinically significant hematuria postoperatively, and none suffered clot retention.Photoselective laser vaporization prostatectomy is a suitable treatment option in men being treated with anticoagulants, who are at high risk for clinically significant bleeding.

Urinary adverse events after radical prostatectomy, particularly urinary incontinence and formation of an anastomotic stricture, are bothersome and can lead to significant decrease in quality of life (Walsh et al., J Urol 152:1831–6, 1994; Catalona and Basler, J Urol 150:905–7, 1993; Potosky et al., J Natl Cancer Inst 96:1358–67, 2004;Stothers et al., Urinary incontinence in men. In: Litwin MS, Saigal CS, editors. Urologic diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington DC: US Government Publishing Office, NIH Publication No. 07-5512, pp 193–222, 2007; Wei et al., J Urol 164:744–8, 2000). In addition to having knowledge of standard treatment options for these maladies, it is important to understand the risk factors for development of persistent urinary incontinence and anastomotic stricture. The natural history of recovery of urinary function is extremely important in determining when intervention is needed. In this chapter, we review preoperative evaluation, risk factors, and management of voiding dysfunction—urinary incontinence and anastomotic strictures—after radical prostatectomy.

The eukaryotic flagellum (or cilium) is a broadly conserved organelle that provides motility for many pathogenic protozoa and is critical for normal development and physiology in humans. Therefore, defining core components of motile axonemes enhances understanding of eukaryotic biology and provides insight into mechanisms of inherited and infectious diseases in humans. In this study, we show that component of motile flagella 22 (CMF22) is tightly associated with the flagellar axoneme and is likely to have been present in the last eukaryotic common ancestor. The CMF22 amino acid sequence contains predicted IQ and A TPase a ssociated with a variety of cellular a ctivities (AAA) motifs that are conserved among CMF22 orthologues in diverse organisms, hinting at the importance of these domains in CMF22 function. Knockdown by RNA interference (RNAi) and rescue with an RNAi-immune mRNA demonstrated that CMF22 is required for propulsive cell motility in Trypanosoma brucei . Loss of propulsive motility in CMF22-knockdown cells was due to altered flagellar beating patterns, rather than flagellar paralysis, indicating that CMF22 is essential for motility regulation and likely functions as a fundamental regulatory component of motile axonemes. CMF22 association with the axoneme is weakened in mutants that disrupt the nexin-dynein regulatory complex, suggesting potential interaction with this complex. Our results provide insight into the core machinery required for motility of eukaryotic flagella.

Objective To investigate contemporary trends in the use of midurethral sling procedures for the surgical correction of female stress urinary incontinence over the past decade. Methods Annualized case log data for female incontinence surgeries from certifying and recertifying urologists were obtained from the American Board of Urology. Descriptive analysis of the number and type of cases per year was performed. Associations between surgeon characteristics and the use of female incontinence procedures were evaluated. Results A total of 6355 nonpediatric urologists applied for certification or recertification between 2003 and 2012. Two-thirds (4185) reported performing any procedures for female incontinence. Procedures sharply increased from 4632 in 2003 to 7548 in 2004, then remained relatively stable between 2005 and 2012 (range, 8014-10,238 cases). Traditional procedures decreased from 17% of female incontinence procedures in 2003 to 5% in 2004 to

INTRODUCTION AND OBJECTIVES: Surgical correction of pelvic organ prolapse (POP) has undergone a transformation over the past decade with the introduction of trans-vaginally placed mesh kits and the proliferation of laparoscopic/robotic surgery. Training in POP surgery, ease of mesh kit use and FDA warnings on mesh use have all influenced practice patterns. We investigated trends in the use of these treatments over the last decade among US urologists. METHODS: Data on POP procedures (colporrhaphy, colpopexy, hysterectomy), mesh usage (placement, revision), and pessary use were obtained from the American Board of Urology (ABU) via annualized case log data from certifying and recertifying urologists between 2003-2012. Associations between surgeon characteristics (type of certification, annual volume, practice type and location) and use of POP procedures were evaluated. RESULTS: Among 6,355 urologists applying for certification or recertification between 2003 and 2012, 2,192 reported performing any procedures for POP. POP procedures have risen steadily over the past decade, from 930 procedures in 2003 to 6,978 procedures in 2012. Colporrhaphies have increased each year, from 806 to 2670 between 2003-2012. Colpopexies increased steadily from 2003 (n 32) through 2012 (n 1414). Vaginal colpopexies increased from 24 to 1016 between 2003-2012. Sacrocolpopexies rose from 8 cases in 2003 to 398 cases by 2012. Laparoscopic sacrocolpopexies increased exponentially, reaching 282 cases by 2012. Mesh insertion rose sharply from 10 in 2005 to 640 in 2006, and to 1552 in 2012 (p 0.0005). There were no mesh revisions reported between 2003-2006. In 2007, 52 revisions were performed and the number of revisions has increased consistently up to 2012 (n 214). Nearly 40% of surgeons who perform POP surgery used mesh, whereas 6% reported performing mesh revisions. The rate of hysterectomies was low over time, with only 34 surgeons reporting use for POP. Pessary use has remained stable over time. Urologists who completed a female urology fellowship performed more POP procedures (p 0.0005). CONCLUSIONS: POP surgical procedures performed by US urologists have increased significantly over the last decade. The rise in colporrhaphies has been mirrored by the rise in mesh utilization. More colpopexies are now performed presumably due to an increased understanding of the need for apical repair. Sacrocolpopexy has increased exponentially perhaps due to adoption of robotic techniques amongst urologists. The proliferation of mesh-based surgeries has given rise to a latter trend of mesh revision surgeries for complications.

INTRODUCTION AND OBJECTIVES: Half of men with prostate cancer (PCa) will choose radiotherapy (RT) for treatment. A prostate biopsy is not routinely performed after RT as a recurrence is determined by elevated PSA. We sought to determine the incidence of persistent PCa in patients who received definitive RT for PCa and subsequently developed bladder cancer necessitating radical cystectomy (RC). METHODS: We identified 78 men who underwent RC for bladder cancer between 1993 and 2012 at our center who had a previous history of PCa treated with RT between 1986 to 2010. A biochemical recurrence (BCR) before surgery was identified by the treating physician, PSA greater than 2 ng/ml or the administration of androgen deprivation therapy (ADT). All pathologic specimens were evaluated by a genitourinary pathologist. RESULTS: Of the 78 men who underwent RC the median time from radiotherapy was 77 months (IQR 38-118) with only 12 patients undergoing RC less than 30 months from radiation treatment. External beam radiotherapy (EBRT) was performed in 35 men (45%), while 12 men received brachytherapy (15%) and 24 (31%) receiving both EBRT and brachytherapy and 6 (14%) received unknown radiation dose or type. For those men undergoing EBRT, the median dose of radiation was 7020 cGY. One in three men had a history of ADT and 21% had a known BCR prior to RC. PSA values were available for 62 men prior to RC (80% of patients). The median PSA prior to RC was 0.95 (IQR 0.06-2.11) with 24% of patients having a PSA of 2 ng/ml or greater. The rate of histologic gradable prostate cancer was 45% at RC with 10% having ungraded PCa, 14.1% Gleason 6 or less, 18% Gleason 7 and 13% Gleason 8 or higher. Prostate lymph node metastasis were found in four men (5%) associated with Gleason 8 (2 men) and 9 (2 men) tumors. The prostate surgical margins were positive in 8 (10%) with 11.5% pT3b or greater. When grouped by time of radiotherapy, the prevalence of PCa was 100% before 1980 (4/4), 67% between 1980 and 2000 (33/49), and 24% since 2000 (6/25) (p 0.0001). Of those patients with persistent PCa, 11% received brachytherapy, 70% received EBRT and 19% received both EBRT and brachytherapy (p 0.001). CONCLUSIONS: In our series of men undergoing RC after RT, 45% of men had persistent gradable PCa with a decrease in PCa rates associated with later years of treatment and the combined brachytherapy/EBRT modality. These findings are consistent with higher radiation dose levels administered in the more recent era of treatment. The prostate should be treated with similar oncologic attention during the RC in men with prior radiation treatment.

Objective To report on a safe endoscopic management technique for the treatment of an anastomotic stricture (AS) in patients with an artificial urinary sphincter (AUS). Methods Five patients with a history of salvage prostatectomy after radiation therapy that developed an AS after AUS placement were treated with a rigid ureteroscope and a Holmium YAG (Ho: YAG) laser to incise the AS. The AUS was opened and deactivated but not decoupled or removed during the procedure. The rigid ureteroscope allowed complete control of the laser fiber to incise the stricture at the 3 and 9 o' clock positions and then circumferentially. Results There were no intraoperative complications and the mean operative time was 42.6 minutes. Of the 5 patients who underwent holmium laser incision of an AS after AUS placement, none developed AUS malfunction or required device replacement. No patients reported worsening of urinary incontinence after treatment. Two patients required repeat holmium laser incision for AS recurrence. Conclusion Using a rigid ureteroscope and a holmium laser to incise an AS after AUS placement seems to be a safe management option that does not damage the AUS or result in worsening incontinence. This treatment strategy provides an endoscopic alternative to using open surgical technique to uncouple or remove the AUS while treating the AS.

The artificial urinary sphincter (AUS) has been the gold standard treatment for male stress urinary incontinence over the last quarter century and continues to be the workhorse procedure for male incontinence. In this issue of European Urology, Van der Aa et al. provide a systematic review of its use in male nonneurogenic incontinence [1], concluding that data regarding continence, complications, and patient satisfaction are scarce in the literature and suggesting that large-scale prospective studies with standardized methodology and instruments are needed. Unfortunately, there are very few surgeons performing the AUS in meaningful numbers [2], and as such, performing prospective trials will be limited to a very small number of high-volume centers or will have to include multiple centers. With multiple centers, surgical quality becomes an issue. Standardized surgical technique, proper patient selection, and proper surgeon training would be minimal criteria for selection of centers for multicenter trials. As we have shown, surgeon volume plays an enormous role in AUS efficacy as measured by a strict outcome: 5-yr reoperative rates [3]. In our report, reoperative rates decreased by roughly 50% as surgeons reached their 200th case. Increasing surgeon experience likely results not only in improved surgical technique, but also better patient selection and therefore improved surgical outcome. There are very few manuscripts in the literature that report on series with >200 cases [4–6], and only one of these was included in the review by Van der Aa et al. [1]. Patient education after AUS is another very important factor that may also play a role in outcomes. At our

Laser vaporization of the prostate is widely used to treat lower urinary tract symptoms. It may decrease the hospital cost and morbidity associated with transurethral resection of the prostate. However, prostate cancer may go undetected because tissue is not taken at laser vaporization. To our knowledge the rate of clinically significant prostate cancer missed by laser vaporization has not been assessed to date. We determined the rate of clinically significant prostate cancer detected by transurethral resection of the prostate compared to the estimated number of cancers missed by laser vaporization.A total of 74,505 men diagnosed with stage T1 prostate cancer between 2004 and 2006 were identified from the SEER (Surveillance, Epidemiology and End Results) program in the United States. The total number of laser vaporizations and transurethral resections were calculated based on Medicare claims for the same period. Clinically significant cancer was defined as that with a Gleason score of 7 or greater in men 40 to 75 years old.If prostate specific antigen screening were used uniformly (excluding men with prostate specific antigen greater than 4 ng/ml), only 1 of 382 transurethral resections of the prostate would identify clinically significant prostate cancer for a total of 390 in the American population in 3 years. Based on Medicare reported laser vaporization use a total of only 163 clinically significant cancers would be missed in more than 60,000 procedures.The incidence of T1a and T1b prostate cancer remains low and few patients have clinically significant prostate cancer. When prostate specific antigen screening is used, the number of clinically significant tumors missed by ablative procedures is low (average of 0.26% of all procedures) and can be identified by prostate specific antigen screening.

INTRODUCTION AND OBJECTIVES: We aimed to describe contemporary trends in transurethral resection of prostate (TURP) by examining case logs submitted for American Board of Urology (ABU) certification. We compared electrosurgical TURP versus laser vaporization TURP and examined the impact of surgeon age on those practice patterns. METHODS: US urologists submit case logs for their initial board certification and recertification. We analyzed these logs from 20042010 for trends and used logistic regression to assess the impact of age on TURP utilization. RESULTS: In total 4,709 urologists submitted case logs for certification between 2004 and 2010. Of these, 3,955 urologists included at least 1 TURP, of which 2,334 (59%) performed exclusively electrosurgical TURP and 309 (8%) performed exclusively laser vaporization TURP. We observed a large increase in the number and proportion of laser vaporization TURP procedures performed and a smaller corresponding decrease in electrosurgical TURPs. In 2004, only 11% of patients received a laser vaporization TURP by certifying urologists; in 2010 44% did (Table). Median age for urologists performing exclusively electrosurgical TURP was the same as those performing laser vaporization TURP (43 years). Those performing any laser vaporization procedures had substantially higher case volumes compared with those performing only electrosurgical procedures (median annual case volume, [IQR]: any laser vaporization: 18 cases [10, 30], electrosurgical only: 10 [4, 18]; Wilcoxon rank-sum test p 0.0005). Compared to their younger colleagues, older urologists were significantly less likely to perform iÝ1 laser vaporization TURP when undergoing their second recertification (odds ratio [OR] per year: 0.94; p 0.009), but not their initial certification (OR per year: 0.98; p 0.3) or first recertification (OR per year: 0.97; p 0.13). CONCLUSIONS: Among urologists undergoing board certification or recertification in 2010, 56% of TURPs were done electrosurgically. We also found that older age was significantly associated with lower likelihood of performing laser vaporization TURP among those undergoing their second recertification. These data provide estimates of current TURP practice patterns and further our understanding of the evolving surgical treatment of benign prostatic hyperplasia.

Objective To characterize the clinicopathologic features of patients who developed pubovesical fistula (PVF) after treatment of prostate cancer and to identify some possible methods of reducing the incidence of this rare complication for which no well-established guidelines exist. Methods We identified men at 2 centers who presented with PVF after prostate cancer treatment from January 2000 to December 2010. Prostate cancer was treated with radiotherapy (RT) or radical prostatectomy, or both. Patients with bladder neck contracture (BNC) received endoscopic treatment. The demographic and clinical data were collected. Results Of the 12 patients who presented with PVF, the treatment of prostate cancer was external beam RT in 8 (5 of whom underwent subsequent salvage radical prostatectomy) and radical prostatectomy (followed by salvage RT) in 4. All patients developed BNC requiring endoscopic treatment. The median interval between primary endoscopic treatment of BNC and the development of PVF was 35.9 months (range 0.6 to 97). The most common presenting symptom was suprapubic or groin pain. Of the 12 patients, 10 ultimately required cystectomy with urinary diversion. Conclusion The treatment of prostate cancer with RT followed by the development of BNC requiring endoscopic intervention appears to be associated with PVF development Despite conservative measures, patients who developed PVF often required cystectomy with urinary diversion. To avoid PVF, care should be taken during endoscopic intervention for BNC in patients who have received RT for prostate cancer. PVF should be on the differential diagnosis of patients with a history of RT and BNC who develop pubic pain or recurrent urinary tract infection.

Introduction: The objective was to determine the prevalence of, and factors that predict, detrusor underactivity (DU) in patients presenting with incontinence or lower urinary tract symptoms (LUTS) following radical prostatectomy (RP). We also determined the prevalence of bladder outlet obstruction (BOO) and detrusor overactivity (DO) in this population. Methods: Patients who underwent urodynamics post-RP were identified. Detrusor underactivity was defined as a maximum flow rate (Qmax) of ≤15 mL/s and detrusor pressure (Pdet) Qmax

Several options exist for the surgical correction of male stress urinary incontinence including periurethral bulking agents, artificial urinary sphincters and the recently introduced male urethral slings. We investigated contemporary trends in the use of these treatments.Annualized case log data for incontinence surgeries from certifying and recertifying urologists were obtained from the ABU (American Board of Urology), ranging from 2004 to 2010. Chi-square tests and logistic regression models were used to evaluate the association between surgeon characteristics (type of certification, annual volume, practice type and practice location) and the use of incontinence procedures.Among the 2,036 nonpediatric case logs examined the number of incontinence treatments reported for certification has steadily increased over time from 1,936 to 3,366 treatments per year from 2004 to 2010 (p = 0.008). Nearly a fifth of urologists reported placing at least 1 sling. The proportion of endoscopic procedures decreased from 80% of all incontinence procedures in 2004 to 60% in 2010, but they remained the exclusive incontinence procedure performed by 49% of urologists. A urologist's increased use of endoscopic treatments was associated with a decreased likelihood of performing a sling procedure (OR 0.5, p0.0005). Artificial urinary sphincter use remained stable, accounting for 12% of procedures.Incontinence procedures are on the rise. Urethral slings have been widely adopted and account for the largest increase among treatment modalities. Endoscopic treatments continue to be commonly performed and may represent overuse in the face of improved techniques. Further research is required to validate these trends.

should not be at the cost of potential unfavourable outcomes in the case of delayed radical prostatectomy. We evaluated reasons for deferred treatment and pathological findings after RP in our AS cohort. METHODS: Between December 2006 and October 2010, 1482 men with low-risk PC (clinical stage T2, PSA 10 ng/ml, PSA density 0.2 ng/ml/ml, 1 or 2 positive biopsy cores and Gleason score 6) were included in the PRIAS study (Prostate Cancer Research International: Active Surveillance). PSA was measured 3-monthly and repeat biopsies were applied according to protocol (at least after 1, 4 and 7 years). Deferred radical treatment was advised in the case of risk reclassification towards high risk on repeat biopsy (Gleason score 7 or 3 positive biopsy cores) or a PSA doubling time (PSA-DT) 3 years. Pathological findings of cases receiving delayed radical prostatectomy (RP) were analyzed. RESULTS: A total of 135 (9%) men underwent RP at a median of 1.2 years (25–75p: 1.0–1.5) after diagnosis. Reasons for switching to RP were: risk reclassification to higher risk on repeat biopsy (48%), PSA-DT 3 yrs (16%), combination of biopsy findings and PSA-DT 3 years (14%), anxiety (10%) or other reasons (11%). Histopathological outcomes were available in 69 (51%) men. Organ confined disease was present in 55 (80%) cases, of which 27 (49%) were Gleason 6. Extracapsular extension was found in 14 cases (20%) and primary Gleason scores of 4 or 5 were found in 7 (10%) and 1 (1%) men respectively. In 38 of 42 (90%) cases of either upgrading or upstaging on RP, the reason of initiating invasive therapy was protocol based. CONCLUSIONS: The greater part of cases with upgrading or upstaging on RP in our AS cohort has a protocol based reason to undergo deferred treatment. Careful selection of patients and strict follow-up is warranted to preserve the window of opportunity for curative treatment for men on AS. A relatively higher rate of unfavourable characteristics than shown in series of immediate RP in AS suitable patient might be expected, due to self-selection of men who start on AS and receive RP due to reclassification to higher risk during follow-up. The current results are preliminary, but complementary data are expected at short notice.

• To evaluate feasibility, safety and oncological efficacy of salvage laparoscopic radical prostatectomy for pathology-proven biochemical recurrence after primary radiation therapy or cryotherapy for prostate cancer.• This retrospective pilot study examined 15 patients from 2004 to 2010 with biochemical recurrence after external beam radiation therapy (N= 8), brachytherapy (N= 6) or cryotherapy (N= 1). • Patients were treated with salvage laparoscopic radical prostatectomy (11 conventional, four robotic-assisted) with bilateral pelvic dissection.• Median duration of surgery was 235 min. None of the following occurred: conversion to open surgery, transfusion, urethrovesical stenosis or perioperative or postoperative mortality. One patient presented with a rectal injury, repaired using uninterrupted sutures and a colostomy. One patient had anastomotic leak treated with prolonged Foley catheterization. • Pathological stage was pT2a in three, pT2b in three, pT3a in four, pT3b in three and pT4 in two patients; two patients had nodal metastasis. Within an 8-month median follow-up, 11 patients were disease-free and three had persistent postoperative prostate-specific antigen (PSA) elevation; the remaining patient experienced PSA recurrence after 21 months. • Seven patients achieved continence (no pads) by 8.4 months (median), one patient manifested severe incontinence corrected by implanting an artificial sphincter, and seven patients with a 12.6-month mean follow-up continued to need one or two pads per day. • Erectile dysfunction was present in five patients before surgery and in 14 patients after surgery.• Salvage laparoscopic radical prostatectomy seems to offer a safe therapeutic alternative for patients failing primary radiation or cryotherapy. However, larger studies with longer-term data are required.