What has changed during the state of emergency due to COVID-19 on an Academic Urology Department of a Tertiary Hospital in Portugal. / Los cambios producidos durante el estado de alarma debido a la COVID-19 en un Servicio de Urología de un Hospital Universitario Terciario en Portugal.

OBJECTIVE: To compare the activity the Urology Department of a Portuguese Academic Hospital during the state of emergency and the equivalent period at the previous year. We compared the number of elective consultations and diagnostic urologic examinations, number and type of elective surgeries, as well as patients' demographic characteristics and main causes of presentation to Urology Emergency Department (ED) during the two mentioned periods MATERIALS AND METHODS: Data from 691 patients coming to emergency department were collected from institutional clinical software from March 18 th 2020 to May 2 nd 2020 - and from the same period the previous year. Data collected were age, sex, day of the presentation to Emergency Department, referral from other hospitals, triage color, reason of admission, diagnosis of discharge, and the need for emergency surgery or hospitalization. In order to identify associations between demographic and clinical variables with having been submitted to an emergency surgery (outcome), logistic regression models were applied. RESULTS: Multivariable analysis showed an association of sex with being submitted to surgery, 65.6% decrease in the odds for the male gender. The period (COVID versus non-COVID) did not show a significant association with surgery. CONCLUSION: Our department experienced a noticeable activity reduction. We also observe a reduction in urgent causes to attend the ED considered less serious. The percentage of cases requiring emergency surgery and hospitalization was higher during COVID-period.

Transobturator mid-urethral sling in females with stress urinary incontinence and detrusor underactivity: effect on voiding phase.

INTRODUCTION AND HYPOTHESIS: To assess whether detrusor underactivity (DU) is a risk factor for voiding dysfunction (VD) after transobturator tape (TOT) and if a detrusor pressure at maximum flow (PdetQmax) value predicts postoperative VD in DU patients. Also, we examined uncomplicated patients for postoperative VD. METHODS: This is a prospective long-term study on SUI patients who underwent TOT. Exclusion criteria were preoperative POP stage ≥ 2, previous anti-incontinence surgery and comorbidities. Patients were grouped by detrusor contractility using the projected isovolumetric pressure (PIP) index (PdetQmax + maximum flow rate) with values of 30-75 cmH2O indicating normal contractility. Follow-up was at 1, 3, 6 and 12 months, and then annually. All patients underwent a stress test and responded to the Urogenital Distress Inventory questionnaire and to the King's Health Questionnaire. The subjective cure was evaluated using the Patient Global Impression of Improvement. We determined the diagnostic accuracy of PdetQmax levels using ROC curve analysis, with a cut-off point calculated for optimal sensitivity and specificity. RESULTS: In 2007-2013, 118 patients underwent TOT. We included 50 in the undercontractility group (G1) and 50 in the normocontractility group (G2). Continence rates were 82% in G1 and 84% in G2 (mean follow-up 76 months). VD increased from 18 to 36% (p < 0.05) in G1 and from 14 to 16% (p = 0.198) in G2. De novo VD was 28% in G1 and 2% in G2. In the G1 group PdetQmax ≤ 12 cmH2O predicted postoperative VD with 71.4% specificity and 80.0% sensitivity. CONCLUSIONS: DU adversely affects the voiding phase of micturition after TOT. In DU patients, PdetQmax ≤ 12 cmH2O predicts postoperative VD.

Trends and Patterns of Urodynamic Studies in U.S. Males, 2000-2012.

OBJECTIVE: To evaluate trends in urodynamic procedures in the U.S. males from 2000-2012 and determine if a 2010 decline in reimbursement was associated with decreased utilization. SUBJECTS AND METHODS: We analyzed 2000-2012 administrative healthcare claims from Truven Health's Marketscan Database and evaluated males ≥18 years of age. We identified cystometrograms and any concurrent procedures using procedure billing codes. Covariates included age, year of cystometrogram, region and associated diagnosis codes. We estimated standardized cystometrogram utilization rates per 10,000 person-years (PY). We used age, region, and calendar year adjusted Poisson regression models to estimate the independent effect of calendar year and region. RESULTS: During 127,558,186 PY of observation, we identified 153,168 cystometrograms for an overall utilization rate of 12.0 per 10,000 PY (95% CI 11.9-12.1). Cystometrogram utilization increased with age, peaking at age 85 with a rate of 77.7 per 10,000 PY (95% CI 74.7-80.7). Adjusted cystometrogram utilization rate ratios show that compared to a referent of 2000-2004, utilization was significantly higher in each year 2005 to 2011 among all patients and in 2012 among patients ≥ 65. Standardized utilization rates peaked in 2008 at 12.4 per 10,000 PY (95% CI 12.2-12.6), remained elevated until 2010, then decreased slightly in 2011 and substantially in 2012 to 8.5 per 10,000 PY (95% CI 8.4-8.7). CONCLUSIONS: Utilization of urodynamic procedures increased until 2010 and decreased thereafter. Utilization was greatest among men older than 65.

Iatrogenic urological triggers of autonomic dysreflexia: a systematic review.

STUDY DESIGN: This is a systematic review. OBJECTIVE: The objective of this study was to review the literature on iatrogenic urological triggers of autonomic dysreflexia (AD). SETTING: This study was conducted in an international setting. METHODS: A systematic review was conducted from PubMed search using AD/ autonomic hyperreflexia and spinal cord injury (SCI). Studies selected for review involved iatrogenic urological triggers of AD in individuals with SCI, including original articles, previous practice guidelines, case reports and literature reviews. Studies that did not report AD or blood pressure (BP) assessments during urological procedures were excluded. RESULTS: Forty studies were included for analysis and categorized into four groups: (1) urodynamics and cystometry; (2) cystoscopy and transurethral litholapaxy; (3) extracorporeal shock-wave lithotripsy (ESWL); and (4) other procedures. During urodynamics, the incidence of AD ranged from 36.7% to 77.8%. The symptomatic rate ranged from 50% to 65%, with AD symptoms seen predominantly in cervical SCI patients. The studies imply no consensus regarding the relationship between AD, neurogenic detrusor overactivity and detrusor sphincter dyssynergia. Without anesthesia, the majority of individuals develop AD during cystoscopy, transurethral litholapaxy and ESWL. The effectiveness of different anesthesia methods relies on blocking the nociceptive signals from the lower urinary tract (LUT) below the level of the neurological lesion. Other iatrogenic urological triggers were commonly associated with bladder filling. CONCLUSION: The LUT triggers of episodes of AD are often associated with iatrogenic urological procedures. AD was more prevalent in cervical SCI than in thoracic SCI. To detect this potential life-threatening complication following cervical and high thoracic SCI, routine BP monitoring during urological procedures is highly recommended.

Trends and patterns of urodynamic studies in U.S. women, 2000-2012.

OBJECTIVE: To estimate utilization rates for cystometrograms and describe trends in urodynamic procedures among U.S. women from 2000 to 2012. METHODS: We analyzed outpatient administrative health care claims for women aged 18 years or older from 2000 to 2012. The database contains deidentified and adjudicated claims from approximately 150 U.S. payers for employees, spouses, and retirees. We identified cystometrograms, which occur during bladder filling and represent a major component of complex urodynamics, and concurrent procedures; we also assessed age, year, region, health care provider specialty, and associated diagnosis codes. We estimated standardized cystometrogram utilization rates per 10,000 person-years and 95% confidence intervals (CIs) and used stratified Poisson models to estimate the independent (adjusted) effects of year and region. RESULTS: During 142,928,847 person-years of observation among 57,629,961 eligible women, we identified 561,823 cystometrograms for an overall utilization rate of 39.3 per 10,000 person-years (95% CI 39.2-39.4). Cystometrogram utilization increased with age with a peak at age 76 years (86.6/10,000 person-years, 95% CI 84.5-88.7). Standardized rates were relatively constant from 2000 to 2004 and then increased and peaked in 2009 (43.3/10,000 person-years, 95% CI 43.0-43.7). In 2012, they were substantially lower (27.6/10,000 person-years, 95% CI 27.4-27.9). CONCLUSION: Urodynamic procedures were more commonly performed in women aged 65 years or older. Utilization peaked in 2009 and declined sharply in 2012. Clinically, we need to assess the underlying reasons for these trends (ie, whether they reflect a decrease in urodynamics before stress urinary incontinence surgery) and whether these trends reflect appropriate use of this diagnostic study. LEVEL OF EVIDENCE: : II.

CROATIAN UROLOGISTS' CLINICAL PRACTICE AND COMPLIANCE WITH GUIDELINES IN THE MANAGEMENT OF NON-NEUROGENIC MALE LOWER URINARY TRACT SYMPTOMS.

The aim of this study was to assess the Croatian urologists' management of non-neurogenic male lower urinary tract symptoms (LUTS) and their compliance with the European Association of Urology (EAU) guidelines. A cross-sectional survey included 51/179 Croatian urologists. We developed a questionnaire with questions addressing compliance with EAU guidelines. The rate of performing recommended evaluations on the initial assessment of patients with benign prostate hyperplasia (BPH)/LUTS varied from 8.0% (serum creatinine and voiding diary) to 100.0% (physical examination, prostate specific antigen and ultrasound). The international prostate symptom score was performed by 31%, analysis of urine sediment by 83%, urine culture by 53%, and serum creatinine by 8% of surveyed urologists. Only 8% of urologists regularly used bladder diary in patients with symptoms of nocturia. Our results indicated that 97% of urologists preferred alpha blockers as the first choice of treatment; 5-alpha reductase inhibitors (5ARI) were mostly prescribed (84%) in combination with an alpha-blocker, preferably as a continuous treatment, whilst 29% of urologists used to discontinue 5ARI after 1-2 years. Half of the Croatian urologists used antimuscarinics in the treatment of BPH/LUTS and recommended phytotherapeutic drugs in their practice. In conclusion, Croatian urologists do not completely comply with the guidelines available.

Trends in urodynamics in U.S. female medicare beneficiaries, 2000-2010.

AIMS: To document variations and temporal trends in the use of urodynamics (UDS) in female U.S. Medicare beneficiaries. METHODS: Using a 5% sample of U.S. Medicare utilization records, we identified female beneficiaries who had undergone UDS studies between 2000 and 2010 by the presence of Common Procedural Terminology codes for cystometrogram in claims from the Carrier file. We abstracted data for each patient on age, race, residence, ICD9 diagnoses, dates of service, and provider specialty. We calculated rates per 100,000 beneficiaries with data available from the enrollment files (i.e., Denominator files) and reported the numbers and rates per 100,000 by year. RESULTS: During this period, 1.4 million female U.S. Medicare beneficiaries underwent UDS, of which 6% were videourodynamics. Seventy four percent of UDS were associated with a diagnosis of any urinary incontinence, with 50% specific for stress incontinence. The annual rates of UDS increased by 29%, from 422 in 2000 to 543 in 2010 per 100,000. Similar increases were seen across age groups, geographic regions and racial/ethnic groups. The rate of UDS performed by gynecologists increased by 144% over the study period, while that of urologists decreased by 3%. In 2010, gynecologists performed 35% and urologists 58% of all UDS. CONCLUSIONS: The use of UDS in the female Medicare program increased substantially between 2000 and 2010, with some variation across demographics and marked variation across provider specialty.

Variation in the intensity of hematuria evaluation: a target for primary care quality improvement.

BACKGROUND: Hematuria is a common clinical finding and represents the most frequent presenting sign of bladder cancer. The American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients aged more than 35 years. Nonetheless, less than half of patients presenting with hematuria undergo proper evaluation. We sought to identify clinical and nonclinical factors associated with evaluation of persons with newly diagnosed hematuria. METHODS: We performed a retrospective cohort study, using claims data and laboratory values. The primary exposure was practice site, as a surrogate for nonclinical, potentially modifiable sources of variation. Primary outcomes were cystoscopy or abdomino-pelvic imaging within 180 days after hematuria diagnosis. We modeled the association between clinical and nonclinical factors and appropriate hematuria evaluation. RESULTS: We identified 2455 primary care patients aged 40 years or more and diagnosed with hematuria between 2004 and 2012 in the absence of other explanatory diagnosis; 13.7% of patients underwent cystoscopy within 180 days. Multivariate logistic regression revealed significant variation between those who did and did not undergo evaluation in age, gender, and anticoagulant use (P < .001, P = .036, P = .028, respectively). Addition of practice site improved the predictive discrimination of each model (P < .001). Evaluation was associated with a higher rates of genitourinary neoplasia diagnosis. CONCLUSIONS: Patients with hematuria rarely underwent complete evaluation. Although established risk factors for malignancy were associated with increasing use of diagnostic testing, factors unassociated with risk, such as practice site, also accounted for significant variation. Inconsistency across practice sites is undesirable and may be amenable to quality improvement interventions.

A survey of current procedural practices of Australian and New Zealand nephrologists.

The aim of this study was to describe the range and extent of current procedural practices of Nephrologists and trainees in Australia and New Zealand with a specific focus on renal biopsy. A web-based survey was constructed based on a 2009 pilot survey conducted by the authors. The survey was distributed by email. A total of 118 responses were received from 60 centers, including six pediatric centers; Nephrologists or trainees performed the following procedures: urine microscopy 36.4%; diagnostic ultrasound 10.2%; renal biopsy 93.2%; simple vascath insertion 64.4%; cuffed vascath insertion 22%; peritoneal catheter insertion 16.9%; fistula ultrasound 20.3%; and fistulography 5%. Trainees performed most renal biopsies (67.8% of respondents) and real-time ultrasound was the commonest technique (97%). The majority of respondents believe that renal biopsy is an essential skill for trainees (78.8%); 10-25 biopsies are required for trainee proficiency (59.3%); an online training module would assist in teaching renal biopsies (67.8%). Cuffed catheter insertion and fistulography were more often performed in nonmetropolitan than in metropolitan centers. Procedures are part of Australian and New Zealand Nephrology, including specialized procedures in a minority of centers. Vascular access procedures are more common in nonmetropolitan centers. Renal biopsy is an important skill, considered essential for trainees by most.

The burden of specialist urologic care in abuja, federal capital city, Nigeria: a single surgeons 4-year case load.

BACKGROUND: Urologic surgery is believed to form a major part of the surgical workload in many centers but this volume of clinical workload has not been extensively reported. Abuja is Nigeria's capital with a population of about 4 million residents. There are a total of fourteen public general and specialist hospitals with 6 consultant Urologists working in only three of these hospital serving the population. It is not known what proportion of the total surgical workload in Abuja is urological. OBJECTIVE: To report a single Urologist case load in three hospitals in Abuja, Nigeria over a 4 year period. METHODS: The out-patient clinic register, the Medical Records Department register, the surgical wards register and all retrievable patients' case notes of the Urologic Surgery service of the three hospitals were reviewed for extraction of patient's demographic data and clinical records RESULTS: 2167 urological presentations were recorded within the study period. Of these there were 1903 (87.8%) adult males, 140 (6.5%) adult females,122 pediatric males (5.6%) and 2 pediatric females(0.1%) (with an age range of 18-72 years, 22-55 years, 1 month - 12 years and 11-12 years respectively). Mean ages for the adult male and female patients were 44.4 and 33.4 respectively. The mean ages for male children less than 1 year old was 6.9 months and 3.1 years for those older while the mean age the only 2 female children seen was 11 years. The commonest urologic condition seen were male factor infertility in adult males, possibly renal/ureteric calculi in adult females and communicating hydrocele in male children. CONCLUSION: A total of 2167 cases seen during the period under review by a single urologist is suggestive of a significant urology case load in Abuja. Further study is required to determine if this result is a reflection of the burden of specialist urology care in all the tertiary referral health facilities in Abuja, Nigeria's Federal Capital Territory.

Reliability assessment of international grading system for vesicoureteral reflux.

PURPOSE: The International Reflux Committee proposed a grading system for vesicoureteral reflux in 1985 which has been used extensively in everyday practice and research studies. Despite widespread use, based mainly on face validity, the interrater and intrarater reliability of this tool are not known. A tool cannot be considered valid unless it is reliable. Therefore, we estimated the interrater and intrarater reliability of the international grading system for vesicoureteral reflux. MATERIALS AND METHODS: A series of 28 voiding cystourethrogram studies were selected. The images were assembled in an electronic presentation in random fashion. Four pediatric radiologists, 5 pediatric urologists and 4 senior urology residents graded the studies. The images were then shuffled in a random fashion and re-rated after 7 days (total 728 observations). Cohen weighted kappa statistics were used to determine interrater and intrarater reliability. Subgroup analysis was then performed comparing the variability among the 3 groups of raters and different grades. RESULTS: The average interrater reliability was 0.53 (95% CI 0.52-0.55, p <0.0001). Agreement in subgroups was 0.61 for urologists, 0.59 for residents and 0.56 for radiologists. The lowest agreement was shown in grade III (0.36) and the highest in grade I (0.98). The intrarater reliability was 0.86 (95% CI 0.77-0.95, p <0.001). CONCLUSIONS: The international grading system for vesicoureteral reflux shows low interrater reliability for moderate degrees of vesicoureteral reflux whereas the intrarater reliability is high. Modification of this system may improve its reproducibility.

[Descriptive epidemiological study of the diagnosis of detrusor overactivity in urodynamic units in Spain]. / Estudio epidemiológico descriptivo del diagnóstico de hiperactividad del detrusor en las unidades de diagnóstico urodinámico de España.

OBJECTIVE: To know the relative weight of the diagnosis of detrusor overactivity (DO) in the Urodynamic Units of Spain and relate the prevalence of the overactive bladder (OB) syndrome. MATERIAL AND METHOD: An epidemiological, descriptive, retrospective, multicenter, national study conducted according to registered data in 47 Urodynamic Units covering the Spanish geographic area in the different areas of health distributed among the regional communities. These data inform about the health care received by 35% of the Spanish population. Urodynamic diagnoses and related variables, recorded during 2007 and 2008, were collected. RESULTS: A mean of 346.45 (SD=304.03) and 349.72 (SD=296.49) urodynamics studies per care unit were performed in women during 2007 and 2008, respectively and 181.20 (SD=212.71) and 195.68 (SD=257.58) in men. The relative weight of the diagnosis of non-neurogenic DO in women per unit was 31.39% and 35.28%, in 2007 and 2008, and in men was 21.06% and 20.43%. The diagnostic capacity of DO was 19.28 new cases per 100,000 inhabitants/year. The diagnosis of non-neurogenic DO in the woman accounts for one third of all the urodynamic/year diagnoses and more than half of the diagnoses of DO. In men, DO accounts for 25% of the diagnoses, the most frequent one being that associated with benign prostatic hyperplasia, followed by that of neurogenic cause. Approximately half of the DO diagnoses in children correspond to non-neurogenic DO. CONCLUSIONS: The differences between the capacity of diagnosis of DO (ratio per 100,000 inhabitants) is far from many of the estimations of the prevalence of OB (relationship %). The doubt may exist about whether part of this quota is secondary and not-idiopathic, given the large difference between the frequency of OB and the capacity of diagnosis of DO.

Hematuria one-stop clinic: first experience in Italy with 150 cases.

OBJECTIVES: Starting from the UK experience, we decided to test both the feasibility and the advantages of this diagnostic pathway now established in an Italian hospital. We analyzed the outcomes in detecting transitional cell carcinoma (TCC) of the bladder, other malignant and non-malignant conditions. MATERIALS AND METHODS: Between April and December 2010, one hundred and fifty patients presenting with hematuria were referred to the Hematuria One Stop Clinic (HOSC) at our Institution. Each patient underwent a visit, a Urinary Tract Ultrasound, a Cystoscopy and CT IVP in selected cases (evidence of alterations or lesions of the renal parenchyma, presence of stones of the urinary tract, evidence of doubtful or positive urinary cytology). Where a TCC of the bladder was diagnosed, the patient underwent TUR-BT. In other cases (stones, BPH etc.) the appropriate therapeutic pathway was followed. RESULTS: 25.3% of patients with hematuria were found to have a bladder cancer; 21.3% had a urinary stone (2% in the bladder); 1.3% had prostate cancer; 1.3% had a renal cell carcinoma. The mean age was 69.8 yrs. 6% of the patients (23.6% on patients with TCC of the bladder) had a G3 disease. The mean time from admission to the HOSC until the operation day, in case of TCC of the bladder, was 10.61 days. CONCLUSIONS: The Italian experience of the One Stop Clinic confirms a high rate of bladder cancer detection. Furthermore, a high rate of non-malignant conditions was detected, stressing the importance of the HOSC not only as a cancer clinic but as a complete general urological clinic. We report a shorter waiting time to operation, especially for bladder TCC G3 patients.

Urologist practice styles in the initial evaluation of elderly men with benign prostatic hyperplasia.

OBJECTIVES: To investigate the degree to which expenditures on symptom evaluations vary among urologists and the factors associated with such variation. As the medical and surgical specialists for men with lower urinary tract symptoms (LUTS), urologists provide testing to evaluate symptoms and determine therapy. METHODS: We developed a cohort of men with an initial urologist visit for benign prostatic hyperplasia (BPH) from a 5% sample of Medicare patients (1999-2007) and established a physician level factor, practice style, as a function of average per patient expenditures. We then determined which AUA BPH guideline elements explained variation in quantity and expenditures for BPH testing, and also examined the impact of patient and physician factors on practice style. RESULTS: A nearly 15-fold variation in urologists' average per-patient expenditures existed ($35 to $527 per month; Median $92). Practice styles were associated with physician (P < .01 all examined variables) and patient (P < .01 for comorbidity, race/ethnicity, and socioeconomic status) factors. Guideline recommended care was provided at lower rates by the lowest expenditure urologists compared with middle- to highest-intensity urologists (P < .01). Practice style variations were attributable mainly to differences in tests characterized by the guidelines as optional and not-recommended (P < .01). CONCLUSIONS: Expenditures for BPH evaluations vary substantially by geography, practice setting, and experience and are accounted for largely by differences in the use of optional and not-routinely recommended tests. Greater standardization could enhance patient care and reduce health care costs.

When to perform urodynamics before mid-urethral sling surgery for female stress urinary incontinence?

INTRODUCTION AND HYPOTHESIS: Development of a model that can predict in which group of women pre-operative urodynamics can be safely omitted. METHODS: Three hundred and eighty-one uncomplicated women who underwent pre-operative urodynamics were evaluated. A multivariate logistic regression model was developed based on medical history and physical examination predicting a high probability group of women with detrusor overactivity or a low (<20 cm H2O) mean urethral closure pressure and, therefore, are likely to benefit from urodynamics. RESULTS: Women are likely to benefit from pre-operative urodynamics if they (1) are 53 years of age or older or (2) have a history of prior incontinence surgery and are at least 29 years of age or (3) have nocturia complaints and are at least 36 years of age. CONCLUSION: If urogynaecologists omitted pre-operative urodynamics in women in the low probability group, in our population, pre-operative urodynamics would be reduced by 29%.

Cystodistension: certainly no standards and possibly no benefits--survey of UK practice.

INTRODUCTION AND HYPOTHESIS: Cystodistension is not a standardised procedure; however, it is being used for various indications. METHODS: Four hundred eighty-six questionnaires were posted to consultant gynaecologists, urologists and urogynaecologists in the UK to evaluate the current practice with regards to the indications, technique, benefits and complications of cystodistension. RESULTS: The response rate was 39%. The analysis of each question was done separately. 58.8% of respondents were urogynaecologists or gynaecologists. The most common indication to perform cystodistension was interstitial cystitis both for diagnosis and treatment followed by reduced bladder capacity (40.7%) and overactive bladder (35.4%). Most of the respondents (96%) performed short-duration distension for <20 minutes. CONCLUSIONS: It appears that cystodistension has a role in practice; however, its indications and benefits are still controversial and there is a wide variation in the technique of cystodistension due to lack of standardisation. Further research is needed before any conclusions about its benefits and safety can be made.

Operator is an independent predictor of detecting prostate cancer at transrectal ultrasound guided prostate biopsy.

PURPOSE: We investigated whether interoperator differences exist in the setting of prostate cancer detection by transrectal ultrasound guided prostate biopsy. Our secondary aim was to investigate whether a learning curve exists for prostate cancer detection. MATERIALS AND METHODS: A prospective database from 2000 to 2008 including 9,072 transrectal ultrasound guided prostate biopsies at our institution was limited to 4,724 done at initial presentation. Biopsies were performed by 4 uroradiologists. The OR for detecting cancer on transrectal ultrasound guided prostate biopsy was calculated for likely independent prognostic variables, including operator. We also examined the rate of biopsy positivity in increments, comparing the first and last cohorts. The senior radiologist (AT) with the most biopsies (75%) was considered the referent for prostate cancer detection. Univariate and multivariate logistic regression modeling was used to determine significant covariates with p <0.05 deemed relevant. RESULTS: Prostate cancer was detected in 2,331 men (49.3%). Operators performed a median of 514 transrectal ultrasound guided prostate biopsies (range 187 to 3,509) with a prostate cancer detection rate of 43.8% to 52.4% (p = 0.001). Other significant covariates were prostate specific antigen, suspicious lesions on ultrasound, nodule on digital rectal examination, smaller prostate volume and increasing patient age. Operator was a significant multivariate predictor of cancer detection (OR 0.67 to 0.89, p = 0.003). No learning curve was detected and biopsy rates were consistent throughout the series. CONCLUSIONS: Significant differences in prostate cancer detection exist among operators who perform transrectal ultrasound guided prostate biopsy even in the same setting. The volume of previously performed transrectal ultrasound guided prostate biopsies does not appear to influence the positive prostate cancer detection rate, nor could a learning curve be identified. Differences in prostate cancer detection among operators are likely related to unknown differences in expertise or technique. Further research is needed.

Radiological investigations following urinary tract infection: changes in Australian practice.

OBJECTIVE: To examine practice changes in the conduct of radiological investigations in Australia following urinary tract infection (UTI). DESIGN: Observational study using data from the national Medicare database over the 15-year period July 1993 to June 2008 for four investigations: renal ultrasound (renal US), micturating cystourethrography (MCU), intravenous pyelography (IVP) and nuclear medicine isotope scanning of the renal tract (NM). Rates per 100,000 children in the age groups 0-4 years and 5-14 years were calculated for each test. SETTING: Australian medical practice, including private and public medical settings. RESULTS: The rates of performance of renal US remained fairly constant throughout the study period in both age groups, while those for MCU, IVP and NM showed a strong falling trend over time for each test in both age groups. For the more invasive tests (MCU, IVP and NM) the total number performed per annum fell from 11,169 (costing 2,032,621 dollars) to 3361 (costing 689,742 dollars) in the last 10 years. CONCLUSION: There have been very marked practice changes over the last 10-15 years. This trend followed the publication of scientific evidence which has raised doubts about the benefit of performing these investigations.

Increasing detection rate of benign renal tumors: evaluation of factors predicting for benign tumor histologic features during past two decades.

OBJECTIVES: To determine whether the detection of benign renal tumors is increasing and to identity the predictors of benign histologic features. The detection of renal cortical tumors has increased with the increased use of abdominal imaging. Current imaging and biopsy techniques cannot predict the renal tumor histologic features with complete accuracy, and many patients undergo surgery for benign lesions. METHODS: The Columbia Urologic Oncology Database was reviewed, and 1244 patients who had undergone partial or radical nephrectomy from 1988 to 2007 were identified. A cohort of 775 patients with a tumor diameter of .05). CONCLUSIONS: Even when controlling for tumor diameter and sex, the incidence of benign tumors detected at renal surgery at our institution has increased significantly in the past 2 decades.

Bladder diary measurements in asymptomatic females: functional bladder capacity, frequency, and 24-hr volume.

AIMS: To study the effects of age and 24-h volume (V(24)) on bladder diary measurements of voiding frequency (F(24)) and functional bladder capacity (FBC) from an asymptomatic female population. Also, to use these data to develop clinical reference values. (We use FBC as a generic term for bladder diary volume-per-void measurements.) MATERIALS AND METHODS: Computer-processed 3-day bladder diaries were collected from 161 females (median age: 46.6 years; range = 19.6-81.8 years) claiming no urological symptoms, previous pelvic surgery and diseases and medications effecting urologic function. Regression analysis was used to investigate relationships among age, FBC and V(24). RESULTS: Both FBC and F(24) increase as V(24) increases (P < 0.0005). With aging, F(24) increases (P = 0.026) and FBC may decrease slightly (P = 0.02-0.08). There is a concave downward, curvilinear relationship between age and V(24). We used multiple regression to generate tables of FBC and F(24) "normal limits" adjusted for these simultaneous influences of V(24) and age. Removing their relationships to age reduces the variability of FBC and F(24) reference values by 50% and 20%, respectively. CONCLUSIONS: Our finding, supported by others, that, with increasing V(24), FBC increases more than F(24) suggests an adaptive mechanism that adjusts FBC to urine production to minimize changes in voiding frequency. We illustrate adjustment of reference values for age and V(24) by calculating traditional clinical "normal limits." However, the probable large overlap between "normal" and "abnormal" suggests that it may be more useful to report bladder diary measurements as reference population percentiles rather than to designate them "normal" or "abnormal".