Epididymal Sparing Bilateral Simple Orchiectomy: Cost-Effectiveness and Aesthetic Preservation for Men with Metastatic Prostate Cancer.

INTRODUCTION: In the last 2 decades medical androgen deprivation therapy has replaced surgical castration for the treatment of metastatic prostate cancer. We assessed costs and patient satisfaction associated with epididymal sparing bilateral simple orchiectomy in an underinsured, immigrant population. METHODS: We performed epididymal sparing bilateral simple orchiectomy in patients with metastatic prostate cancer between January 2003 and September 2014 at our institution. Procedures were performed in the operating room with the patient under general anesthesia and later under conscious sedation. Associated material and facility costs were calculated and compared to costs of androgen deprivation therapy with leuprolide or degarelix. Medication costs were calculated using wholesale acquisition costs. Patient satisfaction and body image perception were evaluated using a survey questionnaire. RESULTS: A total of 108 orchiectomies were performed in the operating room and 12 in the outpatient unit. The total cost of bilateral simple orchiectomy in the operating room was $4,118. By performing orchiectomy in the outpatient unit we reduced the cost to $2,101. The cost of orchiectomy in the operating room is the equivalent of 4 months of leuprolide and 7.8 months of degarelix. When performed in the outpatient clinic the cost of bilateral simple orchiectomy is equivalent to 2.1 months of leuprolide and 4 months of degarelix. Overall 95% of participants surveyed were pleased with the surgical results. CONCLUSIONS: The average life expectancy of men with metastatic prostate cancer is 30 months and, thus, a onetime surgical cost offers significant cost savings. Further cost reductions are achieved by performing bilateral simple orchiectomy in the outpatient setting. By sparing the epididymis, patients are left with a sense of testicular preservation. Epididymal sparing bilateral simple orchiectomy is a cost-effective and cosmetically acceptable method of androgen deprivation therapy for patients with metastatic prostate cancer.

Biochemical Measures of Diabetes are Not Independent Predictors of Urinary Incontinence in Women.

PURPOSE: Diabetes mellitus type II is considered an important risk factor for urinary incontinence. We investigated associations among biochemical measures of diabetes with stress and urgency urinary incontinence in a nationally representative sample of American women. MATERIALS AND METHODS: We performed a cross-sectional analysis of female adult participants in the 2001 to 2010 NHANES (National Health and Nutrition Examination Survey). Urinary incontinence was ascertained by self-report. Diabetes was defined by calculated measures of glycemic control and insulin resistance. Glycemic control was classified by HbA1c and fasting plasma glucose. Insulin resistance was estimated by fasting plasma insulin and the homeostasis model assessment of insulin resistance definition. Logistic regression models adjusted for sociodemographic variables and risk factors were fitted for each measure of diabetes mellitus type II severity, and stress and urgency urinary incontinence. Stepwise multivariable logistic regression models were developed to characterize independent risk factors for these conditions. RESULTS: Compared to women with normal HbA1c participants with diabetes mellitus type II had an increased prevalence of stress and urge urinary incontinence (38.6% vs 52.5% and 21.7% vs 40.3%, respectively, each p<0.001). Diabetes measures were each significantly associated with urinary incontinence in unadjusted models. However, they were not independently associated with stress or urge urinary incontinence in multivariable models when adjusted for patient body mass index. CONCLUSIONS: Despite an increased prevalence of stress and urge urinary incontinence among women with diabetes, measures of diabetes mellitus type II are not independently associated with female incontinence. Rather, body mass index and several other characteristics are the dominant risk factors for stress or urge urinary incontinence.

Diabetic severity and risk of kidney stone disease.

BACKGROUND: The prevalence of kidney stone disease is rising along with increasing rates of obesity, type 2 diabetes mellitus (T2DM), and metabolic syndrome. OBJECTIVE: To investigate the associations among the presence and severity of T2DM, glycemic control, and insulin resistance with kidney stone disease. DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional analysis of all adult participants in the 2007-2010 National Health and Nutrition Examination Survey (NHANES). A history of kidney stone disease was obtained by self-report. T2DM was defined by self-reported history, T2DM-related medication usage, and reported diabetic comorbidity. Insulin resistance was estimated using fasting plasma insulin (FPI) levels and the homeostasis model assessment of insulin resistance (HOMA-IR) definition. We classified glycemic control using glycosylated hemoglobin A1c (HbA1c) and fasting plasma-glucose levels (FPG). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Odds ratios (OR) for having kidney stone disease were calculated for each individual measure of T2DM severity. Logistic regression models were fitted adjusting for age, sex, race/ethnicity, smoking history, and the Quételet index (body mass index), as well as laboratory values and components of metabolic syndrome. RESULTS AND LIMITATIONS: Correlates of kidney stone disease included a self-reported history of T2DM (OR: 2.44; 95% confidence interval [CI], 1.84-3.25) and history of insulin use (OR: 3.31; 95% CI, 2.02-5.45). Persons with FPG levels 100-126 mg/dl and >126 mg/dl had increased odds of having kidney stone disease (OR 1.28; 95% CI, 0.95-1.72; and OR 2.29; 95% CI, 1.68-3.12, respectively). Corresponding results for persons with HbA1c 5.7-6.4% and ≥ 6.5% were OR 1.68 (95% CI, 1.17-2.42) and OR 2.82 (95% CI, 1.98-4.02), respectively. When adjusting for patient factors, a history of T2DM, the use of insulin, FPI, and HbA1c remained significantly associated with kidney stone disease. The cross-sectional design limits causal inference. CONCLUSIONS: Among persons with T2DM, more-severe disease is associated with a heightened risk of kidney stones.

Diabetes severity, metabolic syndrome, and the risk of erectile dysfunction.

INTRODUCTION: Erectile dysfunction (ED) is more common in men with type 2 diabetes mellitus (T2DM), obesity, and/or the metabolic syndrome (MetS). AIM: The aim of this study is to investigate the associations among proxy measures of diabetic severity and the presence of MetS with ED in a nationally representative U.S. data sample. METHODS: We performed a cross-sectional analysis of adult participants in the 2001-2004 National Health and Nutrition Examination Survey. MAIN OUTCOME MEASURES: ED was ascertained by self-report. T2DM severity was defined by calculated measures of glycemic control and insulin resistance (IR). IR was estimated using fasting plasma insulin (FPI) levels and the homeostasis model assessment of IR (HOMA-IR) definition. We classified glycemic control using hemoglobin-A1c (HbA1c) and fasting plasma glucose (FPG) levels. MetS was defined by the American Heart Association and National Heart, Lung, and Blood Institute criteria. Logistic regression models, adjusted for sociodemographics, risk factors, and comorbidities, were fitted for each measure of T2DM severity, MetS, and the presence of ED. RESULTS: Proxy measures of glycemic control and IR were associated with ED. Participants with FPG between 100-126 mg/dL (5.6-7 mmol/L) and ≥ 126 mg/dL (>7 mmol/L) had higher odds of ED, odds ratio (OR) 1.22 (confidence interval or CI, 0.83-1.80), and OR 2.68 (CI, 1.48-4.86), respectively. Participants with HbA1c 5.7-6.4% (38.8-46.4 mmol/mol) and ≥ 6.5% (47.5 mmol/mol) had higher odds of ED (OR 1.73 [CI, 1.08-2.76] and 3.70 [CI, 2.19-6.27], respectively). When FPI and HOMA-IR were evaluated by tertiles, there was a graded relation among participants in the top tertile. In multivariable models, a strong association remained between HbA1c and ED (OR 3.19 [CI,1.13-9.01]). MetS was associated with >2.5-fold increased odds of self reported ED (OR 2.55 [CI, 1.85-3.52]). CONCLUSIONS: Poor glycemic control, impaired insulin sensitivity, and the MetS are associated with a heightened risk of ED.

A case of genitourinary Crohn's disease.

Scrotal swelling in young boys is a common problem. The differential diagnosis includes testicular torsion, epididymoorchitis, and idiopathic scrotal edema. We report the unusual case of a 17-year-old boy who presented with recurrent episodes of penile and scrotal edema as extraintestinal manifestations of Crohn's disease. Genitourinary complications of Crohn's disease are not uncommon; however, they more typically present in the form of nephrolithiasis, obstructive uropathy, and enterovesical fistulization. Few reports have described Crohn's disease presenting with isolated genital edema in the absence of associated intestinal or systemic symptoms.

Thromboembolic complications of sling surgery for stress urinary incontinence among female Medicare beneficiaries.

OBJECTIVES: To determine the rate of thromboembolic complications after sling surgery for stress urinary incontinence among female Medicare beneficiaries aged 65 and older. METHODS: We analyzed the 1999-2001 Medicare public use files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women undergoing sling procedures from January 1, 1999 to July 31, 2000 were identified by the Physicians Current Procedural Terminology Coding System (4th edition) codes and tracked for 12 months. Diagnoses of postoperative thromboembolism were identified with International Classification of Diseases (9th revision) codes. Multivariate analysis was used to determine independent risk factors for developing a thromboembolic event. RESULTS: A total of 1356 slings were performed on patients in the 5% sample of female Medicare beneficiaries during the 18-month index period. Concomitant prolapse surgery was performed in 467 (34.4%) cases. At 3 months after surgery, thromboembolic complications had occurred in 0.9% women undergoing a sling alone and in 2.2% women undergoing concomitant prolapse surgery (P = .05). Multivariate analysis revealed that concomitant prolapse surgery was associated with nearly 3 times the odds of thromboembolic complications (odds ratio 2.86, 95% confidence interval 1.10-7.45). CONCLUSIONS: Our results show a low rate of thromboembolism after an isolated sling procedure. However, we found an increased rate of deep venous thrombosis and pulmonary embolism among women undergoing sling surgery with prolapse repair, which emphasizes the need for appropriate deep venous thrombosis prophylaxis in this patient group.

Trends in surgical management of stress urinary incontinence among female Medicare beneficiaries.

OBJECTIVES: To identify patterns in the surgical treatment of women with stress urinary incontinence in the United States from 1992 to 2001. METHODS: As a part of the Urologic Diseases in America Project, we analyzed data from a 5% national random sample of female Medicare beneficiaries aged > or =65 years. The data were obtained from the Centers for Medicare and Medicaid Services carrier and outpatient files from 1992, 1995, 1998, and 2001. Women in the sample with a diagnosis of urinary incontinence were identified using the International Classification of Diseases, 9th edition, codes. Surgical procedures were identified using the Current Procedural Terminology, 4th edition, codes. The patterns of care were then analyzed during the 10-year period. RESULTS: The overall number of surgical procedures increased from 18 820 to 32 480 during the 10-year period, likely owing to the growing population of Medicare beneficiaries. Needle suspension was the most commonly performed incontinence procedure in 1992 and 1995. Collagen injections gained rapid popularity and became the most common procedure by 1998. A drastic increase in the numbers and rates of sling placements occurred from 1995 to 2001. CONCLUSIONS: A rapid shift occurred in the surgical management of stress urinary incontinence in the 1990s. The rapid increase in the use of sling procedures corresponded with a decrease in the use of the many other available anti-incontinence procedures. As in previous years, we identified a trend toward minimally invasive approaches to surgery, without the presence of randomized controlled clinical trials to support these trends. We anticipate that the analysis of Medicare claims from 2004 onward will demonstrate an additional increase in the use of sling procedures.