Objective: In 2012 the US Preventive Services Task Force released recommendations against prostate specific antigen (PSA) based screening for prostate cancer, but did not fully address screening via ...digital rectal exam (DRE). As such, many practitioners continue to perform DRE in attempts to identify men with clinically significant prostate cancer (CSPC). This study seeks to determine the value of DRE in detecting CSPC in the era of PSA-based screening.
Methods: Data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial, a nationwide population-based study evaluating cancer screening programs and their impact on cancer mortality, was analyzed for PSA, DRE, and cancer status. In the screening arm of the PLCO, 38,340 men received annual PSA and DRE examinations for the first 3 years. Those with an abnormal test result were referred to their individual care provider for biopsy. The ability of DRE to detect CSPC, defined as intermediate risk or higher based on National Comprehensive Cancer Network guidelines and age ≤75, was evaluated in the context of both normal and abnormal PSA.
Results: A total of 5064 men had abnormal DRE in the setting of normal PSA, of whom 99 (2%) were diagnosed with CSPC. When both PSA and DRE were abnormal, 218 (20%) participants were diagnosed with CSPC (RR = 2.06 1.78-2.39 versus abnormal PSA alone).
Conclusions: DRE screening in the setting of normal PSA captured an additional 2% of men with CSPC. This incremental gain suggests that routine DRE screening subjects a large number of men to invasive, potentially uncomfortable examinations for relatively minimal gain.
Key limitations: Our conclusions are based on data derived from the PLCO study which has been criticized on the basis of inconsistent biopsies following positive screening tests, lack of end of study biopsies to determine population disease burden, and low numbers of black men.
Purpose We determined the efficacy and potential complications of endoscopic incision and balloon dilation with double stenting for the treatment of primary obstructive megaureter in children. ...Materials and Methods We prospectively reviewed cases of primary obstructive megaureter requiring repair due to pyelonephritis, renal calculi and/or loss of renal function. A total of 17 patients were identified as candidates for endoscopy. Infants were excluded from study. All patients underwent cystoscopy and retrograde ureteropyelography to start the procedure. In segments less than 2 cm balloon dilation was performed, and for those 2 to 3 cm laser incision was added. Two ureteral stents were placed within the ureter simultaneously and left indwelling for 8 weeks. Imaging was performed 3 months after stent removal and repeated 2 years following intervention. Results Mean patient age was 7.0 years (range 3 to 12). Of the patients 12 had marked improvement of hydroureteronephrosis on renal and bladder ultrasound. The remaining 5 patients had some improvement on renal and bladder ultrasound, and underwent magnetic resonance urography revealing no evidence of obstruction. All patients were followed for at least 2 years postoperatively and were noted to be symptom-free with stable imaging during the observation period. Conclusions Endoscopic management appears to be an alternative to reimplantation for primary obstructive megaureter with a narrowed segment shorter than 3 cm. Double stenting seems to be effective in maintaining patency of the neo-orifice. Followup into adolescence is needed.
To identify and describe the characteristics of a group of patients at our institution who are satisfied with cutaneous vesicostomy for long-term bladder management and never undergo subsequent ...continence surgery.
Using an IRB-approved registry of our patients undergoing reconstructive urinary tract surgery since 1985, we identified patients who underwent vesicostomy creation and were 15 years or older as of October 2017 and performed a retrospective chart review.
Sixty-seven patients were included with the most common diagnosis being spina bifida and the average duration of vesicostomy 14.3 years (range 8 months to 35 years). In follow-up, 38 patients (56.7%) had conversations regarding further surgery and 31 (46.3%) had their vesicostomies taken down. Of the 36 patients who still had their vesicostomy at last follow-up, 29 (80.6%) had spina bifida and 14 (38.9%) were satisfied, 1 (2.8%) was unhappy, 4 (11.1%) were deceased and satisfaction was unknown for 17 (47.2 %).
Although often intended to be temporary, in our experience many patients keep their vesicostomy for a long time and into adulthood, with generally high satisfaction and low complications. In the properly selected patient, vesicostomy may be a good long-term operation to prevent infection and renal deterioration, though more rigorous studies of these patients are needed.
Abstract Purpose Mohs micrographic surgery (MMS) is a low-risk penile cancer management option. However, contemporary patients’ short-term oncologic control and preoperative characteristics ...predicting reconstruction needs are undefined. This study assesses MMS’s oncologic efficacy for low-risk penile cancer and identifies baseline predictors of post-resection reconstruction referral. Methods We retrospectively reviewed 73 adult males with 78 penile cutaneous malignancies treated with MMS from 2005 to 2019. Patients underwent MMS with or without surgical reconstruction. Demographic information, MMS operative details, lesion pathology, and short-term outcomes were recorded. Descriptive statistics for all variables were calculated, and logistic regression identified predictive factors for urologic referral for complex reconstruction. Results Seventy-three men with 78 lesions, all staged ≤ cT1a prior to MMS, were identified. Twenty-one men were found to have invasive SCC. Median follow-up was 2.0 years (IQR 0.8–5.2 years). MMS was able to clear the disease in 90.4% of cases. One patient had disease related death following progression. Dermatology closed primarily in 68% of patients. Twenty percent of patients had a complication, most commonly poor wound healing. On univariate and multivariate linear regression analysis, lesion size > 3 cm and involvement of the glans independently predicted the need for referral to a reconstructive surgeon. Conclusions MMS for penile cancer appears to provide sound oncologic control in the properly selected patient. Involvement of a reconstructive surgeon may be needed for glandular and large lesions, necessitating early referral to a comprehensive multidisciplinary care team.
To describe a technique for surgical correction of adult buried penis, including a technique for skin graft harvesting from the escutcheonectomy specimen itself, with an emphasis on remaining open ...questions in the literature.
We present our method for surgical correction of adult buried penis with a review of the literature.
Components of successful buried penis repair include return of directed voiding, elimination of local skin inflammation and infection, improvement in hygiene, return of sexual functioning, cosmesis, and patient satisfaction. To date, there are no broadly accepted tools for comprehensive measurement of outcomes after buried penis repair.
Adult buried penis repair is generally associated with excellent rates of satisfaction and improvement in functioning. Currently available data are extremely limited; however, they do suggest that, when in doubt, more aggressive debridement of diseased tissue combined with split-thickness skin grafting may provide superior outcomes. Split-thickness skin grafts are associated with excellent rates of successful graft take, even in cases of severe preoperative pathology and patient comorbidity. Although these grafts come at the cost of some increased surgical morbidity, they are associated with low rates of major complications. Morbidity can be further significantly decreased by harvesting the graft from the excised escutcheon itself, a technique that we present here.
Surgical correction of adult buried penis is safe and effective; however, future work is required to further optimize outcomes and reduce surgical morbidity.
Strother MC, Skokan AJ, Sterling ME, et al. Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting. J Sex Med 2018;15:1198–1204.
A 72 year old male developed severe obstructive voiding symptoms status post radical prostatectomy. Imaging showed a large pelvic mass causing mass effect on the bladder that ultimately proved to be ...a sperm granuloma. To the best of our knowledge the development of sperm granuloma post-prostatectomy has not been previously reported.
Prostate cancer is the most common malignancy diagnosed in men. PI-RADS 3 lesions on multiparametric MRI, when histologically proven malignant, overwhelmingly represent prostatic adenocarcinoma. ...Primary lymphoma of the prostate, especially follicular lymphoma, is exceedingly rare. To our knowledge, its presentation with a PI-RADS 3 lesion and elevated PSA has not been previously described. We report the case of a 68-year-old, healthy male presenting with elevated PSA and lower urinary tract symptoms found to have a PI-RADS 3 lesion. Prostate biopsy revealed low-grade follicular lymphoma, and staging showed no other lesions. The patient is currently being managed with close surveillance.
•SCC and EMPD of the scrotum are exceedingly rare and highly morbid conditions.•MMS may improve both oncologic outcomes and decreases reconstructive issues.•These patients should be referred to ...urologists at centers with MMS capabilities and advanced reconstructive urologic and plastic surgery care.
Squamous cell carcinoma (SCC) and extramammary Paget's Disease (EMPD) of the scrotum are exceedingly rare. Given their propensity for local invasion and treatment with wide local excision, they can be highly morbid conditions. Outcomes of Mohs Micrographic Surgery (MMS) for scrotal cutaneous malignancy is not well described in current literature. We hypothesized that MMS for scrotal cutaneous malignancy would provide equivalent or improved oncologic outcomes while limiting the morbidity associated with wide excision.
This is a retrospective review and analysis of a prospectively maintained database spanning entries from 2005 to 2019. Collected data included general patient characteristics and surgical characteristics reported on a per lesion basis. MMS was performed by our institution's department of dermatology using their standard technique.
Overall, a total of 26 consecutive patients with 28 lesions (SCC or EMPD) were analyzed. Out of our cohort of 15 patients with 16 scrotal SCC lesions, 10 (66%) patients were current or former smokers, 4 (26%) were immunosuppressed, and 2 (13%) had HPV infections. The median preoperative and postoperative size of SCC lesions were 5.7cm 2 and 20.2cm 2 respectively. There was one (6%) oncologic recurrence of SCC of the scrotum and one (6%) local wound complication. Our cohort also included 11 patients with 12 scrotal EMPD lesions. One patient (9%) had an underlying associated malignancy (prostate cancer). The preoperative and postoperative area of lesions were 50.6cm 2 and 96.4cm 2 respectively. One (9%) EMPD lesion had a positive final margin at resection requiring reoperation. After achieving negative surgical margins, no patients in this cohort had an oncologic recurrence. 3 (26%) scrotal EMPD cases had local wound postoperative complications, only one required reoperation.
To our knowledge, this is the first case series focused on MMS for both SCC and EMPD with scrotal involvement. Our data suggests that MMS for scrotal cutaneous malignancy may improve oncologic outcomes and may decreases local post-operative reconstructive issues when compared to reported outcomes of treatment with wide local excision. When able, scrotal cutaneous malignancy patients should be referred to urologists at centers with MMS capabilities as it likely will improve their outcomes. The urologist should maintain active involvement with these patients to coordinate this complex and advanced pattern of care.
This 68-year-old male, with a history of treated testicular seminoma, developed scrotal SCC 30 years later, with a metastatic SCC recurrence following another interval of 10 years. He exhibited good ...response to multimodal therapy, though subsequently underwent orchiectomy, revealing SCC invading his solitary testicle. This case presents a unique danger of adjuvant radiation in testicular cancer survivors, demonstrates the efficacy of multimodal therapy with GU SCC, and describes a highly unusual histologic finding.
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