Search

Aims We explored re-interventions and short and long term adverse events associated with procedures for male incontinence among Medicare beneficiaries. Methods All inpatient and outpatient claims for a simple random sample of Medicare beneficiaries for 2000–2011 were queried to identify patients of interest. All male patients with an International Classification of Diseases, 9th Edition (ICD-9) diagnosis code for stress incontinence or mixed incontinence were included. Artificial urinary sphincter recipients, patients who underwent a sling operation and those receiving an injection of a bulking agent were identified with Current Procedure Terminology (CPT-4) and ICD-9 Procedure Codes. Results The entire cohort of 1,246 patients were operated on between 2001 and 2011. 34.9% of them received an artificial urinary sphincter (AUS), 28.7% with a bulking agent, and 36.4% with a sling. There were no statistically significant differences in demographics or comorbidities between the treatment groups, except that more sling patients were obese (P = 0.006) and fewer bulk patients had diabetes (P = 0.007). There are, however, significant changes in procedures selected over time (P

Background Nodal metastasis is the strongest risk factor of disease recurrence in patients with localized prostate cancer (PCa) treated with radical prostatectomy (RP). Objective To develop a model that allows quantification of the likelihood that a pathologically node-negative patient is indeed free of nodal metastasis. Design, setting, and participants Data from patients treated with RP and pelvic lymph node dissection (PLND; n = 7135) for PCa between 2000 and 2011 were analyzed. For external validation, we used data from patients (n = 4209) who underwent an anatomically defined extended PLND. Intervention RP and PLND. Outcome measurements and statistical analysis We developed a novel pathologic (postoperative) nodal staging score (pNSS) that represents the probability that a patient is correctly staged as node negative based on the number of examined nodes and the patient's characteristics. Results and limitations In the development and validation cohorts, the probability of missing a positive node decreases with an increasing number of nodes examined. Whereas in pT2 patients, a 90% pNSS was achieved with one single examined node in both the development and validation cohort, a similar level of nodal staging accuracy was achieved in pT3a patients by examining five and nine nodes, respectively. The pT3b/T4 patients achieved a pNSS of 80% and 70% when 17 and 20 nodes in the development and validation cohort were examined, respectively. This study is limited by its retrospective design and multicenter nature. The number of nodes removed was not directly correlated with the extent/template of PLND. Conclusions Every patient needs PLND for accurate nodal staging. However, a one-size-fits-all approach is too inaccurate. We developed a tool that indicates a node-negative patient is indeed free of lymph node metastasis by evaluating the number of examined nodes, pT stage, RP Gleason score, surgical margins, and prostate-specific antigen. This tool may help in postoperative decision making. © 2013 European Association of Urology.

Aims Sacral nerve stimulation (SNS) is FDA approved as second-line therapy for both urinary and bowel control. However, there is limited evidence regarding long term safety. We determined adverse events associated with SNS among Medicare beneficiaries. Methods We used the 5% national random sample of Medicare claims for 2001–2011 to identify patients. Patients who underwent SNS implantation were identified with Current Procedure Terminology (CPT-4) codes. We determined safety of SNS using analysis of complication occurrences on day of surgery and during 5 years following initial procedure. SAS v9.3 statistical package was used. Results One thousand four hundred seventy-four patients underwent treatment with SNS in the 5% national sample of Medicare patients within the time period. Representative of real-world patients undergoing SNS surgery, comorbidities included hypertension (69.3%), diabetes (29.4%), chronic pulmonary disease (25.5%), hypothyroidism (25.2%), and depression (22.7%). Few complications occurred on day of surgery. At 90 days, 3.2% of patients had bowel complications, 2.0% urological, 9.4% infectious, and 1.5% stroke. Overall, bowel, neurological health event occurrences were consistent with prior year rates, while infectious events decreased. Of 206 patients who were followed for at least 5 years, 17.3% had devices removed and 11.3% replaced, with 26.1% having at least one of those, leaving 73.9% with original devices. Conclusions Urological, infectious, and bowel complication occurrences were low after SNS among Medicare beneficiaries with multiple comorbidities. There were infrequent serious complications like hemorrhage and stroke postoperatively. Although SNS appears safe in this high-risk population, a comprehensive registry will ensure continuous safety. Neurourol. Urodynam. 34:???–???, 2015. © 2014 Wiley Periodicals, Inc.

Primary open-angle glaucoma (POAG) is a leading cause of blindness worldwide. Using genome-wide association single-nucleotide polymorphism data from the Glaucoma Genes and Environment study and National Eye Institute Glaucoma Human Genetics Collaboration comprising 3,108 cases and 3,430 controls, we assessed biologic pathways as annotated in the KEGG database for association with risk of POAG. After correction for genic overlap among pathways, we found 4 pathways, butanoate metabolism (hsa00650), hematopoietic cell lineage (hsa04640), lysine degradation (hsa00310) and basal transcription factors (hsa03022) related to POAG with permuted p&nbsp

Objective To assess the impact of cigarette smoking status, cumulative smoking exposure, and time from cessation on intravesical recurrence (IVR) outcomes in patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Patients and Methods In all, 519 patients underwent RNU at five institutions. Smoking history included smoking status, quantity of cigarettes smoked per day (cpd), duration, and time from cessation. The cumulative smoking exposure was categorised as light-short-term (≤19 cpd and ≤19.9 years), moderate (all combinations except light-short-term and heavy-long-term), and heavy-long-term (≥20 cpd and ≥20 years). Univariable/multivariable cox regression analyses assessed the effects of smoking on IVR. Results In all, 190 patients (36%) never smoked; 205 (40%) and 125 (24%) were former and current smokers, respectively. Among smokers, 42 (8%), 185 (36%), and 102 (20%) patients were light-short-term, moderate, and heavy-long-term smokers, respectively. Within a median follow-up of 37 months, 152 patients (29%) had IVR. Actuarial IVR-free-survival estimates (standard error) at 2, 5, and 10 years were 72 (2)%, 58 (3)%, and 51 (4)%, respectively. In multivariable analyses, current smoking status, smoking intensity (≥20 cpd), smoking duration (≥20 years), and heavy-long-term smoking were associated with higher risk of IVR (all P ≤ 0.01). Patients who quit smoking ≥10 years before RNU had better IVR outcomes than current smokers and those patients who quit smoking 10 years before RNU seems to mitigate these detrimental effects.

Context Abdominal sacrocolpopexy (ASC) represents the superior treatment for apical pelvic organ prolapse (POP) but is associated with increased length of stay, analgesic requirement, and cost compared with transvaginal procedures. Laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) may offer shorter postoperative recovery while maintaining equivalent rates of cure. Objective This review evaluates the literature on LSC and RSC for clinical outcomes and complications. Evidence acquisition A PubMed search of the available literature from 1966 to 2013 on LSC and RSC with a follow-up of at least 12 mo was performed. A total of 256 articles were screened, 69 articles selected, and outcomes from 26 presented. A review, not meta-analysis, was conducted due to the quality of the articles. Evidence synthesis LSC has become a mature technique with results from 11 patient series encompassing 1221 patients with a mean follow-up of 26 mo. Mean operative time was 124min (range: 55–185) with a 3% (range: 0–11%) conversion rate. Objective cure was achieved in 91% of patients, with similar satisfaction rates (92%). Six patient series encompassing 363 patients treated with RSC with a mean follow-up of 28 mo have been reported. Mean operative time was 202min (range: 161–288) with a 1% (range: 0–4%) conversion rate. Objective cure rate was 94%, with a 95% subjective success rate. Overall, early outcomes and complication rates for both LSC and RSC appeared comparable with open ASC. Conclusions LSC and RSC provide excellent short- to medium-term reconstructive outcomes for patients with POP. RSC is more expensive than LSC. Further studies are required to better understand the clinical performance of RSC versus LSC and confirm long-term efficacy. Patient summary Laparoscopic and robot-assisted sacrocolpopexy represent attractive minimally invasive alternatives to abdominal sacrocolpopexy. They may offer reduced patient morbidity but are associated with higher costs.

Aims The goal of this study is to develop an image-based model of urethral distention and resistance in women with and without SUI. Methods A biomechanical vector force model was created to simulate the mechanical deformation of pelvic floor structures during cough and Valsalva in order to measure urethral distension and predict flow resistance patterns. Dynamic MRI images were used to create a spatial model to construct an accurate representation of tissue thickness and location, which was combined with tissue property values (MATLAB 2011a, MathWorks, Natick, MA). Spatial profiles were created to demonstrate the effects of hypermobility and tissue property variability on distensibility and flow resistance along the urethra. Sensitivity analyses were conducted to demonstrate the relationship between flow resistance and various tissue properties. Results The average distension for incontinent cases (3.8 mm) was significantly greater than that of continent cases (2.6 mm) (t = 3.3083, df = 8, P

PURPOSE: To evaluate the glaucoma diagnostic performance of ganglion cell inner-plexiform layer (GCIPL) parameters used individually and in combination with retinal nerve fiber layer (RNFL) or optic nerve head (ONH) parameters measured with Cirrus HD-OCT (Carl Zeiss Meditec, Inc, Dublin, CA). DESIGN: Prospective cross-sectional study. PARTICIPANTS: Fifty patients with early perimetric glaucoma and 49 age-matched healthy subjects. METHODS: Three peripapillary RNFL and 3 macular GCIPL scans were obtained in 1 eye of each participant. A patient was considered glaucomatous if at least 2 of the 3 RNFL or GCIPL scans had the average or at least 1 sector measurement flagged at 1% to 5% or less than 1%. The diagnostic performance was determined for each GCIPL, RNFL, and ONH parameter as well as for binary or-logic and and-logic combinations of GCIPL with RNFL or ONH parameters. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR). RESULTS: Among GCIPL parameters, the minimum had the best diagnostic performance (sensitivity, 82.0%; specificity, 87.8%; PLR, 6.69; and NLR, 0.21). Inferior quadrant was the best RNFL parameter (sensitivity, 74%; specificity, 95.9%; PLR, 18.13; and NLR, 0.27), as was rim area (sensitivity, 68%; specificity, 98%; PLR, 33.3; and NLR, 0.33) among ONH parameters. The or-logic combination of minimum GCIPL and average RNFL provided the overall best diagnostic performance (sensitivity, 94%; specificity, 85.7%; PRL, 6.58; and NLR, 0.07) as compared with the best RNFL, best ONH, and best and-logic combination (minimum GCIPL and inferior quadrant RNFL; sensitivity, 64%; specificity, 100%; PLR, infinity; and NPR, 0.36). CONCLUSIONS: The binary or-logic combination of minimum GCIPL and average RNFL or rim area provides better diagnostic performances than those of and-logic combinations or best single GCIPL, RNFL, or ONH parameters. This finding may be clinically valuable for the diagnosis of early glaucoma.

Background: Intravesical recurrence after radical nephroureterectomy (RNU) is a frequent event requiring intense cystoscopic surveillance. Recently, a prospective randomized clinical trial has shown that a single intravesical postoperative dose of mitomycin C (MMC) reduces the absolute risk of intravesical recurrence after RNU. Objective: The aim of the current study was to identify predictors of intravesical recurrence and to develop a tool to allow a risk-stratified approach supporting patient counseling for cystoscopic surveillance and postoperative intravesical MMC administration. Design, setting, and participants: We performed a retrospective analysis of 1839 patients with upper tract urothelial carcinoma (UTUC). The data set was split into a development cohort of 1261 patients from North America and a validation cohort of 578 patients from Europe. Interventions: RNU with bladder cuff excision was performed. The surgical approach was open in 1424 patients (77.4%) and laparoscopic in 415 patients (22.6%). Outcome measurements and statistical analyses: Univariable and multivariable Cox regression models addressed time to intravesical recurrence after RNU. We developed a nomogram for prediction of the probability of intravesical recurrence at 3, 6, 9, 12, 18, 24, and 36 mo. Predictive accuracy was quantified using the concordance index. Decision curve analysis was performed to evaluate the clinical benefit associated with the use of our nomograms. Results and limitations: With a median follow-up of 45 mo, intravesical recurrence occurred in 577 patients (31%). The probability of intravesical recurrence-free survival at 6, 12, 24, and 36 mo was 85% +/- 1%, 78% +/- 1%, 68% +/- 1%, and 47% +/- 2%, respectively. In multivariable Cox regression analysis, advanced age, male gender, ureteral tumor location, laparoscopic surgical technique, endoscopic distal ureteral management, previous bladder cancer, higher tumor stage, concomitant carcinoma in situ, and lymph node involvement were all significantly associated with intravesical recurrence (p values

Objective To determine the association between peri-operative blood transfusion (PBT) and oncological outcomes in a large multi-institutional cohort of patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). Patients and Methods We conducted a retrospective analysis of 2895 patients treated with RC for UCB. Univariable and multivariable Cox regression models were used to analyse the effect of PBT administration on disease recurrence, cancer-specific mortality, and any-cause mortality. Results Patients' median (interquartile range [IQR]) age was 67 (60, 73) years and the median (IQR) follow-up was 36.1 (15, 84) months. Patients who received PBT were more likely to have advanced disease (P < 0.001), high grade tumours (P = 0.047) and nodal metastasis (P = 0.004). PBT was associated with a higher risk of disease recurrence (P = 0.003), cancer-specific mortality (P = 0.017), and any-cause mortality (P = 0.010) in univariable, but not multivariable, analyses (P > 0.05). In multivariable analyses, pathological tumour stage, pathological nodal stage, soft tissue surgical margin, lymphovascular invasion and administration of adjuvant chemotherapy were independent predictors of disease recurrence, cancer-specific mortality and any-cause mortality (all P values

Objectives.To identify rates of incidentally detected prostate cancer in patients undergoing surgical management of benign prostatic hyperplasia (BPH).Materials and Methods.A retrospective review was performed on all transurethral resections of the prostate (TURP) regardless of technique from 2006 to 2011 at a single tertiary care institution. 793 men (ages 45–90) were identified by pathology specimen. Those with a known diagnosis of prostate cancer prior to TURP were excluded (n=22) from the analysis.Results.760 patients had benign pathology; eleven (1.4%) patients were found to have prostate cancer. Grade of disease ranged from Gleason3+3=6to Gleason3+4=7. Nine patients had cT1a disease and two had cT1b disease. Seven patients were managed by active surveillance with no further events, one patient underwent radiation, and three patients underwent radical prostatectomy.Conclusions.Our series demonstrates that 1.4% of patients were found to have prostate cancer, of these 0.5% required treatment. Given the low incidental prostate cancer detection rate, the value of pathologic review of TURP specimens may be limited depending on the patient population.

PEX stems from a pathologic elastotic process involving the cross-linking gene lysyl oxidase-like-1 (LOXL1), and is associated with abnormal formation of elastic extracellular matrix. We previously described a protein sink model to explain PEX material deposition on the lens capsule and other intraocular surfaces. Recent research findings not only provide evidence to support this hypothesis, but also further our understanding of the fundamental disease process. A key aspect of the pathogenic process is the compromise of blood-aqueous barrier integrity in PEXG. Decreased level of LOXL1 is associated with decreased elastin incorporation into elastic tissues, including the elastic lamina of blood vessels. This results in unincorporated elastin that is released as soluble elastin, and leakage of serum proteins, inflammatory cytokines, and extracellular matrix components into aqueous humor. This ultimately leads to aggregation and precipitation of large protein complexes, or PEX material, throughout intraocular surfaces as described in the protein sink model. The pathologic PEX process also affects the biomechanical properties of elastic tissues, such as the trabecular meshwork, lens zonules, and lamina cribrosa. This may be part of the primary pathologic process with intrinsically altered extracellular matrix proteins. This fundamental change in the structural composition of these tissues may alter their rigidity, elasticity, and other biomechanical properties. This likely contributes to increased trabecular meshwork outflow resistance and high intraocular pressure, and mechanical injury to retinal ganglion cell axons at the lamina cribrosa, which are conducive to glaucoma. These pathophysiologic processes combined may underlie some of the clinical hallmarks observed in PEXG.

To evaluate the outcome and the costs of stenting in uncomplicated semirigid ureteroscopic stone removal. A decision tree model was created to evaluate the economic impact of routine stenting versus non-stenting strategies in uncomplicated ureteroscopy (URS). Probabilities of complications were extracted from twelve randomized controlled trials. Stone removal costs, costs for complication management, and total costs were calculated using Treeage Pro (TreeAge Pro Healthcare version 2015, Software, Inc, Williamstown Massachusetts, USA). Stone removal costs were higher in stented URS (€1512.25 vs. €1681.21, respectively). Complication management costs were higher in non-stented procedures. Both for complications treated conservatively (€189.43 vs. €109.67) and surgically (€49.26 vs. €24.83). When stone removal costs, costs for stent removal, and costs for complication management were considered, uncomplicated URS with stent placement yielded an overall cost per patient of €1889.15 compared to €1750.94 without stent placement. The incremental costs of stented URS were €138.25 per procedure. Semirigid URS with stent placement leads to higher direct procedural costs. Costs for managing URS-related complications are higher in non-stented procedures. Overall, a standard strategy of deferring routine stenting uncomplicated ureteroscopic stone removal is more cost efficient.

Purpose of review Optical coherence tomography (OCT) has become an integral component of modern glaucoma practice. Utilizing color codes, OCT analysis has rendered glaucoma diagnosis and follow-up simpler and faster for the busy clinician. However, green labeling of OCT parameters suggesting normal values may confer a false sense of security, potentially leading to missed diagnoses of glaucoma and/or glaucoma progression. Recent findings Conditions in which OCT color coding may be falsely negative (i.e., green disease) are identified. Early glaucoma in which retinal nerve fiber layer (RNFL) thickness and optic disc parameters, albeit labeled green, are asymmetric in both eyes may result in glaucoma being undetected. Progressively decreasing RNFL thickness may reveal the presence of progressive glaucoma that, because of green labeling, can be missed by the clinician. Other ocular conditions that can increase RNFL thickness can make the diagnosis of coexisting glaucoma difficult. Recently introduced progression analysis features of OCT may help detect green disease. Summary Recognition of green disease is of paramount importance in diagnosing and treating glaucoma. Understanding the limitations of imaging technologies coupled with evaluation of serial OCT analyses, prompt clinical examination, and structure-function correlation is important to avoid missing real glaucoma requiring treatment.

Mechanical ocular trauma involving the anterior segment may result in damage to the conjunctiva, cornea, limbus, anterior chamber angle, iris, lens, and ciliary body. The mechanism of trauma (closed or open, blunt, penetrating, or perforating), force and extent of trauma, and whether a foreign body is involved determine the pathophysiologic consequence of injury to the various anterior segment structures. The treatment modalities employed and the final visual outcome are also dependent upon these trauma variables. Thorough history taking and careful clinical examination are crucial in the proper assessment and management of anterior segment trauma.

IMPORTANCE: Genetic variants associated with primary open-angle glaucoma (POAG) are known to influence disease risk. However, the clinical effect of associated variants individually or in aggregate is not known. Genetic risk scores (GRS) examine the cumulative genetic load by combining individual genetic variants into a single measure, which is assumed to have a larger effect and increased power to detect relevant disease-related associations. OBJECTIVE: To investigate if a GRS that comprised 12 POAG genetic risk variants is associated with age at disease diagnosis. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study included individuals with POAG and controls from the Glaucoma Genes and Environment (GLAUGEN) study and the National Eye Institute Glaucoma Human Genetics Collaboration (NEIGHBOR) study. A GRS was formulated using 12 variants known to be associated with POAG, and the alleles associated with increasing risk of POAG were aligned in the case-control sets. In case-only analyses, the association of the GRS with age at diagnosis was analyzed as an estimate of disease onset. Results from cohort-specific analyses were combined with meta-analysis. Data collection started in August 2012 for the NEIGHBOR cohort and in July 2008 for the GLAUGEN cohort and were analyzed starting in March 2018. MAIN OUTCOMES AND MEASURES: Association of a 12 single-nucleotide polymorphism POAG GRS with age at diagnosis in individuals with POAG using linear regression. RESULTS: The GLAUGEN study included 976 individuals with POAG and 1140 controls. The NEIGHBOR study included 2132 individuals with POAG and 2290 controls. For individuals with POAG, the mean (SD) age at diagnosis was 63.6 (9.8) years in the GLAUGEN cohort and 66.0 (13.7) years in the NEIGHBOR cohort. For controls, the mean (SD) age at enrollment was 65.5 (9.2) years in the GLAUGEN cohort and 68.9 (11.4) years in the NEIGHBOR cohort. All study participants were European white. The GRS was strongly associated with POAG risk in case-control analysis (odds ratio per 1-point increase in score = 1.24; 95% CI, 1.21-1.27; P = 3.4 × 10(−66)). In case-only analyses, each higher GRS unit was associated with a 0.36-year earlier age at diagnosis (β = −0.36; 95% CI, −0.56 to −0.16; P = 4.0 × 10(−4)). Individuals in the top 5% of the GRS had a mean (SD) age at diagnosis of 5.2 (12.8) years earlier than those in the bottom 5% GRS (61.4 [12.7] vs 66.6 [12.9] years; P = 5.0 × 10(−4)). CONCLUSIONS AND RELEVANCE: A higher dose of POAG risk alleles was associated with an earlier age at glaucoma diagnosis. On average, individuals with POAG with the highest GRS had 5.2-year earlier age at diagnosis of disease. These results suggest that a GRS that comprised genetic variants associated with POAG could help identify patients with risk of earlier disease onset impacting screening and therapeutic strategies.

BackgroundThe ShangRing is a disposable, collar clamp circumcision device pre-qualified for use in men and boys 13 years and above. It has been shown to be faster than conventional circumcision with comparable adverse event (AE) rates and high client satisfaction. Voluntary medical male circumcision (VMMC) has been shown to dramatically reduce the risk of HIV acquisition in males. However, the fear of pain during circumcision is an important barrier to uptake. Use of topical anesthesia thus presents an opportunity to address this.ObjectivesWe sought to evaluate the safety, effectiveness and acceptability of the use of topical anaesthesia with ShangRing circumcision of men and boys 10 years of age and above.MethodsParticipants were randomised 2:1 to receive topical or injectable anaesthesia. All participants underwent no-flip ShangRing circumcision. The primary outcome measure was pain. Secondary outcomes included ease of use of topical versus injectable anaesthesia, AEs and participant satisfaction.ResultsCompared to the topical group, participants in the injectable group reported significantly more pain on administration of the anesthesia and at approximately 20 minutes after the procedure. In the topical group, sufficient anaesthesia with topical cream was not achieved in 21 (9.3%) cases before the start of the procedure; in another 6 (2.6%), supplementary injectable anaesthesia was required as the circumcision was being carried out. The AE rate was significantly lower (pConclusionsOur results demonstrate the safety, improved clinical experience, effectiveness, and acceptability of the use of topical anaesthesia in ShangRing circumcision using the no-flip technique. Topical anaesthesia effectively eliminates needlestick pain from the clients' VMMC experience and thus has the potential to increase demand for the service.Trial registrationClinicalTrials.gov NCT02390310.

Context The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options. Objective To critically review the peer-reviewed literature on the function and oncological outcomes, complications, and factors influencing choice of procedure with urinary diversion after RC for bladder carcinoma. Evidence Acquisition A Medline search was conducted to identify original articles, review articles, and editorials on urinary diversion in patients treated with RC. Searches were limited to the English language. Keywords included: ‘bladder cancer’, ‘cystectomy’, ‘diversion’, ‘neobladder’, and ‘conduit’. The articles with the highest level of evidence were selected and reviewed, with the consensus of all of the authors of this paper. Evidence Synthesis Both continent and incontinent diversions are available for urinary reconstruction after RC. In appropriately selected patients, an orthotopic neobladder permits the elimination of an external stoma and preservation of body image without compromising cancer control. However, the patient must be fully educated and committed to the labour-intensive rehabilitation process. He must also be able to perform self-catheterisation if necessary. When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent cutaneous reservoir may still offer the opportunity for continence albeit one that requires obligate self-catheterisation. For patients who are not candidates for continent diversion, the ileal loop remains an acceptable and reliable option. Conclusions Both continent and incontinent diversions are available for urinary reconstruction after RC. Orthotopic neobladders optimally preserve body image, while continent cutaneous diversions represent a reasonable alternative. Ileal conduits represent the fastest, easiest, least complication-prone, and most commonly performed urinary diversion.

Objective To assess trends in the surgical management of ureteric calculi over a 10-year period. Materials and Methods An analysis of the 5% Medicare Public Use Files, from 2001, 2004, 2007 and 2010, was performed to assess the use of ureteroscopy (URS), extracorporal shockwave lithotripsy (ESWL) and ureterolithotomy (UL) in treating ureteric calculi. Patients were identified using International Classification of Diseases 9th edition (Clinical Modification) and Current Procedure Terminology codes. Statistical analyses using the Fisher and chi-squared tests, and multivariate logistic regression analysis (dependent variables: URS, ESWL, UL, treatment, no treatment; independent variables: age, gender, ethnicity, geography and year of treatment) were performed. Results A total of 299 920 patients with ureteric calculi were identified. Of these, 115 200 underwent surgery. Men (odds ratio [OR] = 1.15, P 84 years old (P = 0.29). The predominant surgical approach was URS (65.2%), followed by ESWL (33.6%) and UL (1.2%). The use of URS increased over time, while the use of ESWL and UL declined. Women (OR = 1.25, P < 0.001) were more likely to undergo URS. Patients in the South of the USA (OR = 1.51, P < 0.001) and patients from ethnic minorities were more likely to undergo ESWL (OR = 1.23, P = 0.03). Conclusions The surgical treatment of ureteric calculi changed significantly between 2001 and 2010. The use of URS expanded at the expense of ESWL and UL. Multiple inequalities existed in overall surgical treatment rates and in the choice of treatment; age, gender, ethnicity and geography influenced both whether patients underwent surgical intervention and the type of surgical approach used.

To evaluate the surgical performance of the new Greenlight XPS-180 W laser system (American Medical Systems, Minnetonka, MI) and the effect of prostate volume (PV), in comparison with the former HPS-120 W system, for the treatment of benign prostatic hyperplasia by photo-selective vaporization of the prostate.Between July 2007 and March 2012, 1809 patients underwent laser photo-selective vaporization of the prostate (1187 patients with the use of HPS-120 W and 622 patients with the use of XPS-180 W) at 7 international centers. All data were collected prospectively. Comparative analysis was performed between XPS and HPS according to PV measured by transrectal ultrasound.The XPS compared with HPS, allowed significantly reduced laser and operative time (29.6 minutes vs 65.8 minutes and 53 minutes vs 80 minutes, respectively; P.01 for both). The number of fiber used during the procedures was significantly reduced with the XPS system (1.11 vs 2.28; P.01), whereas total energy delivered was lower (250.2 kJ vs 267.7 kJ; P = .043). Overall, the mean operative time, mean laser time, and mean energy were all significantly increased according to PV80 mL vs80 mL. However, when stratified according to PV, XPS demonstrates significant advantages compared with HPS, regardless of prostate size in all operative parameters (P.01).The new XPS-180 W system exhibits significant advantages in all surgical parameters compared with the HPS-120 W system. Overall, with XPS-180 W and HPS-120 W, mean operative time, laser time, and energy usage increased according to PV. This suggests that preoperative evaluation of PV by transrectal ultrasound should be mandatory.

Objective To assess the efficacy of long-acting fesoterodine on persistent lower urinary tract symptoms in men who have had previous surgical treatment for bladder outlet obstruction (BOO). Materials and methods Seventeen patients with overactive bladder (OAB) secondary to BOO, persisting for 3 months after the obstruction was surgically relieved, were treated with fesoterodine. Follow up was performed at 2 months, 3 months, and 7 months. The primary endpoint was change in the International Prostate Symptom Score (IPSS). The secondary endpoints were change in the maximum flow rate (Qmax) and postvoid residual (PVR). Results Patients receiving fesoterodine demonstrated trends for improvement in mean nocturia episodes (3.2–2.6, p = 0.065), IPSS irritative subscore (6.2–2.0, p = 0.066), and quality of life score (4.2–3.5, p = 0.067) over 7 months of follow up. There was also a reduction in the mean IPSS score which was not significant over time (18.8–15.1, p = 0.183). There was no significant change observed in Qmax or PVR. Six patients (33%) had significant side effects and did not complete the study. Conclusion Patients with persistent OAB symptoms after surgical treatment of BOO displayed possible reductions in the IPSS, IPSS irritative subscore, and mean number of nocturia events after 7 months of follow up, as well as trends for an increased quality of life when treated with fesoterodine. Larger trials are needed to help characterize the utility of fesoterodine in the treatment of persistent lower urinary tract symptoms after surgical treatment of benign prostatic hyperplasia.

Background The pathophysiology of male lower urinary tract symptoms (LUTS) is highly complex and multifactorial. The shift in perception that LUTS are not sex or organ specific has not been followed by significant innovations regarding the available drug classes. Objective To review pathophysiologic mechanisms and clinical and experimental data related to the development of new pharmacologic treatments for male LUTS. Evidence acquisition The PubMed database was used to identify articles describing experimental and clinical studies of pathophysiologic mechanisms contributing to male LUTS and, supported by them, new pharmacotherapies with clinical or experimental evidence in the field. Evidence synthesis Several pathologic processes (eg, androgen signaling, inflammation, and metabolic factors) and targets (eg, the urothelium, prostate, interstitial cells, detrusor, neurotransmitters, neuromodulators, and receptors) have been implicated in male LUTS. Some newly introduced drugs, such as phosphodiesterase type 5 inhibitors and β3-adrenergic agonists, have just started broad use in clinical practice. Drugs with potential benefit, such as vitamin D3 receptor analogs, gonadotropin-releasing hormone antagonists, cannabinoids, and drugs injected into the prostate, have been evaluated in experimental studies and have progressed to clinical trials. However, safety and efficacy data for these drugs are still scarce. Some compounds with interesting profiles have only been tested in experimental settings (eg, transient receptor potential channel blockers, Rho-kinase inhibitors, purinergic receptor blockers, and endothelin-converting enzyme inhibitors). Conclusions New pathophysiologic mechanisms of male LUTS are described that lead to the continuous development of new pharmacotherapies. To date, few drugs have been added to the current armamentarium, and several are in various phases of clinical or experimental investigation.

The impact of diabetes mellitus (DM) and metformin use on biochemical recurrence (BCR) in patients treated with radical prostatectomy (RP) remains controversial. We retrospectively evaluated 6,863 patients who underwent RP for clinically localized PC between 2000 and 2011. Univariable and multivariable Cox regression models addressed the association of DM and metformin use with BCR. Overall, 664 patients had a diagnosis of DM from which 287 (43 %) were on metformin and 377 (57 %) were on anti-diabetics other than metformin. DM and metformin were not associated with any clinicopathologic features (p values >0.05). Within a median follow-up of 25 months (interquartile range 35 months), 774 (11.3 %) patients experienced BCR. Actuarial 5-year biochemical-free survival was 83 % for non-diabetic, 79 % for diabetic patients without metformin use, and 85 % for diabetic patients with metformin use (log rank p = 0.17). In uni- and multivariable Cox regression analyses with the non-diabetic group as referent, DM without metformin use (HR = 0.99; 95 % CI 0.75–1.30, p = 0.65) and DM with metformin use (HR = 0.84, 95 % CI 0.58–1.22, p = 0.36) were not associated with BCR after RP. A subgroup analysis stratified by nodal status, surgical margins, tumor stage, and Gleason sum did not reveal any significant association between DM, use of metformin and risk of BCR. We found no association between DM or metformin use and cancer-specific features or BCR in patients treated with RP. The effect of DM and metformin on complications, wound healing and overall survival needs to be assessed in similar cohorts.

OBJECTIVES Medical male circumcision (MMC) is recommended for HIV prevention in men. We assessed the acceptability and safety of the Shang Ring device compared with those of the dorsal slit method. METHODS HIV-negative, uncircumcised men aged 18 years or older who requested free MMC services in rural Rakai, Uganda, were informed about the Shang Ring and dorsal slit procedures and offered a free choice of procedure. Men were followed at 7 days postoperatively to assess adverse events related to surgery and to remove the Shang Ring. Wound healing was assessed at 4 weeks postoperatively. RESULTS Six hundred twenty-one men were enrolled, of whom 508 (81.8%) chose the Shang Ring and 113 the dorsal slit. The Shang Ring was provided to 504 men, among whom there were 4 failures of Ring placement (0.8%) that required surgical hemostasis and wound closure. Five hundred men received the Shang Ring and postoperative surgery-related moderate adverse events were 1.0%, compared with 0.8% among dorsal slit recipients. Complete wound healing at 4 weeks was 84% with the Ring and 100% with the dorsal slit (P < 0001). Resumption of intercourse before 4 weeks was 7.0% with the Ring and 15.0% with the dorsal slit (P = 0.01.) The mean time for surgery was 6.1 minutes with the Ring and 17.7 minutes with the dorsal slit. The mean time for Ring removal was 2.2 minutes. CONCLUSIONS The Shang Ring is highly acceptable and safe in this setting, and could improve the efficiency of MMC services. However, back-up surgical services are needed in cases of Ring placement failures.

Aims To compare the cost-effectiveness (CE) of retropubic midurethral sling (RMS) versus transobturator midurethral sling (TMS) for the treatment of female stress urinary incontinence (SUI). Methods A Markov chain decision model was created to simulate treatment of SUI with RMS versus TMS. Costing data were obtained from the Medicare RBRVS. Data regarding the efficacy and complications associated with RMS versus TMS was compiled from a literature review of 21 randomized RCTs with a minimum of 12 months follow-up, as were corresponding utilities for different continence states. Deterministic and probabilistic estimates of cost-effectiveness (CE) for each procedure were calculated and compared, and sensitivity analyses were performed. Results In the base-case deterministic analysis, the efficacy of RMS was 6.275 versus 6.272 QALYs for TMS. QALYs represent a measure of disease burden accounting for both quantity and quality of life lived and are used to assess the monetary value of a medical intervention. The average cost for treatment with RMS however was higher at $9,579 versus $9,017 with TMS. TMS was therefore overall more cost-effective than RMS (CE = $1,438/QALY vs. $1,527/QALY). Sensitivity analysis demonstrated that physician and sling characteristics such as device cost, surgeon fee, efficacy of treatment, operative time, and duration of hospitalization could all affect the relative CE of the therapies. Conclusions Our study demonstrated that TMS was more cost-effective than RMS as a treatment for female SUI. The efficacy of the two treatments could be affected by physician and sling characteristic factors. Neurourol. Urodynam. 33:1186–1192, 2014. © 2013 Wiley Periodicals, Inc.

Lower urinary tract symptoms (LUTS) in young men are becoming a more recognized urologic issue that can arise from many causes, each with their own management strategy. The purpose of this study was to determine the rates and types of voiding dysfunction causing LUTS in men under 40 years. Videourodynamic studies (VUDS) of 87 men 40 years of age or less with LUTS for greater than 6 months, performed between July 2004 and June 2012 at Weill Cornell Medical College, were retrospectively analyzed. Patients with culture-proven bacterial prostatitis, symptoms for less than 6 months, a history of neurologic disease, or previous urological surgery affecting voiding function were excluded from the analysis. The mean age of the patients was 31.84 ± 5.78. There were 37 patients that presented with more than one urinary symptom (42.5 %). The most frequent complaints included: urinary frequency (N = 42, 48.28 %), difficulty with urination (N = 41, 47.13 %), and urinary urgency (N = 21, 24.14 %). The most common urodynamic abnormality was bladder outlet obstruction (BOO) (N = 37, 42.53 %), dysfunctional voiding (N = 25, 28.74 %), detrusor underactivity (N = 10, 11.49 %), and detrusor overactivity (N = 7, 8.05 %). There were no differences seen in AUA symptom and quality of life scores across diagnosis groups. Lower urinary tract symptoms can present in younger men with a variety of types of voiding dysfunction. This study uses VUDS to show that the most common types of voiding dysfunction in this population with chronic LUTS are BOO followed by dysfunctional voiding.

To determine the differential profiles of cholesterol and glycosphingolipid species and their quantitative differences between control and glaucomatous aqueous humor (AQH) and the trabecular meshwork (TM) derived from human donors.Control TM and selected primary open angle glaucoma (POAG) TM samples were collected from cadaveric donors. Other TM samples, glaucomatous AQH and control AQH were procured during intraocular surgery. Lipid extraction was performed using modifications of the Bligh and Dyer method. Protein concentration was estimated using the Bradford colorimetric assay. Cholesterol and glycosphingolipids were identified and subjected to ratiometric quantification utilizing precursor ion scan and neutral ion loss scan in positive ion mode using appropriate class specific lipid standards (Cholesterol and Psychosine) on a TSQ Quantum Access Max mass spectrometer.Control and glaucomatous AQH demonstrated 7 and 4 unique cholesterol species, whereas the TM demonstrated 7 and 12 unique species, respectively. The control and POAG AQH showed 6 and 0 whereas TM samples showed 5 and 1 unique glycosphingolipids, respectively. A total of 65 and 62 common cholesterol species and 59 and 58 common glycosphingolipids were found in AQH and TM, respectively. Increased zymosterol and glucopyranosyl cholesterol levels were found in glaucomatous AQH. Significantly decreased levels of galactosylceramide, glucosylceramide in glaucomatous TM were found compared to control TM.A high percentage of cholesterol and glycosphingolipid species was found to be common between control and POAG AQH and TM. Several cholesterol and glycosphingolipid species was found to be unique in a subset of POAG or controls. Glaucomatous aqueous humor and TM showed relatively higher levels of zymosterol (an intermediate precursor of cholesterol) and decreased glycoceramide levels, respectively.

Objective To compare the cost-effectiveness (CE) of tension-free vaginal tape (TVT) with that of burch colposuspension (BC) for the treatment of female stress urinary incontinence (SUI). Materials and Methods A Markov-chain decision model was created to simulate treatment of SUI with TVT or BC using Treeage Pro 2011 software (Treeage Software Inc., Williamstown, MA, USA). Costing data were obtained from the Medicare Resource-Based Relative Value Scale. Data regarding the success of TVT vs BC were obtained from the peer-reviewed literature, as were corresponding utilities for different continence states. The CE of each procedure was calculated and compared, and sensitivity analyses were performed. Results At 10-year follow-up, TVT was more cost-effective (CE = $1495/quality-adjusted life year [QALY]) than BC (CE = $1824/QALY). Sensitivity analysis showed that TVT was more cost-effective than BC if the cost of the TVT device was

BACKGROUND AND PURPOSE Transurethral laser enucleation of the prostate (TLEP) using the potassium-titanyl-phosphate (KTP) laser offers an alternative technique to traditional photovaporization. The study objective was to determine the comparative efficacy between transurethral photovaporization of the prostate (PVP) with a TLEP technique using the 80W 532 nm KTP laser. PATIENTS AND METHODS A series of 97 vs 170 patients who underwent PVP vs TLEP, respectively, with the KTP laser system at Weill Cornell Medical College from September 2001 to May 2009 was studied retrospectively. Outcome measures included laser time, prostate volume lased per unit time, International Prostate Symptom Score (IPSS), postvoid residual (PVR), and maximum flow rate (Qmax). Statistical analyses were performed using the Shapiro-Wilk, Mann-Whitney, Wilcoxon, and unpaired t tests. RESULTS Baseline parameters were similar between groups, although volume was greater in the TLEP group (83 vs 63 cc, P=0.04). Median laser time was longer in the TLEP group (90 vs 50 min, P

Benign prostate hyperplasia (BPH) occurs in up to 50 % of men by age 50, and the incidence increases with age. The rate of erectile dysfunction (ED) in patients with BPH ranges from 30 to 70 %, but can be as high as 90.5 % in males aged over 50 years. BPH/lower urinary tract symptoms (LUTS) and sexual dysfunction (SD) can have a substantial negative impact on a man’s quality of life (QoL). Symptom severity and impact on QoL in each condition increase when LUTS and ED coexist. Age and erection change in patients with LUTS could also correlate with ejaculation dysfunction. However, urologists and primary care physicians appear to under-recognize SD in men with BPH/LUTS. We review the mechanisms of action, association, and effect of treatment between BPH and ED.

To investigate the impact of variant histologies of urothelial carcinoma of the bladder (UCB) on oncologic outcomes after radical cystectomy (RC).Data from 1984 UCB patients treated by RC without preoperative chemo- or radiotherapy were reviewed for histological differentiation and variants. We analysed the differences between pure UCB and UCB with variant histology, and those between the different histological variants using various stratifications.Overall, 488 (24.6%) patients had UCB variants with squamous cell (11.4%) and glandular differentiation (3.8%) being the most common. Histological UCB variants were associated with advanced tumour stage, lymphovascular invasion and lymph node metastasis (all p-values0.01) when compared to pure UCB. In univariable analyses, patients with non-squamous UCB variants were at significantly higher risk for disease recurrence and cancer-specific mortality than those with pure UCB patients (p-values=0.001) and those with squamous cell differentiated UCB (p-values=0.04); the latter two had the same risk. In multivariable analyses that adjusted for the effects of standard clinicopathologic characteristics, variant UCB histology was not associated with both survival end-points. In patients treated with adjuvant chemotherapy (n=492) there was no difference in cancer-specific survival between pure UCB, squamous cell differentiated UCB and other histological UCB variants.A quarter of UCB patients treated with RC harboured histological UCB variants. Variant UCB histologies were associated with features of biologically aggressive disease. While variant UCB histology was associated with worse outcomes in univariable analyses, this effect did not remain significant in multivariable analyses.

The Bulbocavernosus Reflex System (BRS) (Laborie, Canada) is an office-based procedure used to measure the bulbocavernosus reflex (BCR) latency period. The aim of this study is to evaluate the BCR as a predictor of specific voiding dysfunction patterns confirmed by urodynamics (UDS). A total of 87 men were evaluated with BRS, UDS, and electromyography at Weill Cornell Medical College from March to August 2010. Baseline characteristics, demographics, UDS, and latency parameters were recorded. Multivariate logistic regression analysis was performed to evaluate prolonged BCR (latency >45 ms) as a predictor of specific voiding dysfunction patterns. The median age of men was 70.4 years (IQR 57.6–75.6). Based on UDS, 60 men were given a primary or secondary diagnosis of bladder outlet obstruction (BOO), 43 a diagnosis of detrusor overactivity (DO), 11 a diagnosis of intrinsic sphincter deficiency (ISD), and 4 a diagnosis of detrusor sphincter dyssynergia (DSD). Median BCR latency was 57.0 ms (IQR 47.5–76.5) and 68 (78 %) men demonstrated a prolonged latency. In multivariate analysis, latency period was not significantly associated with DO, BOO, ISD, or DSD (p = 0.067, 0.696, 0.999, 0.971, respectively). Prolonged bulbocavernosus reflex latency was not associated with DO, BOO, ISD, or DSD. Although evidence in the literature suggests a link between this reflex arc and voiding, its specific diagnostic role remains unclear. Large prospective trials are needed to further explore the role of BCR in the evaluation of patients with voiding dysfunction.

Objective To evaluate the gender-specific differential effects of smoking habits and cumulative smoking exposure on outcomes in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU). Patients and Methods A total of 864 consecutive patients, comprising 553 (64%) men and 311 (36%) women, from five international institutions underwent RNU without neoadjuvant chemotherapy. Smoking history included smoking status (current, former or never), quantity of cigarettes per day (CPD), smoking duration in years and years since smoking cessation. Cumulative smoking exposure was categorized as light short-term (≤19 CPD and ≤19.9 years), moderate (all combinations except light short-term and heavy long-term), and heavy long-term (≥20 CPD and ≥20 years). Uni- and multivariable competing risk regression models were used to assess the associations with outcomes. Results Overall, 244 (28.2%), 297 (34.4%) and 323 (37.4%) patients were never, former and current smokers, respectively. There were no differences in smoking status, quantity and duration between the genders. In female ever smokers, 30 (9.6%), 121 (38.9%) and 67 (21.5%) were light short-term, moderate and heavy long-term smokers, respectively. Compared with men, female current smokers were more likely to experience disease recurrence in univariable analysis (P = 0.013). In heavy long-term smokers, female gender was significantly associated with disease recurrence (hazard ratio [HR] 1.7; P = 0.03) and cancer-specific mortality (HR 2.0; P = 0.009) in multivariable analysis that adjusted for standard clinico-pathological features. In female patients only, smoking quantity, duration and cumulative exposure were associated with disease recurrence and cancer-specific mortality on multivariable analyses (P ≤ 0.025). Conclusions The impact of smoking on UTUC outcomes after RNU is gender-specific. Females who are current and heavy long-term smokers experience worse outcomes than their male counterparts. Further research is needed to elucidate the molecular mechanisms underlying the gender-specific differential effect of smoking on UTUC outcomes.

eligibility to only 16 and 52% of patients based on the thresholds of 60 and 45 mL/min/1.73 m 2 , respectively. Taken together with the rest of the literature, the findings of the study support the use of cisplatin-based chemotherapy, when indicated, in the neoadjuvant rather than adjuvant setting.

This review provides an evidence-based comparison of aqueous shunts in common use.Aqueous shunts are being used with increasing frequency in the surgical management of glaucoma. Recent retrospective studies and prospective clinical trials have compared the outcomes of different shunt designs. Larger end-plate size is associated with greater intraocular pressure (IOP) reduction, but there may be an upper limit beyond which a further increase in plate surface area does not contribute beneficially to pressure control. The biocompatibility of plate material may also influence shunt efficacy. The flow restrictor of the Ahmed glaucoma valve provides an added level of safety by reducing the risk of postoperative hypotony, but this implant also appears to have a higher incidence of bleb encapsulation.Several aqueous shunts are commercially available, and all have been shown to be safe and effective in lowering IOP. Studies comparing aqueous shunts have provided valuable information to assist in surgical decision-making in similar patient groups.

Lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) commonly affect older men. Fifty percent of men in their sixties and 80% of men in their nineties will be affected. Many of these men will seek care for their bothersome symptoms and decreased quality of life. There is a poor association between LUTS and objective measures such as post void residual, voided volumes, or maximal flow. Pressure flow studies are considered the gold standard for detecting bladder outlet obstruction. These studies tend to be cumbersome, expensive, and have exposure to ionizing radiation. There are several techniques which may offer noninvasive methods of detecting bladder outlet obstruction (BOO) in men.

Purpose: Improvements to photoselective vaporization of the prostate (PVP) have been made over time, particularly with the introduction of higher power systems. Few studies however have compared the performance of these systems to their predecessors. The purpose of this study was to compare the clinical and perioperative outcomes of 80 W vs. 120 W PVP. Materials and Methods: A series of 267 and 209 consecutive patients underwent 80 W and 120 W PVP, respectively, from September 2001 to May 2009 at Weill Cornell Medical College (GreenLightTM laser system, American Medical Systems, Inc., Minnetonka, MN). Data were collected on patient demographics, International Prostate Symptom Score (IPSS), prostate-specific antigen (PSA), and perioperative parameters. Maximum flow rate (Qmax), postvoid residual (PVR), and transrectal ultrasound prostate volume were recorded. Statistical analyses were carried out utilizing the Shapiro-Wilk, Mann-Whitney, Wilcoxon and unpaired t tests (SPSS 15.0, SPSS Inc., Chicago, IL, USA). Results: Baseline parameters were similar between the two groups except for greater median age (72.8 vs. 69.2 years, p = 0.01) and lower median PSA (2.0 vs. 3.3, p = 0.01) in the 80 W group. Median laser time was longer in the 80W group (85 vs. 51 minutes, p 0.001) with a higher median energy utilized (253 vs. 210 kJ, p = 0.001). Final IPSS, Qmax, PVR, and PSA were equivalent between the two groups. Conclusions: In our series, PVP was safe and effective. Durable and similar improvements in symptoms and objective parameters were achieved in patients with both 80 W and 120 W laser systems. PVP with the 120 W system, however, provided faster and more efficient vaporization compared to the 80 W system.

After robot-assisted laparoscopic prostatectomy, total anatomic reconstruction (TR) with the additions of a circumapical urethral dissection, a dynamic detrusor cuff trigonoplasty, and placement of a suprapubic catheter was performed in 49 patients from June to July 2012. Continence at 6 weeks after catheter removal was assessed for an initial group of 23 patients, and also at 2 weeks in an additional 26 patients who most recently had undergone surgery. Follow-up appointments and telephone interviews were used to assess pad use and continence. Of the initial 23 patients receiving the modified TR, 60.9% had 0 pad use at 6 weeks. By 2 weeks, 65.4% of the most recent 26 patients operated on achieved continence with 0-1 pad use. Preservation and reconstruction of the pelvic floor and supporting bladder structures leads to an earlier return of continence. These key steps need to be validated and confirmed in larger and randomized trials.

Retinal ganglion cells (RGCs) are the output neuron of the eye, transmitting visual information from the retina through the optic nerve to the brain. The importance of RGCs for vision is demonstrated in blinding diseases where RGCs are lost, such as in glaucoma or after optic nerve injury. In the present study, we hypothesize that normal RGC function is transcriptionally regulated. To test our hypothesis, we examine large retinal expression microarray datasets from recombinant inbred mouse strains in GeneNetwork and define transcriptional networks of RGCs and their subtypes. Two major and functionally distinct transcriptional networks centering around Thy1 and Tubb3 (Class III beta-tubulin) were identified. Each network is independently regulated and modulated by unique genomic loci. Meta-analysis of publically available data confirms that RGC subtypes are differentially susceptible to death, with alpha-RGCs and intrinsically photosensitive RGCs (ipRGCs) being less sensitive to cell death than other RGC subtypes in a mouse model of glaucoma.

Background: Men's understanding of counseling messages after voluntary medical male circumcision (VMMC) plays an important role in whether they follow them. Data on triggers for early resumption of sex may be useful as scale-up of VMMC for HIV prevention continues in sub-Saharan Africa. Methods: Data on understanding of post-VMMC abstinence recommendations, resumption of sex, condom use, and triggers for resuming sex were collected from participants during a follow-up interview 35–42 days after ShangRing circumcision in Kenya and Zambia. Results: Of 1149 men who had ShangRing circumcision, 1096 (95.4%) completed follow-up. Nearly all (99.2%) reported being counseled to abstain from sex post-VMMC; among those, most (92.2%) recalled the recommended abstinence period was 6 weeks. Most men (94.1%) reported that the counselor gave reasons for post-VMMC abstinence and recalled appropriate reasons. Few (13.4%) men reported resuming sex at 35–42 days' follow-up. Among those, 54.8% reported never using a condom post-VMMC. Younger participants (odds ratio 0.3, 95% confidence interval: 0.2 to 0.5, P < 0.0001) and those reporting at least some condom use at baseline (odds ratio 0.5, 95% confidence interval: 0.3 to 0.7, P = 0.0003) were less likely to report resuming sex. Among men who reported some condom use, most (71.5%) said condoms were much easier or easier to use after circumcision. Men reported various reasons for early resumption of sex, primarily strong sexual desire (76.4%). Conclusions: Most men reported awareness of and adherence to the counseling recommendations for post-VMMC abstinence. A minority reported early resumption of sex, and, among those, condom use was low. Results could be used to improve post-VMMC counseling.

Reply to ‘Comment on: Long-term outcomes of neovascular glaucoma treated with and without intravitreal bevacizumab’

Objective The objective of this study is to investigate the combination effect of anti-muscarinic medication and topical vaginal estrogen in the treatment of overactive bladder (OAB) and female sexual dysfunction in postmenopausal women. Study design After IRB approval, 23 female subjects who met the entry criteria were randomized into two groups: (1) fesoterodine (Toviaz®, Pfizer, NY) with topical vaginal estrogen (Premarin®, Pfizer, NY) once daily or (2) fesoterodine once daily alone. If 4 mg fesoterodine was tolerated at 1-week, the dose was increased to 8 mg. Main outcome measures Primary endpoints were improvement in OAB symptom severity (Overactive Bladder Questionnaire, OAB-Q SF), improvement in OAB health-related quality of life (HRQL) (OAB-Q SF), and sexual function (Sexual Quality of Life–Female, SQOL-F) after 12 weeks. Secondary endpoint was change in total number of micturitions. Results After 12-weeks, the combination group had a significant improvement in OAB symptom severity ( p = 0.006), HRQL ( p = 0.029), and SQOL-F (0.0003). The fesoterodine alone group also had significant improvement in OAB symptom severity ( p Conclusions The combined effect of fesoterodine and topical vaginal estrogen improved OAB symptoms and sexual function in postmenopausal women.

International audience; Primary open-angle glaucoma (POAG) is a leading cause of blindness worldwide. To identify new susceptibility loci, we performed meta-analysis on genome-wide association study (GWAS) results from eight independent studies from the United States (3,853 cases and 33,480 controls) and investigated the most significantly associated SNPs in two Australian studies (1,252 cases and 2,592 controls), three European studies (875 cases and 4,107 controls) and a Singaporean Chinese study (1,037 cases and 2,543 controls). A meta-analysis of the top SNPs identified three new associated loci: rs35934224[T] in TXNRD2 (odds ratio (OR) = 0.78, P = 4.05 × 10(-11)) encoding a mitochondrial protein required for redox homeostasis; rs7137828[T] in ATXN2 (OR = 1.17, P = 8.73 × 10(-10)); and rs2745572[A] upstream of FOXC1 (OR = 1.17, P = 1.76 × 10(-10)). Using RT-PCR and immunohistochemistry, we show TXNRD2 and ATXN2 expression in retinal ganglion cells and the optic nerve head. These results identify new pathways underlying POAG susceptibility and suggest new targets for preventative therapies.

Filtering blebs fail due to wound healing responses along the path of aqueous outflow (Fig. 37.1). there can be significant subconjunctival fibroblast proliferation and biosynthesis of collagen and other extracellular matrix materials in the area of trabeculectomy [1]. The concept behind bleb needling is to reestablish free flow of aqueous humor from the anterior chamber to the subconjunctival bleb space by cutting through postoperative scar tissue that prevents or decreases aqueous outflow. Needling cuts through adhesions formed between the conjunctiva and scleral flap and/or from scleral flap to scleral bed. A retrospective study of 119 trabeculectomies found that one-quarter of eyes underwent needling to increase the rate of filtering success [2]. As with any procedure, many variations exist with regard to bleb needling technique.