The relationship of depression, alcohol and marijuana with treatment for LUTS/BPH.

INTRODUCTION: Despite widespread usage, research on the relationship of marijuana use to disease is sorely lacking. We sought to test the relationship of LUTS/BPH treatment and endocannabinoid agonist usage, as well as alcohol usage and depression, with treatment for LUTS/BPH in our health system. MATERIALS AND METHODS: We queried our hospital system database of nearly three million patients in a marijuana-legalized region for data from the electronic medical record between January 2011 and October 2018. Men over the age of 45 on medical therapy for LUTS (selective alpha blockade and/or finasteride) were included. Exclusions were diagnosis of bladder or prostate malignancy and men with only one visit. Alcohol and marijuana (MJ) use were found from diagnosis code and/or social history text. Medical diagnoses were based on ICD-9/10 codes. Multiple logistic regression was used to control for confounders. We considered all men over the age of 45 who had any of these features: depression, obesity or metabolic syndrome (MetS), hypertension (HTN), erectile dysfunction (ED), hypogonadism, diabetes (DM) and calculated the odds ratio of also receiving medical therapy for LUTS. Univariable and multivariable analyses were employed, multiple logistic regression was used to control for confounders. RESULTS: A total of 173,469 patients were identified meeting criteria with 20,548 (11.9%) on medical treatment for LUTS. After adjusting for confounding variables, MJ and depression remained associated with an increased risk of LUTS medication, within the context of verifying previously established relationships of ED, Obesity/MetS, DM, HTN and hypogonadism. CONCLUSIONS: Men with depression and MJ usage were more likely to be treated for LUTS/BPH in our system. Better understanding of the causality of this relationship and potential interaction of LUTS/BPH with the endocannabinoid system is desirable.

Marijuana, Alcohol, and ED: Correlations with LUTS/BPH.

PURPOSE OF REVIEW: Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is a disease complex with enormous societal burden and yet the pathogenesis of LUTS/BPH is poorly understood. We set out to review the literature on the relationship between depression, marijuana usage, and erectile dysfunction (ED) to LUTS/BPH. RECENT FINDINGS: LUTS/BPH has independent associations with depression as well as with ED. In each case, the causality and mechanistic relationship is unknown. The impact of marijuana, as it increasingly pervades the general population, on the disease complex of LUTS/BPH is not well studied but recent results support short-term benefit and long-term caution. Depression, a form of central nervous dysfunction, and ED, which is likely mediated via endothelial dysfunction, are independently associated with LUTS/BPH. The presence of cannabinoid receptors in urologic organs, coupled with recent population studies, supports a modulatory effect of marijuana on voiding although an enormous knowledge gap remains.

Solitary brain metastasis after recurrent adenocarcinoma of the prostate.

Prostate cancer is rarely metastatic to visceral organs, and even less commonly to the brain. Recent data suggests brain metastasis from prostatic adenocarcinoma occur in 0.16% of patients, and almost universally in the setting of very high-volume disease. We present a man with an abruptly symptomatic brain lesion that developed at a PSA value of 1.5 ng/mL with no other known metastatic disease and required emergent neurosurgical resection. The patient had been initially treated with radiotherapy for Grade Group 4 prostate cancer in 2005 with a long period of PSA suppression.

Novel Prostate Biopsy Technique Using Imaging Fusion in a Patient With Absent Rectum.

INTRODUCTION: A 70-year-old male with prior total colectomy for ulcerative colitis was referred for elevated prostate specific antigen (PSA) (8.01) with PIRADS 4 lesion on magnetic resonance imaging (MRI). Described is a novel technique using pre-operative multi-parametric prostate MRI and intraoperative computed tomography (CT) 3D/3D fusion for systematic and targeted prostate biopsy in a patient lacking a rectum. TECHNICAL CONSIDERATIONS: Under general anesthesia, an ultra-low-dose (ULD) cone beam CT was performed in supine position using a robotic-armed fluoroscopy system (Artis Zeego Care+Clear, Siemens). 3D/3D auto-registration of the femoral heads and prostate from the MRI and ULD CT was performed. The prostate edges and two areas of concern were marked. Then, reduced-dose fluoroscopy-guided prostate biopsy was performed transperineally using triangulation technique. 27 prostate biopsy cores were obtained. Grade group 5 (Gleason 4+5=9) prostate cancer was identified in two cores from the targeted lesion and one core from the prostate base. The remaining twenty-four biopsies were negative for malignancy. Surgical time was 81 minutes. PSMA scan demonstrated no metastasis or lymphadenopathy. Robotic-assisted laparoscopic radical prostatectomy was performed without complications. Final pathology demonstrated T3a, grade group 5 prostate adenocarcinoma involving 10% of the prostate volume with negative surgical margins. CONCLUSION: This is the initial report of fluoroscopy-guided prostate biopsy using imaging fusion techniques in a patient without a rectum. This technique allowed precise identification of localized, very high-risk prostate cancer with over three times the number of cores, and much lower radiation dose, than typical CT-guided biopsies. Our technique could provide a new paradigm in targeted prostate biopsy.

Use of Peripheral Intravenous Access in Patients Undergoing Chemotherapy for Testicular Cancer.

PURPOSE: Systemic chemotherapy, depending on the regimen, can be administered through peripheral intravenous (pIV) access or through central venous access devices (CVADs). There is no current best practice regarding optimal access for chemotherapy for patients with testicular cancer (TC). We retrospectively evaluated patients undergoing systemic chemotherapy for TC and compared baseline characteristics and complications of patients using pIV versus CVADs. METHODS: We included patients with TC who underwent first-line systemic chemotherapy at the University of Colorado Hospitals from 2005 to 2020. Data were collected on demographics, cancer characteristics, type, duration of chemotherapy, pIV or CVAD use, and associated complication rates. We then performed univariate and multivariate regression analyses to compare complication rates and risk factors for each group. RESULTS: One hundred fifty-four patients met inclusion criteria. Ninety-two (60%) patients used CVADs, and 62 patients (40%) used pIV for their initial treatment. Only six (9.7%) of 62 patients transitioned from pIV to CVADs during therapy. Similarly, 10 of 92 (10.9%) patients with initial CVAD needed to transition to a different type of CVAD or to pIV (P = .81). There were a greater number of venous access-related complications (48 of 92 patients, 52.2%) and overall thrombotic events (33 of 92 patients, 35.9%) for the CVAD group (P > .001) when compared with the pIV group. We observed an association between the following factors and venous access-related complications during chemotherapy: higher stage TC, increased total chemotherapy cycles, and delayed therapy. CONCLUSION: Peripheral IV use for first-line nonvesicant chemotherapy in patients with TC appears to be well tolerated with high rates of therapy completion and lower rates of complications when compared with CVADs. These data support our preferred treatment approach and provide evidence that pIV access is a safe and effective way to deliver chemotherapy for patients with TC.

Randomized controlled trial of NSAID prior to cystoscopic ureteral stent removal in a pediatric population.

INTRODUCTION: Ureteral spasm, common with ureteral stents, is partially mediated by prostaglandins and may be suppressed by cyclooxygenase inhibitors like non-steroidal anti-inflammatory (NSAIDs). Practices currently vary widely for pain management in patients with ureteral stents, sometimes including opioids. OBJECTIVE: We aimed to determine if NSAID given prior to stent removal would reduce postoperative pain. We hypothesized there would be at least a 75% reduction in postoperative severe pain (pain score ≥7) in patients receiving ibuprofen compared to placebo. STUDY DESIGN: We performed a double-blind, placebo-controlled randomized controlled trial on pediatric urology patients with an indwelling ureteral stent undergoing removal in the operating room from 2014 to 2019. 20 patients in each arm were needed to achieve 80% power to detect a 75% reduction in the estimated 55% incidence of severe postoperative pain (α = 0.05). Patients ≥4 years old who had a unilateral stent placed after treatment of urolithiasis or ureteropelvic junction obstruction were randomized to NSAID or placebo in a 1:1 ratio at least 15 min prior to scheduled stent removal. Patients estimated pain using Faces Pain Scale-Revised (FPS-R) or visual analogue scale (VAS) prior to and 24 h after stent removal. RESULTS: 254 patients undergoing stent removal were assessed for eligibility, and 44 randomized patients were analyzed using intention to treat analysis. The cohorts were demographically similar and received similar anesthesia treatment. There was no significant difference in maximum post anesthesia care unit pain score (p = 0.269) or use of in-hospital opioids (p = 0.626) between the two groups. No difference was seen in the incidence of severe postoperative pain (p = 1.0), thus rejecting the hypothesis. Significant worsened postoperative pain (pain score increases of ≥2 between time points) decreased from 22.7% to 13.6% between placebo and NSAID, but this did not reach significance (p = 0.410). DISCUSSION: There was no difference in postoperative pain for patients undergoing ureteral stent removal given preoperative NSAID versus placebo. The incidence of severe pain before and after stent removal was low, ranging from 4.5 to 9.1%. CONCLUSION: Research to understand the etiology of pain after stent removal and techniques to minimize or prevent discomfort should continue in order to optimize patient outcomes.

Metastatic renal cell carcinoma to the prostate and seminal vesicle.

Renal cell carcinoma (RCC) a common malignancy with potential to metastasize to visceral organs. However, it uncommonly spreads to the lower genitourinary tract. We present a man with a history of RCC status post radical nephrectomy in April 2012. He presented 8 years later with obstructive lower urinary tract symptoms and an elevated prostate specific antigen (PSA). Further imaging showed a large enhancing mass with internal blood vessels posterior to the left prostate and seminal vesicle. A prostate biopsy was performed and consistent with metastatic RCC. He was ultimately treated with immunotherapy and focal stereotactic radioablation.

Systematic Review of Preoperative Risk Discussion in Practice.

BACKGROUND: Informed consent is an ethical imperative of surgical practice. This requires effective communication of procedural risks to patients and is learned during residency. No systematic review has yet examined current risk disclosure. This systematic review aims to use existing published information to assess preoperative provision of risk information by surgeons. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a guide, a standardized search in Ovid MEDLINE, Embase, CINHAL, and PubMed was performed. Three reviewers performed the study screening, with 2-reviewer consensus required at each stage. Studies containing objective information concerning preoperative risk provision in adult surgical patients were selected for inclusion. Studies exclusively addressing interventions for pediatric patients or trauma were excluded, as were studies addressing risks of anesthesia. RESULTS: The initial search returned 12,988 papers after deduplication, 33 of which met inclusion criteria. These studies primarily evaluated consent through surveys of providers, record reviews and consent recordings. The most ubiquitous finding of all study types was high levels of intra-surgeon variation in what risk information is provided to patients preoperatively. Studies recording consents found the lowest rates of risk disclosure. Studies using multiple forms of investigation corroborated this, finding disparity between verbally provided information vs chart documentation. CONCLUSIONS: The wide variance in what information is provided to patients preoperatively inhibits the realization of the ethical and practical components of informed consent. The findings of this review indicate that significant opportunities exist for practice improvement. Future development of surgical communication tools and techniques should emphasize standardizing what risks are shared with patients.

Use of Surgical Risk Preoperative Assessment System (SURPAS) and Patient Satisfaction During Informed Consent for Surgery.

BACKGROUND: The objective of this study was to determine the effects of using the Surgical Risk Preoperative Assessment System (SURPAS) on patient satisfaction and surgeon efficiency in the surgical informed consent process, as compared to surgeons' "usual" consent process. STUDY DESIGN: Patient perception of the consent process was assessed via survey in 2 cohorts: 10 surgeons in different specialties used their "usual" consent process for 10 patients; these surgeons were then taught to use SURPAS, and they used it during the informed consent process of 10 additional patients. The data were compared using Fisher's exact test and the Cochran-Mantel-Haenszel test. RESULTS: One hundred patients underwent the "usual" consent process (USUAL), and 93 underwent SURPAS-guided consent (SURPAS). Eighty-two percent of SURPAS were "very satisfied" and 18% were "satisfied" with risk discussion vs 16% and 72% of USUAL, respectively. Of those who used SURPAS, 75.3% reported the risk discussion made them "more comfortable" with surgery vs 19% of USUAL, and 90.3% of SURPAS users reported "somewhat" or "greatly decreased" anxiety vs 20% of USUAL. All p values were <0.0001. Among SURPAS patients, 97.9% reported "enough time spent discussing risks" vs 72.0% of USUAL patients. CONCLUSIONS: The SURPAS tool improved the informed consent process for patients compared with the "usual" consent process, in terms of patient satisfaction, ie making patients feel more comfortable and less anxious about their impending operations. Providers should consider integrating the SURPAS tool into their preoperative consent process.

ABO Genotype and Blood Type Are Associated with Otitis Media.

Aim: To determine if there is an association between ABO variants or blood types and otitis media. Methods: DNA samples from 214 probands from Finnish families with recurrent acute (RAOM) and/or chronic otitis media with effusion (COME) were submitted for exome sequencing. Fisher exact tests were performed when (a) comparing frequencies of ABO genotypes in the Finnish probands with otitis media vs. counts in gnomAD Finnish, and (b) within the Finnish family cohort, comparing occurrence of RAOM vs. COME according to ABO genotype/haplotype and predicted blood type. Results: Female sex is protective against having both RAOM and COME. The wildtype genotype for the ABO c.260insG (p.Val87_Thr88fs*) variant resulting in blood type O was protective against RAOM. On the other hand, type A was associated with increased risk for COME. These findings remained significant after adjustment for age and sex. Conclusions: Within the Finnish family cohort, the wildtype genotype for the ABO c.260insG (p.Val87_Thr88fs*) variant and type O are protective against RAOM while type A increases risk for COME. This suggests that the association between the ABO locus and otitis media is specific to blood type, otitis media type and cohort.