Purpose Although long-term outcomes after initial placement of artificial urinary sphincters are established, limited data exist comparing sphincter survival in patients with compromised urethras ...(prior radiation, artificial urinary sphincter placement or urethroplasty). We evaluated artificial urinary sphincter failure in patients with compromised and noncompromised urethras. Materials and Methods We performed a retrospective analysis of 86 sphincters placed at a single institution between December 1997 and September 2012. We assessed patient demographic, comorbid disease and surgical characteristics. All nonfunctioning, eroded or infected devices were considered failures. Results Of the 86 patients reviewed 67 (78%) had compromised urethras and had higher failure rates than the noncompromised group (34% vs 21%, p=0.02). Compared to the noncompromised group, cases of prior radiation therapy (HR 4.78; 95% CI 1.27, 18.04), urethroplasty (HR 8.61; 95% CI 1.27, 58.51) and previous artificial urinary sphincter placement (HR 8.14; 95% CI 1.71, 38.82) had a significantly increased risk of failure. The risk of artificial urinary sphincter failure increased with more prior procedures. An increased risk of failure was observed after 3.5 cm cuff placement (HR 8.62; 95% CI 2.82, 26.36) but not transcorporal placement (HR 1.21; 95% CI 0.49, 2.99). Conclusions Artificial urinary sphincter placement in patients with compromised urethras from prior artificial urinary sphincter placement, radiation or urethroplasty had a statistically significant higher risk of failure than placement in patients with noncompromised urethras. Urethral mobilization and transection performed during posterior urethroplasty surgeries likely compromise urethral blood supply, predisposing patients to failure. Patients with severely compromised urethras from multiple prior procedures may have improved outcomes with transcorporal cuff placement rather than a 3.5 cm cuff.
Study Type – Diagnosis (case series)
Level of Evidence 4
What’s known on the subject? and What does the study add?
Following the updated Gleason grading system in 2005 by the International Society of ...Urological Pathologists (ISUP), studies demonstrated improved prediction of biochemical (PSA) progression‐free outcome by needle core biopsy specimens. To our knowledge, no studies have investigated the impact of the modified grading system on inter‐laboratory agreement of biopsy Gleason score (bGS) and the effect of re‐evaluation on accuracy in predicting the true underlying histopathology. We report that when biopsy re‐evaluation resulted in a change in bGS, there was a marked improvement in the prediction of underlying pathology as determined by prostatectomy Gleason score suggesting that when outside referral of bGS results in an equivocal clinical decision, biopsy re‐evaluation can provide clarity on the true underlying tumour architecture.
OBJECTIVES
• Gleason sum from prostate biopsy (bGS) is an important tool in classifying severity of disease, ultimately influencing clinical management.
• Commonly, pathology specimens are re‐evaluated internally prior to surgery.
• We evaluate agreement of bGS with prostatectomy Gleason sum (pGS) and the impact of re‐grading on prediction of true underlying tumor architecture.
MATERIALS AND METHODS
• Retrospective analysis of men who underwent robotic‐assisted radical prostatectomy (RARP) by two surgeons from 2005–2009. Initial transrectal ultrasound (TRUS) biopsy demonstrated carcinoma at an outside lab. Specimens were re‐evaluated by our GU pathologists prior to surgery. Biopsy data were correlated with pGS.
• Kappa (κ) statistics for agreement and linear regression analyses were used for categorical variables. Coefficient of concordance was used for continuous variables.
RESULTS
• 100 patients had 331 positive biopsies. Agreement (κ) for bGS between outside labs and our pathologists was 0.55 (p < 0.001).
• Internal read was twice as likely to upgrade vs. downgrade outside bGS (23% vs. 11%).
• When re‐evaluation resulted in a change in bGS, agreement with pGS was κ= 0.29, vs. κ=−0.04 for agreement of initial (outside) bGS with pGS.
• When no change was made to bGS, agreement with pGS was κ= 0.40 (p < 0.001).
CONCLUSION
• Good reproducibility seen between outside labs and our institution on bGS. Internal pathology re‐reads correlated better with pGS than original community bGS. When re‐reads result in a change in bGS, there is a marked improvement in prediction of underlying tumor architecture confirming the value of re‐evaluating all external biopsies prior to definitive surgery.
STIs are the most common infections among adults. Concurrently, pubic hair grooming is prevalent. Small-scale studies have demonstrated a relationship between pubic hair grooming and STIs. We aim to ...examine this relationship in a large sample of men and women.
We conducted a probability survey of US residents aged 18-65 years. The survey ascertained self-reported pubic hair grooming practices, sexual behaviours and STI history. We defined extreme grooming as removal of all pubic hair more than 11 times per year and high-frequency grooming as daily/weekly trimming. Cutaneous STIs included herpes, human papillomavirus, syphilis and molluscum. Secretory STIs included gonorrhoea, chlamydia and HIV. We analysed lice separately.
Of 7580 respondents who completed the survey, 74% reported grooming their pubic hair, 66% of men and 84% of women. After adjusting for age and lifetime sexual partners, ever having groomed was positively associated with a history of self-reported STIs (OR 1.8; 95% CI 1.4 to 2.2), including cutaneous STIs (OR 2.6; CI 1.8 to 3.7), secretory STIs (OR 1.7; CI 1.3 to 2.2) and lice (OR 1.9; CI 1.3 to 2.9). These positive associations were stronger for extreme groomers (OR 4.4; CI 2.9 to 6.8) and high-frequency groomers (OR 3.5; CI 2.3 to 5.4) with cutaneous STIs, and for non-extreme groomers (OR 2.0; CI 1.3 to 3.0) and low-frequency groomers (OR 2.0; CI 1.3 to 3.1) with lice.
Among a representative sample of US residents, pubic hair grooming was positively related to self-reported STI history. Further research is warranted to gain insight into STI risk-reduction strategies.
Human papillomavirus (HPV)-related anal cancer incidence is rising in men who have sex with men (MSM). Effective screening strategies exist, but many patients are lost to follow-up (LTF). We studied ...factors impacting screening compliance to recommended annual screening visits. Retrospective chart review identified MSM with anal dysplasia. MSM were grouped as regular screeners (regular to follow-up RF) (≥1 visit/year), lost to follow-up (LTF) (>1 year since previous screening) and LTF who then returned for screening (lost came back LCB). From June 2007 to March 2008, subjects completed a questionnaire in-person at the time of screening or via telephone (LTF). Questionnaires were completed after anal dysplasia diagnosis. One hundred and ninety-five MSM were enrolled (96 RF, 50 LTF and 49 LCB). RF were compliant for 4.8 years; LTF were lost for 2.3 years. LCB were previously lost for 5.6 years before returning. Mean knowledge score of screening procedures was larger in RF versus LTF (P < 0.001). MSM with more sexual partners in the past six months were more likely to be LCB versus LTF (P = 0.05). RF were more likely to describe their HPV diagnosis as 'upsetting' (P = 0.003). RF were more likely driven by physical symptoms versus LTF (P = 0.002). MSM with high-grade intraepithelial lesions (HSIL) were more likely to be RF versus those with low-grade intraepithelial lesions (P = 0.001. Positive predictors for screening compliance include an upsetting experience during the HPV diagnosis, physical symptoms driving the initial visit and HSIL. Engaging patients in a firm, salient approach may facilitate follow-up compliance.
Electroconvulsive therapy (ECT) is an effective treatment for severe depression; however, the induced therapeutic seizure acts on the autonomic nervous system and results in significant cardiac ...effects. This is an important consideration particularly in the elderly. Magnetic seizure therapy (MST) is in development as a less invasive alternative, but its effects on cardiac function have not been studied. We sought to model those effects in nonhuman primates to inform the development of safer neurostimulation interventions. Twenty four rhesus monkeys were randomly assigned to receive 6 weeks of daily treatment with electroconvulsive stimulation (ECS), magnetic seizure therapy (MST) or anesthesia-alone sham. Digitally acquired ECG and an automated R-wave and inter-R interval (IRI) sampling were used to measure intervention effects on heart rate (HR). Significant differences between experimental conditions were found in the HR as evidenced by changes in the immediate post-stimulus, ictal and postictal epochs. Immediate post-stimulus bradycardia was seen with ECS but not with MST. ECS induced significantly more tachycardia than MST or sham in both the ictal and postictal periods. MST resulted in a small, but statistically significant increase in HR during the postictal period relative to baseline. HR was found to increase by 25% and 8% in the ECS and MST conditions, respectively. MST resulted in significantly less marked sympathetic and parasympathetic response than did ECS. This differential physiological response is consistent with MST having a more superficial cortical site of action with less impact on deeper brain structures implicated in cardiac control relative to ECT. The clinical relevance of the topographical seizure spread of MST and its associated effects on the autonomic nervous system remain to be determined in human clinical trials.
Pubic hair grooming is a common practice that can lead to injury and morbidity.
To identify demographic and behavioral risk factors associated with pubic hair grooming-related injuries to ...characterize individuals with high risk of injury and develop recommendations for safe grooming practices.
This cross-sectional study conducted a national survey of noninstitutionalized US adults (aged 18-65 years). The web-based survey was conducted through a probability-based web panel designed to be representative of the US population. Data were collected in January 2014 and analyzed from August 1, 2016, through February 1, 2017.
Grooming-related injury history (yes or no), high-frequency injuries (>5 lifetime injuries), and injury requiring medical attention.
Among the 7570 participants who completed the survey (4198 men 55.5% and 3372 women 44.5%; mean (SD) age, 41.9 18.9 years), 5674 of 7456 (76.1%) reported a history of grooming (66.5% of men and 85.3% of women weighted percentages). Grooming-related injury was reported by 1430 groomers (weighted prevalence, 25.6%), with more women sustaining an injury than men (868 27.1% vs 562 23.7%; P = .01). Laceration was the most common injury sustained (818 61.2%), followed by burn (307 23.0%) and rashes (163 12.2%). Common areas for grooming-related injury for men were the scrotum (378 67.2%), penis (196 34.8%), and pubis (162 28.9%); for women, the pubis (445 51.3%), inner thigh (340 44.9%), vagina (369 42.5%), and perineum (115 13.2%). After adjustment for age, duration of grooming, hairiness, instrument used, and grooming frequency, men who removed all their pubic hair 11 times or more during their lifespan had an increased risk for grooming injury (adjusted odds ratio AOR, 1.97; 95% CI, 1.28-3.01; P = .002) and were prone to repeated high-frequency injuries (AOR, 3.89; 95% CI, 2.01-7.52; P < .001) compared with groomers who did not remove all their pubic hair. Women who removed all their pubic hair 11 times or more had increased odds of injury (AOR, 2.21; 95% CI, 1.53-3.19; P < .001) and high-frequency injuries (AOR, 2.98; 95% CI, 1.78-5.01; P < .001) compared with groomers who do not remove all their pubic hair. In women, waxing decreased the odds of high-frequency injuries (AOR, 0.11; 95% CI, 0.03-0.43; P = .001) compared with nonelectric blades. In total, 79 injuries among 5674 groomers (1.4%) required medical attention.
Grooming frequency and degree of grooming (ie, removing all pubic hair) are independent risk factors for injury. The present data may help identify injury-prone groomers and lead to safer grooming practices.
Cryoablation is an acceptable treatment option for small renal cortical neoplasms (RCN). Unlike extirpative interventions, intraoperative needle biopsy is the only pathologic data for ablated tumors. ...It is imperative that sampled tissue accurately captures pathology. We studied the optimal intraoperative needle core biopsy protocol for small RCN during laparoscopic renal cryoablation (LCA).
Patients with RCN<4cm underwent intraoperative biopsy during LCA. Four biopsy cores were taken per tumor, 2 before and 2 after LCA by using both a standard and modified technique. Standard technique: needle biopsy device was deployed after insertion into the renal tissue at a depth of 5mm. Modified technique: needle biopsy device was deployed 1mm outside of the renal tissue. Biopsies were examined and compared with reference standard pathology. Percentage agreement was calculated across biopsy types (standard vs. modified) and time points (pre- vs. postcryoablation). Logistic regression was used to identify factors impacting biopsy accuracy.
Thirty patients with 33 RCNs underwent LCA. The mean patient age was 69.1±8.0yrs, and mean tumor size was 2.3±0.7cm. No significant bleeding resulted from biopsies. A definitive diagnosis was made in 31/33 RCNs (94.0%). Ten tumors (30.3%) were benign, 21 (63.7%) were malignant, and 2 (6.0%) were nondiagnostic. Biopsy length was significantly longer using the standard vs. modified technique with mean lengths of 9.3mm vs. 7.0mm, respectively (P=.02). Highest agreement was seen in preablation biopsies (90.3%). A significant association with agreement was seen for younger age (P=.05) and larger tumor size (P=.02).
Younger age and larger tumor size were associated with improved accuracy. Preoperative sampling resulted in superior accuracy and the standard technique resulted in significantly longer cores. Use of preablation standard biopsy technique may result in the most accurate pathologic diagnosis for patients undergoing cryoablation for small RCNs.
Focal cryoablation targets unilateral disease, sparing healthy tissue and the ipsilateral neurovascular bundle. Given half the prostate is spared, proper patient selection is imperative to optimize ...outcomes. We report focal cryotherapy outcome data and evaluate the accuracy of the 2007 Task Force patient selection criteria at predicting disease recurrence.
This is a retrospective patient chart review from a single academic institution. Inclusion criterion is having unilateral prostate cancer treated with primary hemicryoablation. Patients were stratified using the Task Force selection criteria. Exclusion criterion is having had past radiation or hormone therapy. Progression-free survival was calculated using follow-up TRUS biopsy (biopsy done with transrectal ultrasound) and serial prostate-specific antigen (PSA) results (Phoenix criteria). Kaplan-Meier curves were constructed and Cox regression analyses performed, comparing outcomes across patient selection cohorts.
From 2002 to 2009, 77 men underwent primary focal cryosurgery: mean age, 69.5 (SD, 6.7) years; median follow-up time, 24 months (range, 0-87 months); mean precryosurgical PSA, 6.5 (SD, 4.9) ng/mL; median Gleason score, 6 (range, 5-8). There were 44, 31, and 2 men who had D'Amico low-, intermediate-, and high-risk disease, respectively. Seventeen men met Focal Task Force Selection Criteria. After treatment, 22 patients underwent prostate biopsy for suspicion of recurrent disease. Of the 22 patients, 10 (45.5%) had confirmed prostate cancer. Of the 10 patients, 2 had ipsilateral disease, 7 had contralateral disease, and 1 had bilateral disease. Overall biochemical and pathological progression-free survival rates were 72.7% and 87%. The cumulative incidence of biochemical disease progression, using the Kaplan-Meier method, was greater than 75% at 3 years for men with more than 2 positive preoperative biopsy cores and greater than 50% at 5 years for men with 2 or less positive preoperative biopsy cores. No survival differences were seen across cohorts. Pretreatment PSA level, pretreatment Gleason score, number positive cores, and total tumor length were associated with disease progression.
Focal cryotherapy is a promising option for carefully selected patients, although optimization of inclusion criteria is required. Current selection criteria are associated with cancer-free survival. Given no accurate definitions for biochemical failure after focal cryotherapy exist combined with our high biochemical failure rate, mandating 12-month follow-up TRUS biopsy may improve accurate detection of cancer progression. Further follow up will determine optimal patient selection criteria and follow-up protocols for patients undergoing primary focal unilateral nerve-sparing prostate cancer treatment.
Percutaneous nephrolithotomy (PCNL) remains an effective treatment for large stones. When nephrostomy tube (NT) is left post operation, antegrade urine flow is often confirmed with antegrade ...nephrostography (ANG) before tube removal. We compare methylene blue (MB) test combined with NT capping trial against ANG to assess antegrade urine flow after PCNL.
One hundred one consecutive patients undergoing PCNL were prospectively enrolled between 7/2014 and 4/2015. An NT cap was placed the morning of postoperative day 1 (POD1). Failure was defined as need to uncap the NT for any reason. Two hours after capping, 7cc MB was injected into the NT. Positive MB test was defined as presence of blue per bladder Foley. ANG was then performed to assess antegrade urine flow. NTs were removed before discharge home when antegrade flow was documented. Primary outcomes included presence of antegrade flow on ANG and NT removal before discharge home. Receiver operating characteristic (ROC) and areas (Area under the ROC AUC), as well as Cohen's kappa coefficient (κ), were calculated comparing agreement of capping trial, MB, and ANG with NT removal.
One hundred one subjects were included in this analysis. 52.9% were left-sided surgeries and 60.4% utilized lower pole punctures. On ROC areas evaluating tests for agreement with NT removal before discharge, MB AUC 0.71 (95% CI 0.60-0.83), capping trial AUC 0.66 (95% CI 0.57-0.75), combed capping trial and MB AUC 0.72 (95% CI 0.61-0.84), and ANG AUC 0.78 (95% CI 0.68-0.88). In predicting NT removal, ANG performed better than capping trial alone (p = 0.042), but no differences were seen between MB and ANG (p = 0.229), combining the capping trial with MB test and ANG (p = 0.266) or combined testing and MB alone (p = 0.972).
Combining capping trial with MB injection is similarly accurate for predicting NT removal after PCNL compared to ANG. Capping trial and MB may be used in combination to obviate the need for ANG.
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