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Neutrophil-to-lymphocyte ratio (NLR), a marker for subclinical inflammation, has been previously shown to be associated with erectile dysfunction (ED). We studied the potential predictive value of the NLR on ED after prostate brachytherapy (PB) for PCa.Between July 2005 and January 2021, 842 patients were included in this retrospective study of a prospectively maintained database. ED was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) physician-reported scale. ED was defined as a Grade 2 or 3 function. NLR count was determined 1-2 months before PB and separated into values PB2 and ≥2. Patient characteristics and erectile function at last follow-up were compared for patients with a Univariate and multivariate analyses were performed to evaluate the predictive value of baseline NLR ≥2 on post-PB ED.Baseline NLR ≥2 was found to be a statistically significant predictor of post-PB ED on both univariate (p = 0.002) and multivariate analyses (p = 0.008). Furthermore, the difference in ED prevalence between the NLR2 and NLR ≥2 groups became more pronounced with longer follow-up after PB. The ED rate at 5 years post-PB was 43% for the NLR ≥2 groups, compared to 29% for the NLR2 groups.Subclinical systemic inflammation is a potentially important factor for predicting sexual toxicity after pelvic radiotherapy. NLR may be used as a proxy for predicting post-PB ED.

To analyze biochemical failure-free survival and erectile dysfunction (ED) in younger men treated with prostate seed brachytherapy (PB).Included were patients ≤ 55 years treated with PB. Erectile function at baseline and after treatment were assessed using the physician-reported CTCAE version 4.0. Biochemical failure (BF) was defined according to the Phoenix Consensus definition (PSA nadir + 2 ng/mL). The log-rank test (Kaplan-Meier method) and cox-regression analysis was used to calculate BF-free survival.Between July 2005 and November 2020, a total of 137 patients ≤ 55 years (range 44-55 years old) were treated with PB. Median follow up was 72 months. Twenty percent had Gleason 3+4 disease and 6% a PSA10 ng/mL. Median prostate volume was 34 cc. Actuarial biochemical failure free survival at 5, 7, and 10 years, were 98%, 95% and 89%, respectively. Five patients received local salvage treatment. On multivariate analysis, CAPRA-score (HR 4.46, 95%CI 1.76-11.33, p = 0.002) and the dosimetric measure D90130 Gy (p = 0.03) were predictive of BF. Five deaths occurred in our cohort, two due to cardiovascular reasons and three due to another malignancy. At baseline, all patients were able to have erections with or without medication. At 5 years and 7 years after PB, 80% and 64% of patients had little or no ED (erections without the need for medication) respectively.In young-onset patients treated with PB, failure rates are similar to their older counterparts. Sexual function decreases with time, even in patients with good sexual function.

We analyzed the rate of preserved potency after prostate brachytherapy (PB) with radioactive seeds and the impact of patient comorbidities on post-PB erectile dysfunction (ED).We included 627 patients who were assessed for pre- and postimplant potency between 2005 and 2017. Assessment was based on the Common Terminology Criteria for Adverse Events Scale (CTCAEs). Logistic regression models were used to assess clinical predictors of preserved potency after PB defined as having sufficient erections for sexual activity with or without the need of oral pharmacologic assistance. Covariates included age, diabetes (DM), hypertension (HTN), dyslipidemia (DLP), coronary artery disease (CAD), International Prostate Symptom Score (IPSS), prostate volume, and Cancer of the Prostate Risk Assessments (CAPRA) score. Patients on androgen deprivation therapy or using five alpha reductase inhibitors were excluded from analyses.Post-PB potency was assessed at an average of 6 months (n = 627), 1 year (n = 538), 2 years (=440), 4 years (n = 272), and 5 years (n = 124). At 2 and 5 years, post-PB potency was preserved in 87% and 84% of patients, respectively. When adjusting for all available covariates, advanced age, pre-PB potency, and the presence of vascular comorbidities (HTN, DM, and DLP) were all predictors of potency at 2 years after PB (all p0.01). When performing a sensitivity analysis for vascular comorbidities, the presence of DM had the strongest impact on ED than either HTN or DLP (p0.01).More than 84% of patients had preserved potency 5 years after PB. Advanced age, pre-PB potency, and vascular comorbidities had a statistically significant impact on potency after PB.

Introduction: In the past year, due to the COVID-19 pandemic, in-person clinical activities have been drastically restricted, driving the already growing interest in the use of telemedicine in the urban setting to reduce unnecessary commute. Therefore, there has been a rapid shift to telephone and video consultations in outpatient practice. We sought to conduct a pilot trial to establish feasibility and acceptability of video consultations as an alternative to telephone consultations in urology patients to inform the design of a future randomized controlled trial. Methods: We conducted a single-center, prospective, non-randomized pilot trial comparing telephone consultations (TC) vs. video consultations (VC) for urology outpatient visits. Two patient questionnaires were used to collect demographic information, as well as data about acceptability, feasibility, satisfaction, cost, and issues with telemedicine. Questions were identical for both VC and TC except for certain questions inquiring about issues specific to each technology. Results: Forty-eight TC and 66 VC urology patients were included in this study. Patients believed that telemedicine visits did not significantly hinder their ability to communicate with their urologists and that these visits would be associated with cost savings. There was 1/48 (2.1%) failed TC and 16/66 (24.2%) failed VC. VC failures were concentrated at the beginning of the trial prior to giving feedback to the VC platform creators, with only one failure occurring thereafter. When comparing TC to VC, differences between the two patient groups were small but tended to be in favor of VC. Patients’ satisfaction was greater with VC compared to TC. Both modalities were associated with many cost benefits for patients. Conclusions: Despite more technical issues with VC, this modality is feasible and acceptable to patients, likely due to improved shared decision-making with VC. Future considerations for trials comparing VC and TC should include adequate Wi-Fi infrastructure and choice of platform. For the VC, continuous knowledge transfer between investigators and platform engineers plays an important role in limiting failed encounters.

Erectile function has been shown to decline as a function of increasing peripheral blood inflammatory markers, namely the neutrophil-to-lymphocyte ratio (NLR). We evaluated if the association between NLR and erectile dysfunction (ED) applies to patients with localised prostate cancer. We included 1,282 patients who underwent brachytherapy. ED was classified before treatment according to the Terminology Criteria for Adverse Event Scale version 3.0. ED was defined as the need for the use of oral pharmacologic or mechanical assistance to have satisfactory sexual function. We found that patients with ED were older (p

Post-implant management of sacral neuromodulation is crucial in ensuring the success of therapy. Common management dilemmas include various follow-up schedules, circumstances related to pregnancy, and the possible need for magnetic resonance imaging. Moreover, complications such as lack of or declining efficacy over time, painful stimulation, pain at the implantable pulse generator site, and wound complications need to properly be handled. In this chapter, each of these above-mentioned scenarios is explored, and the literature concerning them is reviewed. Tips regarding dealing with management dilemmas and practical resolutions of complications are discussed. In this review, we have given a combination of analysis from the literature and practical suggestions based on years of experience in providing SNM therapy. These tips should be helpful in getting the best result after appropriate patient selection and implant technique have been employed.

Purpose The progress of women in academic medicine appears to be curtailed. We evaluated gender differences in academia for residents in radiation oncology compared with 2 of its related specialties, radiology and medical oncology, across Canada. Methods and Materials We analyzed abstracts presented between 2013 and 2016 at the annual meetings of the Canadian Association of Radiation Oncologists and compared it to the corresponding data for the meetings of the Canadian Association of Radiologists and Canadian Association of Medical Oncology. We further evaluated gender composition of abstracts, presentations, and publications available on PubMed. Conversion rates according to gender and to medical specialties were assessed. Proportions were compared using Fisher exact test or the chi-squared test. Results Among the 198 presented abstracts, 103 (52%) were published. Radiation oncology had the highest publishing rate with 90% (oncology 56%, radiology 40%). The publication rate between the medical specialties was significantly different (P Fifty-seven percent of abstracts presented by women were published versus 48% of abstracts presented by men. Overall, there was no significant difference between genders in terms of subsequent conversions into a scientific publication within each specialty (P = .25-1.0). In radiation oncology, women presented 67% of abstracts and published 95% of their presented abstracts, and in medical oncology, 66% of abstracts were from women and 57% of the presented abstracts were published. Among the published abstracts, 83% had the same first author in the abstract and the publication. Among those who lost their first-authorship status, 59% were women. However, there was no statistically significant difference between specialties for loss of first-author status. Conclusions We observed that from 2013 to 2016, women had the highest presentation and publication rate in radiation oncology. More prospective data are needed to monitor the progress of women in all specialties and their specific needs.

Iatrogenic ureteral injury can occur in many different settings, however, the majority occur in the context of gynecological procedures. We present a case of a ureteral injury during vaginal hysterectomy for severe pelvic organ prolapse. We provide a discussion on the diagnosis and management of ureteral injury after gynecological surgery. In addition, we compare and contrast the American Urologic Association and European Association of Urology guidelines and offer a short, concise algorithm on the management of all type of ureteral injuries.

Sacral neuromodulation (SNM) is one of the few treatment options for patients suffering from non-obstructive urinary retention (NOUR) aside from intermittent or continuous bladder drainage. We describe the surgical techniques of device implantation in these patients and compare advantages and disadvantages of various approaches. We review the mechanism of action of SNM in the context of NOUR and summarize the evidence supporting using this treatment for these patients. We also describe SNM in the setting of Fowler syndrome and how this subset of patients can uniquely benefit.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a common entity in patients with chronic pelvic pain. The diagnosis and treatment of this complex condition remains a challenge. This can lead to delayed management, which can significantly impair the psychosocial functioning and quality of life of patients. Although it is not yet approved by FDA, neuromodulation can have therapeutic benefit for chronic pain and sexual dysfunction. We aim to review the current literature evaluating the role of therapies involving sacral and pudendal neuromodulation and percutaneous tibial nerve stimulation in management of pelvic pain and sexual dysfunction.

Introduction: We aimed to describe the strategies of surgical revision for catheterizable channel obstruction and their outcomes, including restenosis and new channel incontinence.Methods: We retrospectively queried the charts of adults who underwent catheterizable channel revision or replacement from 2000‒2014 for stomal stenosis, channel obstruction, or difficulty with catheterization at the Universities of Minnesota, Michigan, and Utah. The primary endpoint was channel patency as measured by freedom from repeat surgical intervention. Secondary endpoints included post-revision incontinence and complication rates. Revision surgeries were classified by strategy into “above fascia,” “below fascia,” and “channel replacement” groupings.Results: A total of 51 patients who underwent 68 repairs (age 18‒82 years old; mean 45) were identified who met our inclusion criteria. Channel patency was achieved in 66% at a median 19 months post-revision for all repair types. There was no difference in patency by the type of channel being revised, but there was based on revision technique, with channel replacement and above the fascia repairs being more successful (p=0.046). Channel incontinence occurred in 40% and was moderate to severe in 12%. The type of channel being revised was strongly associated (p=0.003) with any postoperative channel incontinence. Surgical complications occurred in 29% of all revision procedures, although most were low-grade.Conclusions: Surgical revision of continent catheterizable channels for channel obstruction can be performed with acceptable rates of durable patency and incontinence; however, the surgeon needs to have experience in complex urinary diversion and familiarity with a variety of surgical revision strategies.

INTRODUCTION The risk of incomplete bladder evacuation requiring catheterization after intravesical onabotulinumtoxinA (BoNT-A) is well established. However, the rates reported in the literature are highly variable and low overall in clinical trials. We attempt to evaluate the rate of symptomatic acute urinary retention requiring catheterization after initial BoNT-A in a private practice setting of patients with idiopathic overactive bladder. METHODS We performed a retrospective study from 2010 to 2014 for patients with idiopathic overactive bladder undergoing their first BoNT-A. Demographic information recorded included age, sex, presence of diabetes, baseline postvoid residual (PVR), presence of urodynamic detrusor overactivity, bladder capacity, peak flow rate (Qmax), BoNT-A unit dose, and carrier volume. Urinary retention was defined as those patients who were symptomatic and required catheterization for a PVR of 200 mL or greater. RESULTS Of 103 patients who received BoNT-A, 21 (20.3%) developed symptomatic retention requiring catheterization. There was no difference in baseline characteristics, preoperative PVR, and units injected (all P > 0.05). The retention group had a higher rate of bacteriuria and symptomatic urinary tract infection (all P < 0.05). Despite developing symptomatic retention requiring performance of catheterization, 47% of these patients continued with a subsequent injection of BoNT-A. CONCLUSIONS The need for catheterization after initial delivery of intravescial BoNT-A is an adverse event that seems to be higher in our clinical practice than seen in clinical trials. This information will be critical in order to properly counsel our future patients about the risks and benefits of this therapy.

This study aims at analyzing the impact of reaching current markers of proficiency on intra and postoperative clinical outcomes of laser vaporization with 180W GreenLight XPS in the treatment of benign prostatic hyperplasia.A retrospective analysis was conducted on a prospectively collected database of 328 consecutive patients who underwent photoselective vaporization of the prostate (PVP) using Greenlight XPS performed by a single experienced laser surgeon. A logarithmic model was used to evaluate the case number to attain benchmark criteria for durable treatment. We compared clinical outcomes before and after current markers of proficiency, defined as either an energy density of 4kJ/cm³ or a 6 month prostate-specific antigen (PSA) drop of = 50%, were attained.Energy delivered per prostate volume increased significantly with experience. The published benchmark values of 4kJ/cm³ and 6 month PSA drop of 50% were attained after 190 and 155 cases, respectively. There were no significant differences between groups in intraoperative complications or postoperative functional outcomes. However, the number of Clavien-Dindo category I adverse events significantly decreased with experience. Sub-analysis evaluating prostate volumes ≤ 80 cm³ and80 cm³ demonstrated comparable clinical outcomes before and after technical proficiency.In our experience, the case volume required to achieve consistent reference values related to durable clinical outcomes and surgical proficiency was150 cases. However, desirable clinical outcomes were attained before reaching current markers of proficiency, regardless of preoperative prostate size. This suggests that current thresholds of technical proficiency may not be a good predictor of satisfying clinical outcomes.

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.

To evaluate the safety, efficacy, and short-term outcomes of the new GreenLight XPS (GL-XPS) 180W laser system (AMS, Minnetonka, MI) in comparison to the former generation GL-HPS 120W system for the treatment of benign prostatic hyperplasia (BPH) in a prospective nonrandomized single-center study.From June 2010 to March 2012, 200 consecutive patients with lower urinary tract symptoms secondary to BPH were included: 80 patients were treated with GL-HPS 120W and 120 with GL-XPS 180W laser vaporization of the prostate. Perioperative variables (International Prostate Symptom Score [IPSS], quality f life [QOL], maximum flow rate (Qmax), post-void residual (PVR), and Sexual Health Inventory for Men (SHIM) were recorded at baseline, 3 months, and 6 months. Serum prostate-specific antigen (PSA) was assessed at baseline and 6-month follow-up.Patient preoperative characteristics were comparable, all P .05. Mean operating room time (43 vs 79 minutes) and mean laser time (22 vs 37 minutes) were significantly shorter for the GL-XPS group (both P .01) and mean energy delivery was comparable (226 vs 268 kJ, P = .21), GL-XPS vs GL-HPS. Mean fiber use (1.0 vs 1.5) and 3L saline bags (4.1 vs 7) were significantly lower with GL-XPS, all P .01. There were no significant differences in the 30-day complication rate. To date, no urethral strictures and 1 GL-HPS retreatment were observed. PSA reduction at 6 months was significantly greater with GL-XPS (54% vs 79%, P .01).Both GreenLight systems provide safe, effective, tissue vaporization with significant clinical relief of BPH obstruction. The GL-XPS 180W system seems to be more favorable with regard to reduced operative time, fiber use, and PSA-reduction, suggesting more cost-effective and efficient tissue removal.

To determine urodynamic studies (UDS) findings in adult cerebral palsy (CP) patients. CP patients may suffer from voiding dysfunction. UDS in children with CP has consistently shown an upper motor neuron bladder with detrusor-sphincter dyssynergia.We included adult CP patients seen at Gillette Transitional Urology Clinic who underwent UDS for voiding dysfunction between 2011 and 2014. Descriptive statistics were used to characterize findings.There were 49/211 CP patients who underwent UDS. Average age was 30 years; 55% were men. Ninety-eight percent had moderate to severe CP. UDS was initiated for irritative symptoms in 55%, obstructive voiding symptoms in 25%, hydronephrosis in 18%, and other reasons in 2%. Incontinence was reported in 57%. Detrusor-sphincter dyssynergia was seen in 12%, detrusor overactivity in 30%, and detrusor leak point pressure (DLPP)40 cmH2O in 51%. Median compliance was 18 mL/cmH2O (0.78-365). Maximum cystometric capacity (MCC) was 80-1400 mL and was300 mL in 27%. Sixteen percent had an MCC300 mL and a compliance20 mL/cmH2O. Twelve percent had an MCC300 mL and a DLPP40 cmH2O.UDS findings in symptomatic adult CP patients are varied. Fifty-one percent had upper motor neuron bladder findings, similar to that seen in the pediatric literature, but 6% had large flaccid bladders. Half of the patients had concerning findings, such as compliance20 or DLPP40 cmH2O. Our results emphasize the need to thoroughly investigate voiding dysfunction in those with CP. Further characterization of this population is needed to correlate these UDS findings with clinical outcomes.

Sacral neuromodulation (SNM) is a minimally invasive, restorative treatment to improve voiding and elimination functions. We give a historical perspective of SNM and explore the evidence for the use of this therapy for Food and Drug Administration-approved pathologies as well as disease processes that are being treated internationally. Ensuring optimal lead placement increases the potential of a comfortable, durable, and efficacious response. The future of SNM aims to maximize its potential benefit, refine its use, and minimize its risks and cost. Evolution of the therapy includes better device options, better software for patient and clinician use, more programming capabilities, and new nerve targets.

The association between marital status and tumor stage and grade, as well as overall mortality (OM) and cancer-specific mortality (CSM) received little attention in patients with squamous cell carcinoma of the penis (SCCP).We relied on the surveillance, epidemiology, and end results (SEER) 17 database to identify patients diagnosed with primary SCCP. Logistic and Cox regression models, respectively, addressed the effect of marital status on the rate of locally advanced disease and its effect on OM and CSM. Covariates consisted of age, race, socioeconomic status, year of surgery, and SEER registries.Between 1988 and 2006, 1,884 patients with SCCP were identified. At surgery, 1,192 (63.3 %) were married and 966 (51.3 %) had locally advanced disease. In multivariable logistic regression models predicting locally advanced disease at surgery, unmarried men had a 1.5-fold higher (p 0.001) risk than others. In multivariable Cox models predicting CSM, marital status had no effect [hazard ratio (HR) = 1.3, p = 0.1]. Finally, in multivariable Cox models predicting OM, unmarried men had a 1.3-fold higher (p = 0.001) risk than others.Unmarried men tend to present with less favorable disease stage at SCCP. Moreover, unmarried men tend to live less long than their married counterparts. However, marital status has no effect on CSM.

The purpose of this article is to review the recent literature concerning obstructive uropathy from advanced cancer. This factor is relevant as it is often a difficult task for physicians to estimate a patient's life expectancy and evaluate the possible benefit of urinary diversion. Recent research has addressed this issue. We now have objective criteria to stratify the possible benefit of urinary diversion in patients with malignant obstructive nephropathy.When dealing with ureteric obstruction treatment must be individualized and risk stratification is of paramount importance. There is no clear evidence that urinary diversion improves quality of life and treatment decisions must be individualized. The decision to treat obstructive nephropathy in the palliative setting should include the patient, his family and members of the support team.Ureteric stents and percutaneous nephrostomies are the preferred initial treatment options, although stent infection, encrustation and blockages are common problems. New compression-resistant metallic stents seem promising for patients with a malignant disease who require long-term urinary drainage. When more conservative measures have failed, supra-vesical reconstruction and diversion may be an option.

With the expanding use of new technology in the treatment of clinically localized prostate cancer (PCa), the financial burden on the healthcare system and the individual has been important. Robotics offer many potential advantages to the surgeon and the patient. We assessed the potential cost-effectiveness of robotics in urological surgery and performed a comparative cost analysis with respect to other potential treatment modalities.The direct and indirect costs of purchasing, maintaining, and operating the robot must be compared to alternatives in treatment of localized PCa. Some expanding technologies including intensity-modulated radiation therapy are significantly more expensive than robotic surgery. Furthermore, the benefits of robotics including decreased length of stay and return to work are considerable and must be measured when evaluating its cost-effectiveness.Robot-assisted laparoscopic surgery comes at a high cost but can become cost-effective in mostly high-volume centers with high-volume surgeons. The device when utilized to its maximum potential and with eventual market-driven competition can become affordable.

Bladder outlet obstruction after prostate cancer therapy imposes a significant burden on health and quality of life in men. Our objective was to describe the burden of bladder outlet obstruction after prostate cancer therapy by detailing the type of procedures performed and how often those procedures were repeated in men with recurrent bladder outlet obstruction.Using SEER (Surveillance, Epidemiology and End Results)-Medicare linked data from 1992 to 2007 with followup through 2009 we identified 12,676 men who underwent at least 1 bladder outlet obstruction procedure after prostate cancer therapy, including external beam radiotherapy in 3,994, brachytherapy in 1,485, brachytherapy plus external beam radiotherapy in 1,847, radical prostatectomy in 4,736, radical prostatectomy plus external beam radiotherapy in 369 and cryotherapy in 245. Histogram, incidence rates and Cox proportional hazards models with repeat events analysis were done to describe the burden of repeat bladder outlet obstruction treatments stratified by prostate cancer therapy type. We describe the type of bladder outlet obstruction surgery grouped by level of invasiveness.At a median followup of 8.8 years 44.6% of men underwent 2 or more bladder outlet obstruction procedures. Compared to men who underwent radical prostatectomy those treated with brachytherapy and brachytherapy plus external beam radiotherapy were at increased adjusted risk for repeat bladder outlet obstruction treatment (HR 1.2 and 1.32, respectively, each p0.05). After stricture incision the men treated with radical prostatectomy or radical prostatectomy plus external beam radiotherapy were most likely to undergo dilation at a rate of 34.7% to 35.0%. Stricture resection/ablation was more common after brachytherapy, external beam radiotherapy or brachytherapy plus external beam radiotherapy at a rate of 28.9% to 41.2%.Almost half of the men with bladder outlet obstruction after prostate cancer therapy undergo more than 1 procedure. Furthermore men with bladder outlet obstruction after radiotherapy undergo more invasive endoscopic therapies and are at higher risk for multiple treatments than men with bladder outlet obstruction after radical prostatectomy.

Background. Retroperitoneal lymphadenectomy (RPLND), chemotherapy, and active surveillance represent treatment options for patients with nonseminomatous germ-cell tumors of the testis (NSGCTT). Our objective was to assess the utilization rate of RPLND in patients with NSGCTT. Methods. Within the Surveillance, Epidemiology and End Results (SEER) cohort, 4,620 and 1,671 patients with stage I and II NSGCTT were diagnosed between the years 1988 and 2006. Univariable and multivariable logistic regression analyses were performed to test the predictors of RPLND use in respectively patients with stage I and II NSGCTT. Results. The rate of RPLND according to stage I and II was 27 and 58%, respectively. In patients with stage I disease, the rate of RPLND decreased from 39% in 1988-1995 to 18% in 2004-2006 (P < 0.001), and remained stable for stage II patients (62-56%, P = 0.2). Regional variability existed regarding the rate of RPLND use only in stage I (Utah: 51% vs. Louisiana: 16%). Multivariable analyses performed in stage I NSGCTT revealed that year of diagnosis, SEER registry, and age were significant predictors of RPLND use. However, none of these variables achieved statistical significance within stage II NSGCTT patients. Conclusions. In patients with stage I NSGCCT, the RPLND utilization rate decreased during the study span. This observation may be ascribed to wider use of surveillance or chemotherapy. No temporal difference was recorded in patients with stage II NSGCCT.

OBJECTIVES To revisit whether the perioperative mortality differs between septuagenarian and octogenarian patients and younger patients in a large contemporary population-based cohort. The data from tertiary care centers have suggested that perioperative mortality after radical cystectomy is not considerably different in septuagenarian or octogenarian patients compared with younger patients. However, population-based data have stated otherwise. METHODS From 1988 to 2006, 12 722 radical cystectomies were performed for urothelial carcinoma of the urinary bladder in 17 Surveillance, Epidemiology, and End Results registries. Of those 12 722 patients, 4480 (35.2%) were aged 70-79 years and 1439 (11.3%) were aged >= 80 years. Univariate and multivariate logistic regression models tested the 90-day mortality after radical cystectomy. Covariates consisted of sex, race, year of surgery, Surveillance, Epidemiology, and End Results registry, and histologic grade and stage. RESULTS The overall 90-day mortality rate was 4% for the entire population, 2% for patients aged

The relationship between provider volume and complication and transfusion rates in patients undergoing minimally invasive prostatectomy (MIRP) for prostate cancer has not been assessed. Temporal trends in MIRP annual surgical caseload (AC), impact of MIRP surgical experience (SE), and in-hospital complication and transfusion rates were evaluated. Between 2002 and 2008, 2,666 patients in Florida underwent MIRP. Surgical experience was defined as the number of procedures performed from the beginning of the study until each individual MIRP. Multivariable logistic regression models using generalized estimating equations assessed the relationship between SE and in-hospital complication and transfusion rates. Overall AC and SE ranged from 1-171 and 1-500, respectively. Between 2002 and 2005, 94-100% of surgeons were considered as low AC tertile (a parts per thousand currency sign15 MIRP) vs. 76-82% between 2006 and 2008. For the same time periods, low AC tertile surgeons performed 46-100 and 27-32% of all MIRPs respectively. Multivariable logistic regression models revealed 51 and 68% lower complication rates in patients operated on by surgeons of intermediate (17-76 MIRPs) and high SE (a parts per thousand yen77 MIRPs) relative to surgeons of low SE (a parts per thousand currency sign16 MIRPs). Similarly, transfusion rates were 80 and 83% lower for the same groups. Our study is the first to indicate that high SE reduces MIRP complication and transfusion rates. Despite this observation, even in the most contemporary study year, most MIRP surgeons (82%) were in the low AC tertile and contributed to as many as 32% of all MIRPs. These findings should be considered at informed consent.

The adherence rate to National Cancer Institute (NCI) recommendations regarding inguinal lymph nodes dissection (ILND) in high grade T1 (G3T1) and T2-4 squamous cell carcinoma of the penis (SCCP) is not known. We assessed ILND rates in a North American cohort. The 17 registries of the Surveillance, Epidemiology, and End Results (SEER) database included 868 patients with SCCP, diagnosed between 1988 and 2006. Analyses consisted of univariable and multivariable logistic regression models. Overall, 27.6% of patients underwent an ILND. ILND rates were directly proportional with T stage: 19.0%, 30.5%, 30.6%, and 32.6% for, respectively, G3T1, T2, T3, and T4 SCCP (chi-square trend, P = 0.01). ILND rates also increased over time and were 19.3, 27.3, 30.7, and 30.8% for respectively, 1988–1995, 1996–2000, 2001–2003, and 2004–2006 periods (chi-square trend, P = 0.03). Finally, ILND rates decreased with patient age and were 42.6, 33.2, 24.7, and 7.3% for, respectively, patients aged ≤57, 58–68, 69–78 and ≥79 years of age (chi-square trend, P

Item does not contain fulltext PURPOSE: Fuhrman grade represents a key determinant of the natural history of small renal masses that represent renal cell carcinoma. We tested whether renal mass biopsy prediction of Fuhrman grade in the nephrectomy specimen could be safely substituted for by an accurate statistical model. To date the best available model has shown poor accuracy (55.6%), which is close to flipping a coin (50%) and clearly inadequate for use in clinical practice. MATERIALS AND METHODS: We identified 1,139 patients with T1aN0M0 renal cell carcinoma treated with partial or radical nephrectomy at 11 participating institutions from 1989 to 2004. This cohort was used in univariate and multivariate logistic regression models predicting high Fuhrman grade (III-IV) at nephrectomy. Predictors included age at diagnosis, gender, tumor size and symptom classification. Multivariate logistic regression coefficients were used to generate a nomogram. RESULTS: The rate of Fuhrman grade III-IV in patients with T1aN0M0 renal cell carcinoma was 12.3%. Stratifying patients with Fuhrman grade III-IV by age, gender, histological subtypes and sample size failed to reveal statistically significant differences. On univariate analysis predicting Fuhrman grade III-IV at nephrectomy only tumor size was a statistically significant predictor (p = 0.05). The most accurate multivariate nomogram for Fuhrman grade III-IV prediction was 58.3% (95% CI 57.8-58.9) accurate. Of all tested predictors only tumor size achieved independent predictor status (p = 0.009). CONCLUSIONS: Our analysis derived in European patients shows that statistical models cannot safely replace renal mass biopsy based prediction of Fuhrman grade III-IV at nephrectomy. Our findings corroborate a report from the United States in which a similar model had 55.6% accuracy. Jointly the studies indicate that statistical models are unreliable and cannot safely be substituted for renal mass biopsy in North American or European patients.

Cerebral palsy is characterized by motor impairment following injury to the developing brain. Neurogenic lower urinary tract dysfunction is estimated to affect at least a third of children with cerebral palsy. However there are limited data as patients transition to adulthood. We sought to describe the symptoms, sequelae and management of neurogenic lower urinary tract dysfunction in adults with cerebral palsy.We retrospectively reviewed the charts of adult patients with cerebral palsy between 2011 and 2014. Patients with prior bladder reconstruction or catheterization based bladder drainage were excluded from study. Cerebral palsy severity was determined using GMFCS (Gross Motor Function Classification System). A conservative evaluation and treatment paradigm was used. Noninvasive treatments were encouraged. Specifically clean intermittent catheterization, which is often not feasible, is avoided unless urinary retention, hydronephrosis or refractory lower urinary tract symptoms develop.There were 121 patients included in final analysis. Median age was 25 and 61 patients (50%) had GMFCS level V. Noninvasive management failed in 28 of 121 patients (23%) as defined by hydronephrosis in 9, persistent urinary retention in 10 and refractory lower urinary tract symptoms/incontinence in 9. Urethral clean intermittent catheterization was poorly tolerated. Of all patients 25% showed evidence of urolithiasis during the study period. Surgical intervention was rare and associated with significant morbidity.Adults with cerebral palsy may present with variable signs and symptoms of neurogenic lower urinary tract dysfunction. Conservative treatment was successful in more than 75% of patients. Clean intermittent catheterization was poorly tolerated in patients in whom conservative treatment failed. Surgical intervention was rarely indicated and it should be reserved for select individuals.

INTRODUCTION AND OBJECTIVES: Patients with neurological conditions often suffer from severe debilitating lower urinary and bowel dysfunction in addition to their physical disabilities. However, only the bladder has received the attention of medical providers with neurogenic bowel being poorly understood and characterized. The primary aim in this study was to determine the level of severity and impact on quality of life of bowel dysfunction in a population with neurogenic bladder using validated surveys and to determine those patient variables that correlate with worse bowel symptoms. Our second aim was to determine if the severity of bowel dysfunction correlates with the severity of bladder dysfunction. METHODS: This is a cross-sectional analysis of a prospective institutional Neurogenic Bladder Database from 2010e2013. RESULTS: Among the 175 patients 60.6% had traumatic SCI and 18.3% MS. Fecal Incontinence Severity Index (FISI) scores were a median of 18.0 1.39 (moderate). Neurogenic Bowel Dysfunction (NBD) score, which is specific to patients with neurological disease, were a median of 11.0 0.63 (moderate). NBD Scores were worse in those patients with SCI and myelomeningocele compared to other diseases (P1⁄40.020), in younger patients (p1⁄40.020) and in the SCI group those with higher levels of injury (p1⁄40.0046). Based on the Bristol stool scale 65% of patient had abnormal stool consistency, mostly constipation. None of the FISI, Bristol or NBD scores correlated significantly with SF12 quality of life measures. None of the urodynamic findings correlated with any of the bowel symptom scores. However, both of the bladder symptom scores Michigan Incontinence Symptom Index (MISI)(p1⁄40.05) and the AUA-SI (p1⁄40.03) correlated with FISI severity and the NBD score correlated with the M-ISI (~ n1⁄40.29, p1⁄40.02). Those patients with abnormal stool consistency on the Bristol reported more urgency and stress incontinence on M-ISI. CONCLUSIONS: Bowel dysfunction is very common among patients with neurogenic bladder. Those patients with worse bladder symptoms also suffered from worse bowel dysfunction although the severity of bowel dysfunction did not correlate with overall quality of life or urodynamic measures.

INTRODUCTION AND OBJECTIVES: Bladder outlet obstruction (BOO) after prostate cancer treatment (PCT) includes urethral strictures, bladder neck contractures and stenosis of the prostatic urethra. We have shown that by 10 years post-PCT, BOO occurs in 20-38% of men, varying by PCT type. BOO recurrence is common and the need for retreatment may burden the cancer survivor. We sought to describe the burden of BOO in a population-based cohort by detailing the types and numbers of BOO procedures performed per patient. METHODS: From a SEER-Medicare cohort of men aged 66 years diagnosed with non-metastatic prostate cancer (1992-2007), we identified 12,676 men who underwent at least one surgery for BOO after radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy (BT), EBRTþBT, RPþEBRT or cryotherapy. To describe the risk of multiple treatments, we report the incidence rate per personyear and incidence rate ratios of BOO treatment. Cox proportional hazards regression with repeated events analysis was used to adjust for demographic, clinical and cancer characteristics. RESULTS: Median follow-up was 8.8 years. 45% underwent more than one treatment; mean number of treatments was 2.5 (range 1 to 7). Men who received EBRTþBT were most likely to receive seven or more treatments (9.2%), and those receiving RP were least likely (4.5%). Incidence rate ratio and Cox proportional hazards of BOO for each treatment group are shown in the Table. Direct vision internal urethrotomy or transurethral incision of bladder neck contracture was the most common type of stricture treatment across all cancer treatment groups (43.0-51.1%). In RP (35.0%) and RPþEBRT (34.7%), dilation was the second most common treatment of BOO. In EBRT (41.2%), BT (37.0%) and BTþEBRT (28.9%), transurethral resection was the second most common surgery treatment. CONCLUSIONS: When BOO occurs after PCT, nearly half of patients undergo multiple treatments. Men with BOO after radiation or cryotherapy undergo treatments that are more invasive and they have a higher retreatment rate than men with BOO after RP. The need for BOO retreatment and the burden it creates for the cancer survivor deserves more investigation.

Posterior urethral injury is a clinically significant complication of pelvic fractures. The management is complicated by the associated organ injuries, distortion of the pelvic anatomy and the ensuing fibrosis that occurs with urethral injury. We report a review of the outcomes after posterior urethroplasty in the context of pelvic fracture urethral injury.

INTRODUCTION AND OBJECTIVES: Robotic assisted radical prostatectomy (RARP) is being increasingly utilized among different institutions in Canada. Despite this, the Canadian literature lacks publications on the oncologic and functional outcomes of RARP. Hence, the objective of this study is to report the largest Canadian experience. METHODS: Data from more than 670 consecutive patients who underwent RARP by 4 distinct surgeons were collected prospectively from Oct 2006 to August 2013. Mean follow-up (range) was 17.9 months (1-72). D’Amico risk stratification distribution was 31.8% low, 57.7% intermediate and 10.5% high-risk groups. RESULTS: Mean operation time ( SD) was 186 60.1min, and estimated blood loss 287 189ml. Transfusion rate was only 0.8%. All procedures were completed robotically. Mean hospital stay was 1.3 days, and 86% of patients were discharged on postoperative day one. Mean catheterization time (range) was 6 days (3-22). There were 0.9% major (Clavien III-IV) and 11.1% minor (Clavien I-II) postoperative complications, and no mortality. On final pathology 73.5% were organ-confined. Pathological Gleason sum 7 accounted for 81.5%. Return of urinary continence (0-pads/day) at 3, 6, 12, and 24 months was 69.0%, 79.2%, 91.0%, and 90.1% respectively. Potency rate (successful penetration with or without medication) at 6, 12, and 24 months was 40.1%, 63.8%, and 77.2% respectively. Twenty-seven patients (5.2%) had no undetectable PSA at first visit (PSA 0.2 ng/ml) was 4.1% (21 patients), and another 3.1% (16 patients) received early salvage radiotherapy (Rising PSA but

INTRODUCTION AND OBJECTIVES: The aim was to evaluate the surgical performance and impact of prostate volume (PV) of the new Greenlight XPS-180W laser system (AMS, Minnetonka, MI, USA) in comparison with the former generation HPS-120W system for the treatment of BPH by photo-selective vaporization of the prostate (PVP). METHODS: From July 2007 to March 2012, a total of 1809 patients underwent Greenlight PVP for the treatment of BPH performed at 7 international centers. 1187 cases were performed using HPS120W and 622 cases using XPS-180W laser system. Data were all collected prospectively. Comparative analysis was performed between XPS and HPS and according to PV 80 and 80 cc. RESULTS: The XPS compared to HPS, allowed significantly reduced laser and operative time with a mean lasing time of 29.6 min vs. 65.8 min and total operative time of 53 min vs. 80 min respectively (p 0.01 for both). The number of fiber used during procedures was significantly reduced with the XPS system 1.11 vs. 2.28 fiber (p 0.01) while total energy delivered was 250.2 vs. 267.7 kJ (p 0.043) respectively. Overall using XPS and HPS systems, the mean operative time (104.3 vs 55.6 min), mean laser time (86.5 vs 37.3 min) and mean energy usages (400 vs 197 kJ) were all significantly increased according to PV 80 cc vs 80cc. However, when stratified according to PV, XPS demonstrates significant advantages compared to HPS regardless of prostate size in all operative parameters (p 0.01) but energy; total energy delivery was equivalent between the two systems (p 0.05). CONCLUSIONS: The XPS-180W system exhibits reduced operative time and laser time with similar total energy delivery per given PV suggesting a significant increased efficiency compared to the HPS-120W system. Overall, both with XPS-180W and HPS-120W mean operative time, laser time and energy usage increased according to prostate size. This suggests evaluation of PV should be a mandatory assessment as part of pre-operative evaluation of Greenlight PVP because it has direct implications for the operating parameters. Source of Funding: None

To evaluate a hybrid technique involving GreenLight 120W HPS vapor incision tissue removal in prostate glands80 cc.Vapor incision technique (VIT) was performed in 25 consecutive men with a prostate80 cc by a single surgeon from May 2010 until September 2010. VIT involved adenoma incisions at 5 and 7-o'clock positions followed by 3, 9 and 12 o'clock down to the surgical capsule. Side-fire vaporization along the capsule excised transurethral resection of the prostate (TURP) like tissue strips for later retrieval. Functional evaluations were performed at 1 and 3 months. Outcomes and complications were compared retrospectively to baseline and a size matched- cohort of 25 men who previously underwent standard vaporization-only photoselective vaporization prostatectomy (PVP).The VIT and control subgroups were comparable. Mean laser time, operative time and energy usage were reduced in the VIT group compared to controls (35 min versus 48 min; 63 min versus 80 min; and 227 k versus 325 kJ respectively; all p0.05). At 3 months the VIT subgroup demonstrated improved Qmax and post void residual (PVR) (197% versus 173%, 88% versus 72%; all p0.05) compared to control. VIT showed a 68% reduction in mean preoperative PSA at 3 months compared to 50% for the control group (p0.01). Hospital stay, catheterization time and complication rates were comparable.Our data demonstrates that VIT provides superior short term outcomes to standard HPS-PVP in men with prostate volumes80 cc. VIT appears to be more time-efficient, consumes less energy and obtains tissue for pathological evaluation. Further follow up is required to assess the durability of GreenLight HPS-VIT to PVP vaporization-only for large prostate glands.

Transrectal ultrasound (TRUS)-guided prostate biopsies using 18G calibre needles are widely used; most often 12-core tissue samples of the peripheral zone are obtained. Although the diagnostic yield of prostate biopsies is fair, there is still a potential for false negative results, which necessitates repeat biopsies. In an effort to improve the accuracy of prostate biopsies, different sampling schemes have been developed. One strategy has been to increase the number of core biopsies performed on each patient. Another strategy has been to improve the reliability of prostate biopsies using larger calibre needles, thereby increasing the amount of tissue obtained for each core biopsy.After approval by our institutional review board, we prospectively compared two biopsy needle sizes (18G vs. 16G) in relation to prostate cancer diagnosis, pain, bleeding and infection rates on 105 patients. Each patient underwent 6 TRUS-guided prostate biopsies with the standard 18G needle and 6 other biopsies with the experimental 16G needle. To evaluate possible complications related to the use of a larger 16G needle in the experimental group, we compared pain, bleeding and infection rates with a control group of 100 patients who underwent 12 biopsies with a single 18G needle (18G group). Pain, bleeding assessment and infection events were evaluated using patient questionnaires and telephone interviews.TRUS-guided prostate biopsies using 16G calibre needles did not increase cancer detection or non-malignant pathology rate, including prostatic intraepithelial neoplasia (PIN) and atypical small acinar proliferatio (ASAP). Pain, bleeding and infectious complications were similar in both groups. Infection was defined as temperature above 38°C occurring within 48 hours after the procedure. We identified 4 patients with post-biopsy fever in the experimental (16/18G) group and 4 other patients in the (18G) control group. The post-biopsy infection rate is higher than reported just a few years ago and indicates that quinolone resistant Escherichia coli seems to be more prevalent in our urban setting than previously suspected. Limitations to our study include small group numbers.Larger 16G needles appear to be safe for TRUS-guided prostate biopsies. Further study in a larger, multi-institutional, prospective, randomized manner with 16G needles is warranted to assess the theoretical benefit of larger core biopsies in prostate cancer detection.

Transurethral resection of the prostate (TURP) is the most common surgical intervention for benign prostatic hyperplasia (BPH), largely due to lower urinary tract symptoms refractory to medical therapy. TURP remains the gold standard for men with prostates sized 30g-80g, while open prostatectomy has been the preferred option for men with glands larger than 80g-100 g and those with other lower urinary tract anomalies such as large bladder stones or bladder diverticula. Unfortunately, these procedures have complications including bleeding (often requiring transfusion in 7%-13% of cases), electrolyte abnormalities (2% TURP syndrome), erectile dysfunction (6%-10%), and retrograde ejaculation (50%-75%). The overall incidence of a second intervention (repeat TURP, urethrotomy and bladder neck incision) has been reported in 12% and 15% of men at 5 and 10 years following TURP. Alternative therapies have been developed with the aim of reducing the level of complications while maintaining efficacy. These include microwave therapy, transurethral needle ablation, and a range of laser procedures (Holmium, Diode, Thulium and 532nm-Greenlight). Photoselective vaporization of the prostate (PVP), initially launched as a 60W prototype, was ultimately introduced to the urology community as a 80W system (American Medical Systems, Minnetonka, Minnesota, USA), has been the predominant device used in clinical trials. This 1st generation used an Nd:YAG laser beam passed through a potassium-titanyl-phosphate (KTP) crystal, halving the wavelength (to 532nm), doubling the laser's frequency, and resulting in a green light. Outcomes have demonstrated a reduced frequency and severity of clinical complications, however it was limited to smaller prostate sizes. In 2006, the 120W lithium triborate laser (LBO), also known as the GreenLight HPS (High Performance System) laser was introduced. This laser utilizes a diode pumped Nd:YAG laser light that is emitted through an LBO instead of a KTP crystal, resulting in a higher-powered 532 nm wavelength green light laser while still using the same 70-degree deflecting, side firing, silica fiber delivery system. The HPS offered an 88% more collimated beam and smaller spot size, resulting in much higher irradiance or power density in its 2 predecessors (60W and 80W) with a beam divergence of 8 versus 15 degrees. The primary aim for this upgrade was to reduce lasing time and improve clinical outcomes while demonstrating the same degree of safety for patients. Limitations of the 120W system included treatment of large prostates greater than 80g-100g and increased cost related to fiber devitrification and fracture. In 2011, the 180W-Greenlight XPS system was introduced, not only with increased power setting to vaporize tissue quicker but significant fiber-design changes. Internal cooling, metal-tip cap protection and FiberLife (temperature sensing feedback), better preserve the integrity of the fiber generally producing a 1-fiber per case expectation. Initial personal experience with XPS has provided comparable outcomes related to morbidity, but with the opportunity to perform a more complete and rapid procedure. Published clinical data with the XPS is unfortunately lacking. The objective of this report is to detail our approach and technique for GreenLight XPS drawing on personal experience with both enucleation and vaporization techniques with various laser technologies along with having performed over 500 GreenLight HPS and 100 XPS procedures. In this regard, recommendations for training are also made, which relate to existing users of the 80W and 120W GreenLight laser as well as to new laser users.