Endoscopic treatments prior to urethroplasty: trends in management of urethral stricture disease.

BACKGROUND: To determine if the number of endoscopic treatments of urethral stricture disease (USD) prior to urethroplasty has changed in the context of new AUA guidelines on management of USD. In addition to an increase in practicing reconstructive urologists and published reconstructive literature, the AUA guidelines regarding the management of male USD were presented in May 2016, advocating consideration of urethroplasty in patients with 1 prior failed endoscopic treatment. METHODS: A retrospective review of a prospectively maintained, multi-institutional urethral stricture database of high volume, geographically diverse institutions was performed from 2006 to 2017. We performed a review of relevant literature and evaluated pre-urethroplasty endoscopic treatment patterns prior to and after the AUA male stricture guideline. RESULTS: 2964 urethroplasties were reviewed in 10 institutions. There was both a decrease in the number of endoscopic treatments prior to urethroplasty in the pre-May 2016 compared to post-May 2016 cohorts both for overall urethroplasties (2.3 vs 1.6, P = 0.0012) and a gradual decrease in the number of pre-urethroplasty endoscopic treatments over the entire study period. CONCLUSION: There was a decrease in the number of endoscopic treatments of USD prior to urethroplasty in the observed period of interest. Declining endoscopic USD management is not likely to be a reflection of a solely unique influence of the guidelines as endoscopic treatment decreased over the entire study period. Further research is needed to determine if there will be a continued trend in the declining use of endoscopic treatment and elucidate the barriers to earlier urethroplasty in patients with USD.

A Review of Urologic Conditions in Remote and Austere Environments: Presentation, Evaluation, and Management.

The objective of this review is to provide recommendations on the evaluation and management of urologic conditions in a resource-poor or austere setting from the perspective of the urological literature. The material was synthesized predominantly from urologic society guidelines and journals to bring additional urology-focused insight to the topic to complement the currently available literature, which is largely based on recommendations from nonurologic specialties. We sought to provide a reference guide from a urology-based framework that encourages a collaborative multidisciplinary approach to the development of a resource that serves those in a wilderness, austere, or resource-poor setting.

The social and environmental context of cross-border drug use in Mexico: findings from a mixed methods study of young injection drug users living in San Diego, CA.

The authors report the results of qualitative (n = 19) and quantitative (n = 545) interviews with young injection drug users (IDUs) in San Diego, California about their experiences using drugs in Tijuana, Mexico, and associated risks for HIV infection. Young IDUs who have ever traveled to Mexico (n = 365) used a variety of injection (54%) and noninjection (30%) drugs there and appear to be heavier users than those who have never traveled to Mexico. Sociocultural themes influencing drug use in Mexico included interactions among the purpose of travel, drug preference, and route of administration; familiarity with the border region; evolving relationships with the United States and Mexican drug markets; and the experience of crossing the U.S.-Mexico border. Interventions for IDUs in border regions need to be sensitive to the ethnicity, familiarity with the border region, and life history of participants, as well as differences in national policies that could influence drug use and risk for HIV on both sides of the border.

Importance of animal/human health interface in potential Public Health Emergencies of International Concern in the Americas.

This study analyzed the importance of zoonoses and communicable diseases common to man and animals as potential Public Health Emergencies of International Concern to build an evidence base for future efforts to reduce risk of infection at the animal/human health interface. The events recorded in the World Health Organization (WHO) Event Management System (EMS) database for the Americas during the 18 months since the implementation of the 2005 revised version of WHO's International Health Regulations (15 June 2007-31 December 2008) were the main source for this analysis. Of the 110 events recorded by the EMS for the Americas during the study period, 86 were classified as communicable diseases-77 (70.0%) "within the animal/human health interface," 9 (8.2%) "not common to man and animals," 16 (14.5%) "syndromes with unknown etiologies," and 8 (7.3%) "product-related/ other." Of the 77 events within the animal/human health interface, 48 were "substantiated" (the presence of hazard was confirmed and/or human cases occurred clearly in excess of normal expectancy). These results confirm previous research and underscore the importance of the animal/human health interface as well as inter-sectoral collaboration.

Bilateral testes fractures from blunt scrotal trauma.

Management of blunt scrotal trauma is classically centered upon evaluation of potential testicular ruptures to that expedient surgical intervention can be employed. We present a unique case of blunt scrotal trauma causing bilateral testes rupture in order to illustrate the rationale for societal guidelines. We additionally offer discussion of potential sequelae of afflicted patients and a sparingly used technique to salvage a severely injured testis.

Symptomatic Ureteral Metastasis from Colon Adenocarcinoma.

Background: Symptomatic ureteral obstruction from a nonurologic metachronous metastatic malignancy is an unusual phenomenon that is underreported in the literature. This potential etiology for ureteral obstruction warrants consideration by the practicing urologist during a comprehensive evaluation as it may alter prognosis and management options for the afflicted patient. Case Presentation: An 80-year-old Caucasian man with a remote history of prostate cancer and colon cancer presented with new unilateral ureteral obstruction characterized by hydronephrosis, acute kidney injury, and right-sided abdominal pain. A high clinical index of suspicion ultimately leads to the diagnosis of metastatic colon cancer on ureteral biopsy specimen. Conclusion: Evaluation of symptomatic ureteral obstruction in a patient with a significant cancer history should include nonurologic malignant obstruction. Diligence in evaluation of the etiology of the ureteral stricture with repeat biopsies should be undertaken if there is clinical concern. Nephroureterectomy should be part of patient counseling for management of long segment malignant ureteral stricture disease.

A Novel Technique of Ureteral Stricture Measurement: Impact on Diagnosis and Subsequent Management.

Background: Appropriate surgical management of ureteral strictures is dependent on not only the etiology of the stricture but also its location and characteristics. Stricture length and location play a significant role in potential surgical options, yet accurate evaluation of these features is limited. We present a case of a complex ureteral stricture where employment of an endoscopic tool in a novel manner helped to better evaluate the patient and provide more precise counseling in the preoperative setting. Case Presentation: A 65-year-old Caucasian man with a history of nephrolithiasis developed a complex ureteral stricture secondary to his calculus disease and prior instrumentation. His stricture was causing obstruction of his left collecting system and the patient was interested in a reconstructive procedure. We present a novel use for a pre-existing endoscopic tool that helped to more accurately delineate the characteristics of his ureteral stricture and improved preoperative planning. Conclusion: Determination of precise stricture length and location is of utmost importance for preoperative patient counseling and surgical planning. Where more sophisticated calibration technology is not available, use of an angiographic catheter during diagnostic endoscopy can improve preoperative assessment and surgical planning for complex ureteral reconstructive procedures.

MicroRNA profile in stage I clear cell renal cell carcinoma predicts progression to metastatic disease.

OBJECTIVE: This study sought to identify microRNA (miRNA) profiles of small, pathologically confirmed stage 1 clear cell renal cell carcinoma (ccRCC) tumors that are associated with progression to metachronous metastatic disease. MATERIALS AND METHODS: Fifty-five pathologic stage 1 ccRCC tumors ≤5cm, from 2 institutions, were examined in a miRNA screening, followed by a validation study. For the screening phase 752 miRNA were evaluated on each sample to identify those with differential expression between tumors that subsequently did (n = 10) or did not (n = 10) progress to metastatic disease. For the validation, 35 additional samples (20 nonprogressors and 15 with distant progression) were utilized to investigate 20 miRNA to determine if a miRNA panel could differentiate aggressive tumors: associations of miRNA expression with cancer specific survival was also investigated. RESULTS: In the screening analysis, 35 miRNA were differentially expressed (P < 0.05, FDR < 0.1) between the groups. In the validation, 11 miRNA were confirmed to have differential expression. The miRNA -10a-5p, -23b-3p, and -26a-5p differentiated nonprogressive and distant progressive disease with a sensitivity of 73.3% and a specificity of 85% (AUC=0.893). In addition, levels of miR-30a-3p and -145-5p were identified as independent prognostic factors of cancer specific survival. CONCLUSIONS: This investigation identified miRNA biomarkers that may differentiate between non-progressive ccRCC tumors and those that progress to metastatic disease in this group of stage I tumors. The miRNA profiles determined in this study have the potential to identify patients with small renal masses who are likely to have progressive ccRCC. Such information may be valuable to incorporate into predictive models.

An Analysis of Staging and Treatment Trends for Upper Tract Urothelial Carcinoma in the National Cancer Database.

BACKGROUND: The purpose of this study was to analyze contemporary trends for diagnosis and treatment of upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS: We identified all cases of UTUC in the National Cancer Database (NCDB) between 2004 and 2013. Data comprising tumor, patient, and facility factors were extracted. Treatment data for surgery and chemotherapy were also collected. Comparisons used χ2 testing. RESULTS: Over this 10-year period, the sex and age distribution of UTUC was stable at 60% male and median age of 72 years. Most tumors were < cT2 at diagnosis, with an upward trend over 10 years (66% to 72%; P < .001). However, presentation with clinical metastatic disease also rose, from 4.6% to 8.9% (P < .001). Primary tumor biopsy increased from 37% to 50%. Overall rate of nephroureterectomy decreased from 59.6% to 56.7% whereas endoscopic ablation increased from 9.8% to 11.5%. Ablation was much more common in < cT2 tumors than ≥ cT2 (18.3% vs. 3.7%) and for low-grade tumors than high-grade (22.6% vs. 5.9%). Neoadjuvant chemotherapy was significantly more used, but still at a low rate. CONCLUSION: Treatment of UTUC appears to be shifting toward conservative surgical management with tumor ablation, and increasing neoadjuvant chemotherapy use. More primary tumor biopsies are being performed, likely reflecting improved ureteroscopic instruments and training. The NCDB also reports an increase in metastatic disease, which must be interpreted cautiously and might be artifactual.

Importance of animal/human health interface in potential Public Health Emergencies of International Concern in the Americas / Importancia de la interfaz entre la salud humana y la sanidad animal en las posibles emergencias de salud pública de importancia internacional en la Región de las Américas

This study analyzed the importance of zoonoses and communicable diseases common to man and animals as potential Public Health Emergencies of International Concern to build an evidence base for future efforts to reduce risk of infection at the animal/human health interface. The events recorded in the World Health Organization (WHO) Event Management System (EMS) database for the Americas during the 18 months since the implementation of the 2005 revised version of WHO's International Health Regulations (15 June 2007-31 December 2008) were the main source for this analysis. Of the 110 events recorded by the EMS for the Americas during the study period, 86 were classified as communicable diseases-77 (70.0 percent) "within the animal/human health interface," 9 (8.2 percent) "not common to man and animals," 16 (14.5 percent) "syndromes with unknown etiologies," and 8 (7.3 percent) "product-related/ other." Of the 77 events within the animal/human health interface, 48 were "substantiated" (the presence of hazard was confirmed and/or human cases occurred clearly in excess of normal expectancy). These results confirm previous research and underscore the importance of the animal/human health interface as well as inter-sectoral collaboration.

En este estudio se analizó la importancia de las zoonosis y las enfermedades transmisibles comunes a los seres humanos y los animales como posibles emergencias de salud pública de importancia internacional, a fin de sentar una base científica para las actividades futuras destinadas a reducir el riesgo de infección en la interfaz entre animales y seres humanos. La fuente principal para este análisis fueron los eventos registrados en la base de datos del Sistema de Gestión de Eventos de la Organización Mundial de la Salud (OMS) para las Américas durante los 18 meses que transcurrieron (15 de junio del 2007 al 31 de diciembre del 2008) desde la puesta en marcha del Reglamento Sanitario Internacional de la OMS (versión revisada en el 2005). De los 110 eventos registrados por el Sistema de Gestión de Eventos para las Américas durante el período de estudio, 86 se clasificaron como enfermedades transmisibles -77 (70,0 por ciento) como "dentro de la interfaz entre animales y seres humanos" y 9 (8,2 por ciento) como "no comunes a seres humanos y animales"-, 16 (14,5 por ciento) como "síndromes de etiología desconocida", y 8 (7,3 por ciento) como "relacionados con productos/otros". De los 77 eventos comprendidos dentro de la interfaz entre animales y seres humanos, se fundamentaron 48 (se confirmó la presencia del riesgo u ocurrieron casos en seres humanos que claramente superaron los casos esperados). Estos resultados confirman las investigaciones anteriores y destacan la importancia de la interfaz entre la salud humana y la sanidad animal, así como la importancia de la colaboración intersectorial.