Factors associated with unplanned clinical encounters for ureteral stent-related symptoms.

BACKGROUND, INTRODUCTION AND AIM: Ureteral stent-related symptoms (USRS) often result in unplanned phone calls and ER visits. We hypothesize that patient factors can be identified to predict these unplanned encounters. METHODS AND MATERIALS: Retrospective analysis of indwelling ureteral stent placements from 2014 to 2019 at a single institution by CPT code was performed. Patient demographics, discharge medications, and clinical factors were evaluated using multiple logistic regression with respect to postoperative telephone and emergency room (ER) encounters for USRS. RESULTS: Of 374 patients, 75 (20.1%) had one or more encounters for USRS: 48 (12.8%) called the clinic and 39 (10.4%) returned to the ER. Chronic opioid use was predictive of calls to clinic and ER visits (OR 3.21 [CI 1.42-6.97], p < 0.01 and OR 3.64 [CI 1.45-8.98], p < 0.01). Survival analysis stratified by history of chronic opioid use and discharge opioid prescriptions demonstrated that opioid naïve patients receiving opioids at discharge had unplanned encounters sooner and more often [Calls p = 0.025, ER p = 0.041]), whereas patients with chronic opioid use returned to the ER sooner and more frequently when prescribed additional opioids (Calls p = 0.4, ER p = 0.002). CONCLUSION: Patients with a history of chronic opioid use may experience more intense USRS or have a lower threshold to seek medical care than opioid naïve patients and tend to bypass calling the clinic for the ER. Given that none of the studied medications reduced unplanned patient contact for USRS, urologists should consider upfront definitive management of urinary obstruction when appropriate.

Prevalence of Trichomonas vaginalis Infection Among US Males, 2013-2016.

Background: Trichomoniasis results from adhesion of Trichomonas vaginalis to the mucous membrane of the urethra or vagina. It has been estimated to have a higher incidence rate than both gonorrhea and chlamydia combined. Although females can experience both clinical symptoms and obstetrical complications, male infections are largely asymptomatic and often unreported. We aim to estimate the prevalence of trichomoniasis in US males using the National Health and Nutrition Examination Survey (NHANES) database. Methods: The NHANES database was queried for all men aged 18-59 years during the years 2013-2016. During these years, the survey included urine testing for trichomoniasis using transcription-mediated amplification. Information was also obtained regarding patient demographics and other sexually transmitted infections. Results: Overall, 0.49% of men aged 18-59 years tested positive for trichomoniasis. The highest rate was seen in black men (3.6%). There was no significant association with trichomoniasis and age. Higher rates of infection were seen in smokers, those with herpes simplex virus type 2 (HSV-2) infection, men who had sex at an early age, those with less condom usage, and those with more lifetime sexual partners. Conclusion: The rates of trichomonas infection in US males are lower than in women. Infections are strongly associated with black males, HSV-2 infection, and other factors known to increase rates of sexually transmitted infection. This information may be helpful for counseling, screening, and management of patients.

Genital Wart and Human Papillomavirus Prevalence in Men in the United States From Penile Swabs: Results From National Health and Nutrition Examination Surveys.

INTRODUCTION: Human papillomavirus (HPV) is a common sexually transmitted infection in the United States that can lead to both malignant (high-risk) and benign (low-risk) findings. These low-risk findings include both genital condyloma, anal warts, and adult or juvenile papillomatosis, which are directly attributable to subtypes HPV 6 and HPV 11. We aim to estimate the prevalence of genital wart infections in men in the US population using a nationwide sample. METHODS: The NHANES database was queried for all men aged 18 to 59 years during the years 2013 to 2014. During these years, the survey included penile swabs that were tested for HPV infection from 37 subtypes using PCR. Information was also obtained regarding patient reported history of having a genital wart infection previously. RESULTS: A total of 1757 men had information regarding HPV DNA. Fifty-three men tested positive for HPV 6 or HPV 11 DNA. This corresponds to an estimated prevalence of 2.9% (95% confidence interval, 2.2-3.8) of men aged 18-59 years. In addition, 2.2% (95% confidence interval, 1.5-3.3) of men reported a history of genital wart infection. There was no significant association with genital HPV DNA detection with age. Increasing number of sexual partners was associated with higher rates of both genital warts and HPV 6 and HPV 11 DNA. CONCLUSIONS: The estimated prevalence of genital HPV DNA in the US male population is 2.9%. This burden of disease could potentially be lowered with increased usage of quadrivalent and nonavalent vaccinations.

Hereditary renal cell carcinoma: genetics, clinical features, and surgical considerations.

OBJECTIVES: Hereditary renal cancer syndromes have been described and have illuminated novel methods to treat sporadic renal cell carcinoma. In this work, we aimed to review the genetic basis, molecular pathology and clinical manifestations of hereditary syndromes, as well as outline principles of surgical management and use of targeted therapy. METHODS: We performed a comprehensive review of selected peer-reviewed publications regarding hereditary renal cancer syndromes, their genetic basis, and recommendations for surgical management. RESULTS: The major syndromes contributing to hereditary renal cell carcinoma are discussed along with relevant literature guiding their management. The evolving surgical and molecular treatments are discussed. CONCLUSIONS: Identification of genetic basis of hereditary carcinomas provides opportunity for targeted therapy of metastatic sporadic renal cell carcinoma. Appropriate and timely surgical management of hereditary renal cancers decreases the possibility of development of metastatic disease, and allows for preservation of renal function despite the need for repeat surgical interventions.

Prostate volume on computed tomography correlates well with magnetic resonance imaging measurements and is reproducible across rater training levels.

BACKGROUND: Data are lacking for the accuracy of computed tomography (CT) in measuring prostate size, which can streamline care and prevent invasive procedures. We evaluate agreement and intra/inter-observer variability in prostate sizing between CT and magnetic resonance imaging (MRI) planimetry for a wide range of gland sizes. METHODS: We retrospectively reviewed 700 patients who underwent MRI fusion biopsy at a single institution and identified 89 patients that had a CT within 2 years of the MRI. Six reviewers from different training levels were categorized as student, resident, or attending and each measured prostate size on CT by the prolate ellipse method. Bland-Altman analysis determined the degree of agreement between CT and MRI. Inter- and intra-observer reliability was calculated for CT. RESULTS: Mean CT volume was higher than MRI volume in the < 60 g group (51.5 g vs. 44.5 g, p = 0.004), but not in the ≥ 60 g group (101 g vs. 100 g, p = 0.458). The bias for overestimation of prostate volume by CT was 4.1 g across prostate volumes, but the proportional agreement between modalities improved with size. The Pearson correlation coefficient between CT/MRI and inter/intra-rater reliability for CT increased in the ≥ 60 g vs. the < 60 g group for all training levels. CONCLUSIONS: Our data show that there is greater clinical utility for prostate size estimation by CT than previously established, particularly for larger glands where accurate size estimation may influence therapeutic decisions. In larger glands, prostate size estimation by CT is also reproducible across various training levels.

Management of Localized T1c Prostate Cancer Among Men 75 Years and Older: A National Cancer Database Study.

INTRODUCTION: Elderly men are underrepresented in prostate cancer (PCa) literature, with management based on individualized care pathways and life expectancy. Reports have shown survival benefit with radiation (XRT), surgery, and hormone (ADT) in localized disease. The objective of this study was to assess treatment trends and overall survival (OS) among men 75 years of age and older with cT1c PCa. METHODS: The National Cancer Database was queried to identify patients with cT1c PCa, aged 75 years and older, between 2004 and 2016. We excluded individuals with N1/NX or M1/MX disease, unknown treatment, treatment with both XRT and surgery, surgery other than radical prostatectomy (RP), or PSA > 10 ng/ml. We described 4 treatment cohorts: observation, XRT, surgery, and ADT alone. Treatment trends and OS were analyzed using SPSS. RESULTS: Among 49,843 patients, 7% had surgery, 66% had XRT, 5% had ADT alone, and 22% were observed. From 2004-2016, a large decline in XRT was noted, with an increase in surgery and observation. Men receiving ADT alone were significantly older, with higher Gleason's score, and lower incomes. Cox regression revealed survival benefit for surgery and XRT (HR 0.44 and 0.69, P < .001 respectively); ADT had worse survival than observation (HR 1.23, P < .001). CONCLUSION: Fewer men 75 years of age and older with cT1c PCa are being diagnosed and treated. Rates of XRT have declined, with rises in surgery and observation. Survival benefit was seen for surgery and XRT among elderly men, which highlights the importance of proper patient selection for improved outcomes in a highly individualized sphere.

Valproic acid decreases urothelial cancer cell proliferation and induces thrombospondin-1 expression.

BACKGROUND: Prevention of bladder cancer recurrence is a central challenge in the management of this highly prevalent disease. The histone deacetylase inhibitor valproic acid (sodium valproate) has anti-angiogenic properties and has been shown to decrease bladder cancer growth in model systems. We have previously shown reduced expression of thrombospondin-1 in a mouse model and in human bladder cancer relative to normal urothelium. We speculated that inhibition of angiogenesis by valproate might be mediated by this anti-angiogenic protein. METHODS: Bladder cancer cell lines UMUC3 and T24 were treated with valproate or another histone deacetylase inhibitor, vorinostat, in culture for a period of three days. Proliferation was assessed by alamar blue reduction. Gene expression was evaluated by reverse transcription of RNA and quantitative PCR. RESULTS: Proliferation assays showed treatment with valproate or vorinostat decreased proliferation in both cell lines. Histone deacetylase inhibition also increased relative expression of thrombospondin-1 up to 8 fold at 5 mM valproate. CONCLUSIONS: Histone deacetylase inhibitors warrant further study for the prevention or treatment of bladder cancer.

Large teratoma at aortic bifurcation: an unusual metastasis of testicular cancer.

A 29-year-old man presented with a right testicular mass. Serum tumor markers were within normal limits. When compared to a previous computed tomography (CT) scan, a new 4 cm presacral mass was present. He underwent radical right inguinal orchiectomy that demonstrated a mature teratoma and seminomatous components. The patient received four cycles of chemotherapy. Over the course of chemotherapy, the mass grew in size and therefore he underwent retroperitoneal lymph node dissection. Pathology confirmed it to be a teratoma with negative retroperitoneal lymph nodes. The unusual presentation of an isolated metastasis to the presacral region raises the question of altered lymphatic drainage.

Transrectal Ultrasound in Prostate Cancer: Current Utilization, Integration with mpMRI, HIFU and Other Emerging Applications.

Transrectal ultrasound (TRUS) has been an invaluable tool in the assessment of prostate size, anatomy and aiding in prostate cancer (PCa) diagnosis for decades. Emerging techniques warrant an investigation into the efficacy of TRUS, how it compares to new techniques, and options to increase the accuracy of prostate cancer diagnosis. Currently, TRUS is used to guide both transrectal and transperineal biopsy approaches with similar cancer detection rates, but lower rates of infection have been reported with the transperineal approach, while lower rates of urinary retention are often reported with the transrectal approach. Multiparametric MRI has substantial benefits for prostate cancer diagnosis and triage such as lesion location, grading, and can be combined with TRUS to perform fusion biopsies targeting specific lesions. Micro-ultrasound generates higher resolution images that traditional ultrasound and has been shown effective at diagnosing PCa, giving it the potential to become a future standard of care. Finally, high-intensity focused ultrasound focal therapy administered via TRUS has been shown to offer safe and effective short-term oncological control for localized disease with low morbidity, and the precise nature makes it a viable option for salvage and repeat therapy.

Applications of Focused Ultrasound in the Treatment of Genitourinary Cancers.

Traditional cancer treatments have been associated with substantial morbidity for patients. Focused ultrasound offers a novel modality for the treatment of various forms of cancer which may offer effective oncological control and low morbidity. We performed a review of PubMed articles assessing the current applications of focused ultrasound in the treatment of genitourinary cancers, including prostate, kidney, bladder, penile, and testicular cancer. Current research indicates that high-intensity focused ultrasound (HIFU) focal therapy offers effective short-term oncologic control of localized prostate and kidney cancer with lower associated morbidity than radical surgery. In addition, studies in mice have demonstrated that focused ultrasound treatment increases the accuracy of chemotherapeutic drug delivery, the efficacy of drug uptake, and cytotoxic effects within targeted cancer cells. Ultrasound-based therapy shows promise for the treatment of genitourinary cancers. Further research should continue to investigate focused ultrasound as an alternative cancer treatment option or as a complement to increase the efficacy of conventional treatments such as chemotherapy and radiotherapy.

Prevalence of Nocturia in United States Women: Results From National Health and Nutrition Examination Survey.

INTRODUCTION: Nocturia can be one of the most bothersome lower urinary tract symptoms that can significantly affect quality of life. In both sexes, nocturia has been associated with decreased overall health. We aim to assess the prevalence of nocturia in US females and identify factors associated with significant nocturia. METHODS: A cross-sectional, US population-based database (National Health and Nutrition Examination Survey) was queried for females surveyed during the years 2009 to 2014. Nocturia information was obtained from the question, "how many times do you urinate at night?" Significant nocturia was defined as those women who urinated 2 or more times per night. Demographic characteristics, information on urinary incontinence, and gynecologic/obstetrical history were analyzed. Multivariable logistic regression was performed to identify factors associated with significant nocturia. RESULTS: A total of 7620 adult women were available for analysis. Of all women, 28.8% (95% confidence interval, 27.3-30.3) reported significant nocturia. Nocturia rates increased with increasing age (P < 0.0001). For those women who underwent childbirth, delivery type had no association with nocturia (P = 0.23). On multivariable analysis, only increasing age, black race, body mass index of 30 or greater, urge incontinence, and poor overall health were associated with increased rates of nocturia. Higher levels of education and increased household income were associated with lower rates of nocturia. CONCLUSIONS: Nocturia is prevalent in the United States with almost 30% of all women reporting significant nocturia. Importantly, nocturia does not affect only older individuals, as 1 in 6 women under the age of 40 years report waking 2 or more times per night to urinate.

Schistosoma haematobium ova in human semen: a case report.

OBJECTIVE: To report a rare case of schistosomiasis observed during semen evaluation. DESIGN: Case report. SETTING: University hospital. PATIENTS: A 30-year-old man referred for semen analysis. INTERVENTIONSS: None. MAIN OUTCOME MEASURESS: Poor sperm motility and viability. RESULTS: The patient produced 9.8 mL of brown colored semen with a bad odor. Total and progressive sperm motility were 9% and 2%, respectively. Sperm concentration was 112 million/mL. Microscopic semen evaluation showed slight sperm agglutination, a large number of Schistosoma haematobium ova, extensive debris, and a large numberot of amorphous cells. Approximately 20 million/mL of neutrophils were observed in the ejaculate. The sperm viability was extremely low (13%). Sperm morphology was 6% normal, and most abnormal sperm had coiled tails in addition to other abnormalities. CONCLUSIONS: A microscopic examination of semen from suspected Schistosoma haematobium-infected patients may not only help in confirming diagnosis but may also highlight the underlying infertility due to this infestation. Such cases are rarely observed in andrology laboratories; therefore, it is important to train all testing staff on rare semen samples.

Looking beyond hypogonadism: association between low testosterone and metabolic syndrome in men 20-59 years.

PURPOSE: Rates of low testosterone and metabolic syndrome are increasing among adult men in the United States. Both are associated with increased cardiovascular mortality. This study aims to assess the association between low testosterone and metabolic syndrome with a population-based contemporary cohort of men aged 20-59 years. METHODS: National Health and Nutrition Examination Survey (NHANES) was used between the years of 2013 and 2016. Men aged 20-59 years with testosterone levels were included. Metabolic syndrome was defined by National Cholesterol Education Program (NCEP) Adult Treatment Protocol (ATP) III. RESULTS: 24.4% of the cohort had low testosterone and 26.4% had metabolic syndrome. Univariate analysis revealed that men with low testosterone had a significantly higher prevalence of metabolic syndrome and metabolic syndrome criteria. Multivariable logistic regression revealed a significant association between low testosterone and a large waistline (Odds ratio (OR) 4.32), as well as low levels of high-density lipoprotein (HDL) (OR 1.67) among all men. Age-stratification revealed that men 20-39 years with a large waistline had an OR 6.43 for low testosterone. CONCLUSION: Nearly one quarter of men aged 20-59 years have low testosterone and metabolic syndrome. A large waistline increases the risk of low testosterone six-fold among young men.

Association Between Stress Urinary Incontinence and the Components of Metabolic Syndrome Among Females 20-59 Years.

OBJECTIVE: To assess the relationship between stress urinary incontinence (SUI) and metabolic syndrome among a population-based cohort of women 20-59 years. METHODS: National Health and Nutrition Examination Survey database was used between the years of 2013 and 2016 and included women aged 20-59 years. SUI was defined as "Urinary leakage with physical activity." Metabolic syndrome was defined as >2 risk factors: fasting blood glucose (FBG) >99 mg/dL, triglyceride >149 mg/dL, high-density lipoprotein <50 mg/dL, waistline >88 cm, and blood pressure >130/85. We generated weighted estimated prevalence and ran multivariable logistic regression models. RESULTS: Among 3430 female subjects, the estimated prevalence of SUI was 38.7% (95% confidence interval [CI] 36.7-40.7%) and metabolic syndrome was 10.2% (95% CI 8.9-11.6). Higher rates of SUI were seen with large waistlines, elevated FBG, and elevated triglycerides. Among women with metabolic syndrome, 56.1% (95% CI 39.7-49.0%) had SUI. Among all women, metabolic syndrome and elevated FBG significantly increase the risk of SUI (odds ratio [OR] 1.53 [95% CI 1.02-2.28] and OR 1.86 [95% CI 1.14-3.03], respectively). In women 20-39 years, a large waistline significantly increased the risk of SUI (OR 1.72 [95% CI 1.00-2.99]). CONCLUSION: Among females 20-59 years in the United States, 38.7% report SUI and 10% have metabolic syndrome. Metabolic syndrome and an elevated FBG significantly increase the risk of SUI among all women. A large waistline increases the risk of SUI in women aged 20-39 years. Weight loss and adequate control of metabolic syndrome should be considered key strategies in the management of SUI.

Vascular anomalies during laparoscopic renal surgery: incidence and management of left-sided inferior vena cava.

BACKGROUND: Left-sided inferior vena cava (IVC) is an unusual abnormality that may be clinically significant during renal surgery. METHODS: We report the unique case of a patient with a centrally located left renal mass who underwent laparoscopic radical nephrectomy. During the hilar dissection, unusual vascular anatomy was encountered. The patient was noted to have a left-sided inferior vena cava with multiple renal veins and anomalous tributaries. Laparoscopic radical nephrectomy was performed without complication. DISCUSSION: The embryology of a left-sided inferior vena cava is reviewed, and the safety and feasibility of a laparoscopic approach is discussed.

Hypoandrogenism is Prevalent in Males With Urethral Stricture Disease and is Associated with Longer Strictures.

OBJECTIVE: To assess the association of hypoandrogenism (HA) with urethral stricture disease in a series of patients undergoing urethroplasty at 2 institutions. HA has recently been associated with increased urethral atrophy in artificial sphincter failures and decreased androgen receptors and periurethral vascularity. HA might be an etiologic factor in urethral stricture disease. METHODS: We reviewed the charts in 202 men with anterior urethral strictures between 2011 and 2017. We excluded patients with radiation-induced stricture, previous prostatectomy, previous urethroplasty, pelvic fracture-related strictures, or those on testosterone replacement. We defined HA by a total testosterone of less than 300 ng/dL. We used as age-matched cohort from a national database (National Health and Nutrition Examination Survey), as a reference. Stricture characteristics, such as length, location, and etiology were compared in HA and eugonadal groups. RESULTS: Of 202 men with anterior urethral strictures, we excluded 45. Of the remaining 157 patients, 115 (73%) had preoperative testosterone measurements. Overall, hypoandrogenism (HA) was found in 65 of 115 (57%) men in the urethral stricture group compared with 28% of age-matched men in the national database. Mean stricture length in HA and eugonadal men was 7.2 cm and 4.8 cm, respectively (P = .02). CONCLUSION: HA may be more prevalent and associated with increased disease severity in men with anterior urethral strictures. The relationship between HA and stricture formation and its potential impact on therapeutic outcomes merit further prospective investigation.

Are we underestimating the rates of incontinence after prostate cancer treatment? Results from NHANES.

PURPOSE: Local therapy for prostate cancer (PCa) includes radical prostatectomy (RP) and radiotherapy (XRT), both of which share a complication of urinary incontinence. Post-treatment incontinence has been reported to occur 6-69%, yet no truly patient-centered report has been compiled. We evaluated patient-reported incontinence rates and bother scores after treatment for prostate cancer. METHODS: The NHANES database was queried for all men who reported a diagnosis and treatment of PCa from 2001 to 2010. A control arm of men without a diagnosis of PCa age 60-80 years was constructed for baseline incontinence rates. Incontinence was patient-reported and obtained through questionnaires. Three additional cohorts were created for patients treated with RP, XRT or combination RP and XRT. RESULTS: We identified 316 men treated for prostate cancer, of which 136 reported RP and 125 reported XRT, who were compared to 3534 controls. Men that underwent RP experience significant incontinence rates of 23% compared to 12% of those patients treated with XRT, whereas those patients with combined therapy had incontinence rates of 52% (p < 0.0001). Bother scores did not significantly vary, but were increased compared to baseline. Urge incontinence did not differ between treatment groups, but stress incontinence was significantly higher in surgical patients. CONCLUSION: These data from a nationwide sample of patient-reported urinary outcomes have limited interviewer bias and report significantly higher incontinence rates, which may impact prostate cancer discussions. This further underscores the importance of patient-reported outcomes in the evaluation of treatment success and counseling for patients with prostate cancer.

An Unusual Etiology of Urinary Retention - Small Cell Prostate Carcinoma.

We report the case of a 63-year-old male who presented with painless gross hematuria and urinary retention. Pathology obtained from transurethral resection of the prostate revealed pure small cell carcinoma of the prostate. Metastatic evaluation confirmed stage IV disease with lymphatic and hepatic metastasis. Despite aggressive systemic chemotherapy, the patient succumbed to his disease eleven months after initial diagnosis. Small cell carcinoma is an aggressive variant of prostate cancer that often presents late in the clinical course. We review the literature and discuss the clinical features associated with this rare subset of prostate cancer.

Valproic Acid Alters Angiogenic and Trophic Gene Expression in Human Prostate Cancer Models.

BACKGROUND/AIM: Only a minority of men succumb to prostate cancer (PCa). Therapy to prevent progression would change treatment paradigms. We investigated the effect of valproic acid (VPA) on PCa cell proliferation and the effects on both angiogenesis and PCa-specific signaling. MATERIALS AND METHODS: LNCaP cells were treated with VPA for 72 h and proliferation was measured. Cellular RNA extracts were used to measure gene expression with RT-profiler2 arrays. Genes with alterations were validated using real-time polymerase chain reaction and western blot. RESULTS: VPA led to a dose-dependent decrease in proliferation. Expression array data revealed an impact on modulators of angiogenesis. Additionally, several cell-cycle control transcripts were affected. There was a strong correlation between gene and protein expression levels for validated targets. CONCLUSION: VPA decreases cellular proliferation of PCa cells in vitro and also affects gene expression suggestive of anti-angiogenic effect with a concomitant decrease in proliferation-related genes.

Incidental computed tomographic bladder wall abnormalities: harbinger or herring?

OBJECTIVE: To evaluate the outcomes of incidental radiographically identified bladder wall abnormalities in the absence of other urologic indications for evaluation. METHODS: All screening cystoscopy evaluations performed at our center over 4 years were identified using surgical logs. We identified patients for whom cystoscopy was performed for a radiographic bladder wall abnormality, defined as diffuse bladder wall thickening, focal bladder wall thickening, or intraluminal bladder mass. Patients with other indications for cystoscopy such as previous bladder cancer, pelvic radiation, or hematuria were excluded. The outcomes including any relevant biopsy or malignant diagnosis were recorded. RESULTS: A total of 2483 cystoscopies were performed in 1418 unique patients, with 34 (2%) performed for radiographic bladder wall abnormalities in the absence of other indications for cystoscopy. Eleven of 34 patients (32.4%) were evaluated for diffuse bladder wall thickening, of which 2 had high-grade carcinoma. Fifteen patients (44.1%) had focal bladder wall thickening, all negative at cystoscopy. Four of the 8 patients (23.5%) evaluated for bladder mass had disease (1 high grade, 3 low grade). CONCLUSION: Although generally nonspecific for malignancy, incidental radiographic finding of bladder wall abnormality led to diagnosis of urothelial carcinoma in >15% of our patients including 3 worrisome tumors. This finding argues for routine cystoscopy in patients with radiographic bladder wall abnormality even in the absence of hematuria.