Efficacy of three BCG strains (Connaught, TICE and RIVM) with or without secondary resection (re-TUR) for intermediate/high-risk non-muscle-invasive bladder cancers: results from a retrospective single-institution cohort analysis.

PURPOSE: (I) To evaluate the clinical efficacy of three different BCG strains in patients with intermediate-/high-risk non-muscle-invasive bladder cancer (NMIBC). (II) To determine the importance of performing routine secondary resection (re-TUR) in the setting of BCG maintenance protocol for the three strains. METHODS: NMIBCs who received an adjuvant induction followed by a maintenance schedule of intravesical immunotherapy with BCG Connaught, TICE and RIVM. Only BCG-naïve and those treated with the same strain over the course of follow-up were included. Cox proportional hazards model was developed according to prognostic factors by the Spanish Urological Oncology Group (CUETO) as well as by adjusting for the implementation of re-TUR. RESULTS: n = 422 Ta-T1 patients (Connaught, n = 146; TICE, n = 112 and RIVM, n = 164) with a median (IQR) follow-up of 72 (60-85) were reviewed. Re-TUR was associated with improved recurrence and progression outcomes (HRRFS: 0.63; 95% CI 0.46-0.86; HRPFS: 0.55; 95% CI 0.31-0.86). Adjusting for CUETO risk factors and re-TUR, BGC TICE and RIVM provided longer RFS compared to Connaught (HRTICE: 0.58, 95% CI 0.39-0.86; HRRIVM: 0.61, 95% CI 0.42-0.87) while no differences were identified between strains for PFS and CSS. Sub-analysis of only re-TUR cases (n = 190, 45%) showed TICE the sole to achieve longer RFS compared to both Connaught and RIVM. CONCLUSION: Re-TUR was confirmed to ensure longer RFS and PFS in intermediate-/high-risk NMIBCs but did not influence the relative single BCG strain efficacy. When routinely performing re-TUR followed by a maintenance BCG schedule, TICE was superior to the other strains for RFS outcomes.

Safety and Feasibility of Outpatient Surgery in Benign Prostatic Hyperplasia: a Systematic Review and Meta-Analysis.

Purpose: Most of the endourologic procedures along the urinary tract have been widely practiced as outpatient operations, including surgery for benign prostatic hyperplasia (BPH). This systematic review and meta-analysis was conducted to assess safety and feasibility of outpatient surgery for patients suffering from symptomatic BPH candidate for endoscopic disobstruction. Materials and Methods: PubMed, Web of Science, Cochrane, and Embase were searched up until March 30, 2020. Methodological index for nonrandomized studies (MINORS) tool was utilized to assess the quality of included studies, and a pooled measure of failure rate (FR) or event rate (ER) estimate was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate contribution of moderators to heterogeneity. Results: Twenty studies with a total of 1626 patients treated according to outpatient criteria for endoscopic BPH surgery were included. In total, 18 studies reporting data on immediate hospital readmission and/or inability to discharge after endoscopic procedure presented FR estimates ranging from 1.7% to 51.1%. Pooled FR estimate was 7.8% (95% confidence interval [CI]: 5.2-10.3); Heterogeneity: Q = 76.85; degree of freedom = 17, p < 0.001; I2 = 75.12%. Subgroup analysis according to surgical technique revealed difference among the three approaches with pooled FR of 3% (95% CI: 1-4.9), 7.1% (95% CI: 3.9-10.4), and 11.8% (95% CI: 7-16.7) for transurethral resection of the prostate, Green-light, and holmium laser vaporesection, respectively (p < 0.001). At meta-regression analysis, none of the retrieved covariates was able to significantly influence the cumulative outcomes reported. ER for postoperative complications and early outpatient visit showed a pooled estimate of 18.6% (95% CI: 13.2-23.9) and 7.7% (95% CI: 4.3-11), respectively. Conclusions: Our analysis revealed how transurethral procedures for BPH on an outpatient setting are overall reliable and safe. Of note, there were significant outcome differences between groups with regard to type of surgical procedure, perioperative prostate volume, and discharge protocol suggesting the need for further prospective analysis to better elucidate the best strategy in such outpatient conduct.

Evaluation of Patient Treatment Preferences for 15 to 20 mm Kidney Stones: A Conjoint Analysis.

Introduction and Objective: Ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) are standard treatments for intermediate-size (15-20 mm) kidney stones but differ in their postoperative recovery, stone-free rates, and complication risks. We aimed to evaluate what affects patient treatment preferences. Methods: Patients with urinary stone disease completed a choice-based conjoint analysis exercise assessing four treatment attributes associated with URS and PCNL. A sensitivity analysis using a market simulator was performed, and the relative importance of each attribute was calculated. Differences in treatment preferences by demographic subgroup were assessed. Results: A total of 58 patients completed the conjoint analysis exercise. Stone-free rate was the most important treatment attribute, while the length of hospital stay and cosmesis were less important. Overall, sensitivity analysis based on market simulation scenarios predicted an almost equal preference for URS (52.4%) compared with PCNL (47.6%) for treatment of an intermediate-size stone. Older patients (>65 years old) expressed their stronger preferences for lower infection rates and shorter hospital stays, and were more likely to prefer URS (67.2%, 95% confidence interval [CI]: 52% to 82.5%) compared with younger patients (20-34 years old) (20.3%, 95% CI: 0% to 41.5%) who preferred higher procedure success rates and fewer repeat procedures. Conclusion: Conjoint analysis predicts nearly equal patient preference for URS or PCNL for the treatment of intermediate-size kidney stones. Older patients prefer the lower urinary tract infection risk and shorter hospital stay associated with URS, while younger patients prefer higher stone-free rates associated with PCNL. These results can help guide urologists in counseling patients and improve the shared decision-making process.

Postoperative vacuum therapy following AMS™ LGX 700® inflatable penile prosthesis placement: penile dimension outcomes and overall satisfaction.

Penile shortening after inflatable penile prosthesis for erectile dysfunction is a common postoperative patient complaint and can reduce overall satisfaction with the procedure. In this prospective study we report our results regarding penile dimensions and patient satisfaction outcomes after 1 year of follow-up from AMS™LGX700® penile prosthesis implant with 6 months of vacuum erectile device therapy. Seventy-four selected patients with medically refractory erectile dysfunction underwent AMS™ LGX 700® IPP placement. Postoperatively, patients were assigned vacuum device therapy for 5 min twice daily. Follow-up continued for 1 year after surgery. Dimensional and functional results were assessed. Baseline median preoperative stretched penile length and girth were 14 cm (range 10-17) and 9 cm (range 7-12), respectively. At the end of the study penile median dimensional outcomes were 17 cm (range 13-23) for length and 11 cm (range 10-13) for girth while a median number of 24 pumps (range 18-29) to fully inflate the device was seen. Baseline median International Index of Erectile Function (IIEF-5) score was 9 (range 5-11), at 6 months 20 (range 18-26) and at 1 year was 25 (range 20-27) (p < 0.0001). Median Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score at the end of the follow-up was 74 (range 66-78). Our postoperative rehabilitation program is feasible and should be recommended after prothesis surgery in order to increase overall satisfaction with the procedure. Penile postoperative dimensional outcomes were statistically significant improved and complications were negligible.

Payer Type, Race/Ethnicity, and the Timing of Surgical Management of Urinary Stone Disease.

PURPOSE: Surgery for upper tract urinary stone disease is often reserved for symptomatic patients and those whose stone does not spontaneously pass after a trial of passage. Our objective was to determine whether payer type or race/ethnicity is associated with the timeliness of kidney stone surgery. MATERIALS AND METHODS: A population-based cohort study was conducted using the California Office of Statewide Health Planning and Development dataset from 2010 to 2012. We identified patients who were discharged from an emergency department (ED) with a stone diagnosis and who subsequently underwent a stone surgery. Primary outcome was time from ED discharge to urinary stone surgery in days. Secondary outcomes included potential harms resulting from delayed stone surgery. RESULTS: Over the study period, 15,193 patients met the inclusion criteria. Median time from ED discharge to stone surgery was 28 days. On multivariable analysis patients with Medicaid, Medicare, and self-pay coverage experienced adjusted mean increases of 46%, 42%, and 60% in time to surgery, respectively, when compared with those with private insurance. In addition, patients of Black and Hispanic race/ethnicity, respectively, experienced adjusted mean increases of 36% and 20% in time to surgery relative to their White counterparts. Before a stone surgery, underinsured patients were more likely to revisit an ED three or more times, undergo two or more CT imaging studies, and receive upper urinary tract decompression. CONCLUSIONS: Underinsured and minority patients are more likely to experience a longer time to stone surgery after presenting to an ED and experience potential harm from this delay.

Crowdsourced Assessment of Ureteroscopy with Laser Lithotripsy Video Feed Does Not Correlate with Trainee Experience.

OBJECTIVES: We sought to validate the use of crowdsourced surgical video assessment in the evaluation of urology residents performing flexible ureteroscopic laser lithotripsy. METHODS: We collected video feeds from 30 intrarenal ureteroscopic laser lithotripsy cases where residents, postgraduate year (PGY) two through six, handled the ureteroscope. The video feeds were annotated to represent overall performance and to contain parts of the procedure being scored. Videos were submitted to a commercially available surgical video evaluation platform (Crowd-Sourced Assessment of Technical Skills). We used a validated ureteroscopic laser lithotripsy global assessment tool that was modified to include only those domains that could be evaluated on the captured video. Videos were evaluated by crowd workers recruited using Amazon's Mechanical Turk platform as well as five endourology-trained experts. Mean scores were calculated and intraclass correlation coefficients (ICCs) were computed for the expert domain and total scores. ICCs were estimated using a linear mixed-effects model. Spearman rank correlation coefficients were calculated as a measure of the strength of the relationships between the crowd mean and expert average scores. RESULTS: A total of 30 videos were reviewed 2488 times by 487 crowd workers and five expert endourologists. ICCs between expert raters were all below accepted levels of correlation (0.30), with the overall score having an ICC of <0.001. For individual domains, the crowd scores did not correlate with expert scores, except for the stone retrieval domain (0.60 p = 0.015). In addition, crowdsourced scores had a negative correlation with the PGY level (0.44, p = 0.019). CONCLUSIONS: There is poor agreement between experts and poor correlation between expert and crowd scores when evaluating video feeds of ureteroscopic laser lithotripsy. The use of an intraoperative video of ureteroscopy with laser lithotripsy for assessment of resident trainee skills does not appear reliable. This is further supported by the lack of correlation between crowd scores and advancing PGY level.

Inflatable Penile Prosthesis Placement, Scratch Technique and Postoperative Vacuum Therapy as a Combined Approach to Definitive Treatment of Peyronie's Disease.

PURPOSE: Peyronie's disease is a devastating condition resulting in penile malformation, erectile dysfunction, pain and emotional distress. In this prospective, 2 institution study we evaluated a multimodal surgical and mechanical combined approach to the definitive treatment of Peyronie's disease and concomitant erectile dysfunction. MATERIALS AND METHODS: A total of 145 select patients underwent endocavernous disruption of Peyronie's disease plaques via the scratch technique, followed by inflatable penile prosthesis insertion. Postoperatively patients were assigned to vacuum device therapy for 3 minutes twice daily to continue penile curvature correction. Followup continued for 1 year after surgery. Anatomical and functional results were assessed. RESULTS: Patients with plaques in the proximal third, middle third and subcoronal areas of the penis had a mean ± SD postoperative residual curvature of 21.5 ± 4.5, 17.3 ± 4.8 and 14.1 ± 3.1 degrees, respectively. After 24 weeks of vacuum therapy the mean penile curvature deviation decreased to 8.7 ± 2.5, 9.1 ± 2.9 and 7.7 ± 0.9 degrees, respectively. The mean IIEF-5 (International Index of Erectile Function) score was 9.8 ± 2.3 preoperatively, 18.9 ± 3.1 at 6 months (p <0.001) and 24.1 ± 3.6 at 1 year (p <0.001). The mean EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) score at the end of followup was 64.6 ± 11.8. Operative and postoperative complications were minimal. CONCLUSIONS: Our novel combination of intraoperative and postoperative therapies in the treatment of patients with Peyronie's disease and an inflatable penile prosthesis was safe and efficacious with excellent functional outcomes. Penile curvature corrections were statistically significant and complications were negligible.

Unplanned Emergency Department Visits and Hospital Admissions Following Ureteroscopy: Do Ureteral Stents Make a Difference?

OBJECTIVE: To evaluate unplanned medical visits within the early postoperative period after ureteroscopy in patients with and without ureteral stent placement. MATERIALS AND METHODS: We identified all ureteroscopic procedures for urinary stone disease in the California Office of Statewide Health Planning and Development database from 2010 to 2012. The primary outcome was any emergency department visit or inpatient hospital admission in the first 7 days following ureteroscopy. Patients were subcategorized by type of ureteroscopy (ie, laser lithotripsy vs basket retrieval) and were analyzed for significant differences between stented and unstented patients. Multivariable logistic regression was performed to determine if ureteral stent placement was independently associated with unplanned visits. RESULTS: Our analytic cohort included 16,060 patients undergoing 17,716 ureteroscopy procedures. A ureteral stent was placed in 86.2% of patients undergoing laser lithotripsy and in 70.5% of patients receiving basket retrieval. In the 7 days following ureteroscopy, 6.6% of patients were seen in the emergency department and 2.2% of patients were admitted to a hospital. In a fully adjusted model, the utilization of a ureteral stent was not associated with emergency department visits or inpatient admissions. CONCLUSION: Ureteral stent placement during ureteroscopy is not associated with an increased odds of emergency department visits and inpatient admissions in the early postoperative period.

Defining the Rate of Negative Ureteroscopy in the General Population Treated for Upper Tract Urinary Stone Disease.

INTRODUCTION: Ureteroscopy is increasingly used to treat upper tract urinary stone disease. A negative ureteroscopy is a ureteroscopy performed with the intent of removing a kidney or ureteral stone, but in which ultimately no stone is removed. Negative ureteroscopy may occur when the stone is found to have already passed, or the presumed stone is found to be outside of the collecting system. We sought to determine the rate of negative ureteroscopy in a large population-based sample as well as factors associated with its use. PATIENTS AND METHODS: We examined nonpublic data from the Office of Statewide Health Planning and Development (OSHPD) Database for all patients in California undergoing outpatient surgery from 2010 to 2012. We identified all patients with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for upper tract urinary stone disease, who underwent a ureteroscopic procedure. After excluding patients undergoing second look procedures or who had diagnosis codes for separate urologic pathology, the negative ureteroscopy rate was defined as the proportion of those ureteroscopy cases coded as a diagnostic ureteroscopy. We fit logistic regression models to evaluate patient factors associated with negative ureteroscopy. RESULTS: During the years 2010 to 2012, 20,236 eligible patients underwent ureteroscopic procedures for upper tract stone disease. Of these, 1287 patients underwent diagnostic ureteroscopy and 19,039 underwent ureteroscopy with stone removal accounting for a negative ureteroscopy rate of 6.3%. The odds of receipt of a negative ureteroscopy rate were higher in females compared to males (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.25, 1.58) and lower in self-pay patients compared with insured patients (OR = 0.55, 95% CI 0.33, 0.91). CONCLUSIONS: Negative ureteroscopy is common, occurring in nearly 1 in 16 procedures to treat urinary stone disease.

Paternal aging and increased risk of congenital disease, psychiatric disorders, and cancer.

As couples are increasingly delaying parenthood, the effect of the aging men and women on reproductive outcomes has been an area of increased interest. Advanced paternal age has been shown to independently affect the entire spectrum of male fertility as assessed by reductions in sperm quality and fertilization (both assisted and unassisted). Moreover, epidemiological data suggest that paternal age can lead to higher rates of adverse birth outcomes and congenital anomalies. Mounting evidence also suggests increased risk of specific pediatric and adult disease states ranging from cancer to behavioral traits. While disease states associated with advancing paternal age have been well described, consensus recommendations for neonatal screening have not been as widely implemented as have been with advanced maternal age.

A new mouse model for female genital schistosomiasis.

BACKGROUND: Over 112 million people worldwide are infected with Schistosoma haematobium, one of the most prevalent schistosome species affecting humans. Female genital schistosomiasis (FGS) occurs when S. haematobium eggs are deposited into the female reproductive tract by adult worms, which can lead to pelvic pain, vaginal bleeding, genital disfigurement and infertility. Recent evidence suggests co-infection with S. haematobium increases the risks of contracting sexually transmitted diseases such as HIV. The associated mechanisms remain unclear due to the lack of a tractable animal model. We sought to create a mouse model conducive to the study of immune modulation and genitourinary changes that occur with FGS. METHODS: To model FGS in mice, we injected S. haematobium eggs into the posterior vaginal walls of 30 female BALB/c mice. A control group of 20 female BALB/c mice were injected with uninfected LVG hamster tissue extract. Histology, flow cytometry and serum cytokine levels were assessed at 2, 4, 6, and 8 weeks post egg injection. Voiding studies were performed at 1 week post egg injection. RESULTS: Vaginal wall injection with S. haematobium eggs resulted in synchronous vaginal granuloma development within 2 weeks post-egg injection that persisted for at least 6 additional weeks. Flow cytometric analysis of vaginal granulomata revealed infiltration by CD4+ T cells with variable expression of the HIV co-receptors CXCR4 and CCR5. Granulomata also contained CD11b+F4/80+ cells (macrophages and eosinophils) as well as CXCR4+MerTK+ macrophages. Strikingly, vaginal wall-injected mice featured significant urinary frequency despite the posterior vagina being anatomically distant from the bladder. This may represent a previously unrecognized overactive bladder response to deposition of schistosome eggs in the vagina. CONCLUSION: We have established a new mouse model that could potentially enable novel studies of genital schistosomiasis in females. Ongoing studies will further explore the mechanisms by which HIV target cells may be drawn into FGS-associated vaginal granulomata.

Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era.

We sought to analyze utilization and survival outcomes of cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (RCC) before and after introduction of targeted therapy. We identified patients with metastatic RCC between 1993 and 2010 in the SEER registry and examined temporal trends in utilization. We performed a joinpoint regression to determine when changes in utilization of CN occurred. We fitted multivariable proportional hazard models in full and propensity score-matched cohorts. We performed a difference-in-difference analysis to compare survival outcomes before and after introduction of targeted therapy. The proportion of patients undergoing CN increased from 1993 to 2004, from 29% to 39%. We identified a primary joinpoint of 2004, just prior to the introduction of targeted therapy. Beginning in 2005, there was a modest decrease in utilization of CN. CN was associated with a lower adjusted relative hazard (0.41, 95% confidence interval 0.34­0.43). Median survival among patients receiving CN increased in the targeted therapy era (19 vs. 13 months), while median survival among patients not receiving CN increased only slightly (4 vs. 3 months). Difference-in-difference analysis showed a significant decrease in hazard of death among patients who received CN in the targeted therapy era. Despite decreased utilization in the targeted therapy era, CN remains associated with improved survival. Prospective randomized trials are needed to confirm the benefit of CN among patients with metastatic RCC treated with novel targeted therapies.

Prostate size does not predict high grade cancer.

PURPOSE: Several radical prostatectomy series have linked small prostates with high grade cancer based on the hypothesis that a small prostate results from a low androgen milieu that selects for less hormone dependent, more aggressive tumors. We previously reported that this association resulted from ascertainment bias from the performance characteristics of prostate specific antigen rather than from tumor biology in our radical prostatectomy cohort. In this study we analyzed this association in a more generalized population of men who underwent prostate needle biopsy. MATERIALS AND METHODS: The prostate needle biopsy database at our institution was queried for all initial biopsies. Included patient characteristics were age, race, family history of prostate cancer, prostate specific antigen, abnormal digital rectal examination and prostate volume in ml on transrectal ultrasound. Multivariate logistic regression was used to determine the influence of prostate volume on the odds of high grade cancer. RESULTS: The study population included 1,295 patients during 2000 to 2010, of whom 582 (44.9%) had prostate cancer and 398 (30.7%) had high grade cancer. When all patients were pooled, the OR for high grade cancer was 0.85 (95% CI 0.78-0.92) for each 10 ml increase in prostate volume. When patients were divided by clinical T stage, the corresponding ORs for those with T1c disease was 0.83 (95% CI 0.74-0.93) and for those with T2 or greater disease it was 0.99 (0.98-1.00). CONCLUSIONS: The association between small prostates and high grade cancer exists only in men with clinical T1c (normal digital rectal examination) prostate cancer. It likely resulted from ascertainment bias due to the performance characteristics of prostate specific antigen rather than tumor biology.

Pathological outcomes of candidates for active surveillance of prostate cancer.

PURPOSE: Active surveillance of prostate cancer has emerged as a viable treatment option for men with features of low risk disease. Five prospective studies have enrolled patients for active surveillance with varying inclusion criteria. We evaluated the pathological outcomes of men meeting published criteria for active surveillance who elected immediate radical prostatectomy to assess the risk of under grading and under staging in candidates for active surveillance. MATERIALS AND METHODS: Data were extracted from our institutional urological oncology database for all men who underwent radical prostatectomy between 1996 and 2007. The primary outcome was pathological up staging, defined as the occurrence of extracapsular extension or seminal vesicle involvement. Pathological upgrading was identified as a secondary outcome. We determined the proportion of men who would have qualified for each published active surveillance study and the respective rates of upgrading and up staging in each group. RESULTS: We identified 1,097 men who underwent radical prostatectomy with a mean age of 59 years. Overall 28% of the men experienced a Gleason upgrade, 21% had extracapsular extension and 11% had seminal vesicle involvement. In men qualifying based on published active surveillance inclusion criteria, rates of upgrading varied between 23% and 35%, the incidence of extracapsular extension ranged from 7% to 19% and seminal vesicle involvement ranged from 2% to 9%. CONCLUSIONS: Varying entry criteria for active surveillance show different rates of adverse pathological features at radical prostatectomy. Predictably fewer men met the more stringent criteria but these men had a lower incidence of seminal vesicle involvement and extracapsular extension. Such data can be used to advise men of the risks of active surveillance.

Risk factors for emotional and relationship problems in Peyronie's disease.

INTRODUCTION: Peyronie's disease (PD) occurs in 3-9% of all men. Little is known regarding the specific psychological or emotional disruptions to sexuality associated with PD. AIM: Our primary aim was to identify risk factors associated with psychosocial difficulties in men with PD. METHODS: This cross-sectional study enrolled patients from a single clinical practice. Detailed medical histories, physical examinations, and a PD-specific questionnaire were used to define clinical characteristics. Odds ratios (ORs) were used as a measure of association. MAIN OUTCOME MEASURES: Emotional and relationship problems were determined by "yes" or "no" answers to two specific questions. RESULTS: The mean age of all PD patients (N = 245) was 54.4 years (range 19.4-75.6); 62% were married, and 59% presented within 2 years of disease onset. The overall prevalence of emotional and relationship problems attributable to PD was 81% and 54%, respectively. Among men who had relationship problems, the prevalence of emotional problems was 93%. In men with emotional problems due to PD, relationship issues were observed in 62%. Multivariable analysis revealed that emotional difficulties (OR 6.9, P < 0.001) and ability to have intercourse (OR 0.4, P = 0.004) were independently associated with relationship problems. Relationship problems (OR 8.0, P < 0.001) and loss of penile length (OR 2.7, P = 0.02) were significant independent predictors of emotional problems after adjustment for the ability to maintain erections, low libido, and penile pain. CONCLUSIONS: Among men with PD, there is a very high prevalence of emotional and relationship problems. Loss of penile length and inability to have intercourse are strong predictors of these problems and as such make ideal targets for intervention. Medical and surgical therapies may enhance quality of life through their ability to improve sexual function. Further research will characterize the ways in which individual symptoms affect emotional and psychological well-being.