Prevalence and significance of fluoroquinolone resistant Escherichia coli in patients undergoing transrectal ultrasound guided prostate needle biopsy.

PURPOSE: We estimated the prevalence of fluoroquinolone resistant Escherichia coli in patients undergoing repeat transrectal ultrasound guided prostate needle biopsy and identified high risk groups. MATERIALS AND METHODS: From January 2009 to March 2010 rectal swabs of 136 men from 3 institutions undergoing transrectal ultrasound guided prostate needle biopsy were obtained. There were 33 men with no previous biopsy who served as the controls. Participants completed questionnaires and rectal swab culture was obtained just before performing the prostate biopsy. Selective media was used to specifically isolate fluoroquinolone resistant E. coli and sensitivities were obtained. The patients were contacted via telephone 7 days after the procedure for a followup questionnaire. RESULTS: A total of 30 patients had cultures positive for fluoroquinolone resistant bacteria for an overall rate of 22% (95% CI 15, 29). Patients with diabetes and Asian ethnicity had higher risks of resistant rectal flora colonization (OR 2.3 and 2.8, respectively). However, differences did not reach statistical significance (p = 0.09 and p = 0.08, respectively). Patients with no prior biopsy had a positive rate of 15% (5 of 33) compared to 24% (25 of 103) in those with 1 or more prior biopsies (OR 1.8, p = 0.27). Five patients (3.6%) had post-biopsy fever while only 1 of those patients had a positive rectal swab. CONCLUSIONS: Using selective media to isolate fluoroquinolone resistant E. coli from the rectum before transrectal ultrasound guided prostate biopsy, we isolated organisms in 22% of patients with a wide resistance pattern. This protocol may be used to provide information regarding targeted antibiotic prophylaxis before transrectal prostate biopsies.

Prospective randomized trial of three different methods of nephrostomy tract closure after percutaneous nephrolithotripsy.

OBJECTIVE: • To evaluate the safety and efficacy of 'tubeless' nephrostomy tract closure in reducing postoperative morbidity after percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: • In all, 31 patients undergoing PCNL were randomized into three groups, each with a different method of nephrostomy tract closure: using either a gelatin matrix haemostatic sealant (FloSeal), fascial stitch or Cope loop nephrostomy tube. • We compared operative time, estimated blood loss (EBL), postoperative stay, analgaesics use, changes in creatinine and haemoglobin levels, and stone clearance rate, as well as postoperative short-form (SF)-36 quality-of-life and pain analogue scores at five different time points after surgery. • All data were analysed using a one-way anova test. • A repeated measures anova test was used selectively to assess the progression of SF-36 and pain analogue scores. RESULTS: • The preoperative variables operative time, EBL, postoperative stay (P = 0.45), analgaesia use (P = 0.79), changes in creatinine (P = 0.28) and haemoglobin (P = 0.09) levels, and postoperative SF-36 scores were not significantly different. • In contrast, the differences in analogue pain scales at 1 week after surgery (P = 0.02) and the trends of analogue pain score progression (P = 0.03) were statistically significant. • Three patients underwent second-look procedures for residual stones and there was one case of postoperative pyelonephritis in a multiple sclerosis patient. CONCLUSIONS: • The Cope loop closure patients recovered fastest, while FloSeal closure patients experienced initial increase in pain followed by resolution at 1 month. • As a result of the small study group sizes, it is difficult to show any significant difference in postoperative pain, especially in long-term follow-up; further clinical evaluation is necessary.

PCA3 molecular urine assay for prostate cancer: association with pathologic features and impact of collection protocols.

INTRODUCTION: PCA3 is a non-coding mRNA molecule that is overexpressed in prostate cancer. The purpose of this study is to evaluate the utility of the PCA3 molecular urine test scores to predict adverse pathologic features and catheterized specimen collection. METHODS: Hundred men with clinically localized prostate cancer scheduled to undergo robotic prostatectomy were enrolled in the study following a standard consent process. The study protocol consisted of providing four urine samples. Voided urine obtained following digital rectal examination (DRE) pre-operatively (Vl), catheterized urine without DRE (V2), and l0-day and 6-week postoperative voided (V3 and V4) urine samples were collected and analyzed. These four urine specimens underwent target capture, transcription-mediated amplification, and hybridization in order to quantify both PCA3 and PSA mRNA. The PCA3 score was calculated as the ratio of PCA3 to PSA. RESULTS: Informative rates (sufficient mRNA for analysis) for VI, V2, V3 and V4 were 91, 85, 0 and 2%, respectively. There was no significant associations with pathological stage, Gleason score >6. Higher PCA3 scores at V1 correlated with increased risk for perineural invasion (P = 0.0479). CONCLUSIONS: Informative PCA3 scores can be obtained from post-DRE voided urine as well as catheterized urine without a DRE. The PCA3 test does not seem to predict adverse pathologic features, though, may have an association with perineural invasion. The ability of PCA3 score to predict clinical outcome remains to be determined.

Impact of a laparoscopic renal surgery mini-fellowship program on postgraduate urologist practice patterns at 3-year followup.

PURPOSE: To assist practicing urologists incorporate laparoscopic renal surgery into their practice we established a 5-day mini-fellowship program with a mentor, preceptor and a potential proctor at our institution. We report the impact of our mini-fellowship program at 3-year followup. MATERIALS AND METHODS: A total of 106 urologists underwent laparoscopic ablative (44) or laparoscopic reconstructive (62) renal surgery training. The 1:2 teacher-to-attendee experience included tutorial sessions, hands-on inanimate and animate skills training, and clinical case observations. Participants were asked to complete a detailed questionnaire on laparoscopic practice patterns 1, 2 and 3 years after the mini-fellowship. RESULTS: The questionnaire response rate at 1 to 3 years was 77%, 65% and 68%, respectively. Of responders 72%, 71% and 71% performed laparoscopic renal surgery at 1 to 3 years, respectively. Of the 106 participants 32 (39%) had previous laparoscopic experience, including 78% who responded to the questionnaire at 3 years. Of those surgeons there was an increase in the practice of laparoscopic radical nephrectomy (88% vs 72%), nephroureterectomy (56% vs 13%), pyeloplasty (40% vs 6%) and partial nephrectomy (32% vs 6%) at 3 years. Of the 106 participants 74 (70%) were laparoscopy naïve, including 48 (65%) who responded to the questionnaire at 3 years. The take rate in this group was 76%, 52%, 34% and 23% for laparoscopic radical nephrectomy, nephroureterectomy, pyeloplasty and partial nephrectomy, respectively. Of the participants 90% indicated that they would recommend this training to a colleague. CONCLUSIONS: An intensive 5-day laparoscopic ablative and reconstructive renal surgery course enabled postgraduate urologists to effectively introduce and expand the volume and breadth of their laparoscopic renal surgery practice.

Continence definition after radical prostatectomy using urinary quality of life: evaluation of patient reported validated questionnaires.

PURPOSE: After radical prostatectomy continence is commonly defined as no pads except a security pad or 0 to 1 pad. We evaluated the association of pad status and urinary quality of life to determine whether security and 1 pad status differ from pad-free status to better define 0 pads as the post-prostatectomy standard. MATERIALS AND METHODS: A total of 500 consecutive men underwent robot assisted radical prostatectomy from October 2003 to July 2007. Data were collected prospectively and entered into an electronic database. Postoperatively men completed self-administered validated questionnaires including questions on 1) daily pad use (0, security, 1, or 2 or more), 2) urine leakage (daily, about once weekly, less than once weekly or not at all), 3) urinary control (none, frequent dribbling, occasional dribbling or total control), 4) American Urological Association symptom score and 5) urinary quality of life. RESULTS: Postoperatively men who indicated 0 pad use had a mean +/- SE symptom score of 5.8 +/- 0.3 and pleased quality of life (1.16 +/- 0.08). In contrast, men with a security pad and 1 pad had a symptom score of 7.6 +/- 0.7 and 9.2 +/- 0.6 but mixed quality of life (2.78 +/- 0.18 and 3.41 +/- 0.15, respectively, p <0.0005). CONCLUSIONS: Results show a significant decrease in quality of life between no pads (1.16 or pleased), a security pad and 0 or 1 pad (2.78 and 3.41 or mixed, respectively). Findings do not support defining continence with a security pad or 0 to 1 pad. Continence should be strictly defined as 0 pads.

Periprostatic adipose tissue as a modulator of prostate cancer aggressiveness.

PURPOSE: Adipose tissue has been suggested to contribute to the pathogenesis of various disease states, including prostate cancer. We investigated the association of cytokines and growth factors secreted by periprostatic adipose tissue with pathological features of aggressive prostate cancer. MATERIALS AND METHODS: Periprostatic adipose tissue was harvested from patients undergoing radical prostatectomy and cultured for 24 hours to generate conditioned medium or snap frozen immediately for functional signaling profiling. Multiplex analysis of the periprostatic adipose tissue conditioned medium was used to detect cytokine levels and compared to patient matched serum from 7 patients. Interleukin-6 in serum and periprostatic adipose tissue conditioned medium was further analyzed by enzyme-linked immunosorbent assay and correlated with clinical variables, such as age, body mass index and Gleason score, in 45 patients. Interleukin-6 expression in periprostatic adipose tissue was determined by immunohistochemistry. Reverse phase protein microarray technology was used to analyze cell signaling networks in periprostatic adipose tissue. RESULTS: Interleukin-6 in periprostatic adipose tissue conditioned medium was approximately 375 times greater than that in patient matched serum and levels correlated with pathological grade. This finding was further extended by cell signaling analysis of periprostatic adipose tissue, which showed greater phosphorylation on Stat3 with high grade tumors (any component of Gleason score 4 or 5). CONCLUSIONS: Higher Gleason score correlated with high levels of conditioned medium derived interleukin-6. Moreover, cell signaling analysis of periprostatic adipose tissue identified activated signaling molecules, including STAT3, that correlated with Gleason score. Since STAT3 is interleukin-6 regulated, these findings suggest that periprostatic adipose tissue may have a role in modulating prostate cancer aggressiveness by serving as a source of interleukin-6. Also, we found low numbers of inflammatory cells in the fat, suggesting that adipocytes are the major secretors of interleukin-6.

Long-term impact of a robot assisted laparoscopic prostatectomy mini fellowship training program on postgraduate urological practice patterns.

PURPOSE: Robot assisted laparoscopic prostatectomy has stimulated a great deal of interest among urologists. We evaluated whether a mini fellowship for robot assisted laparoscopic prostatectomy would enable postgraduate urologists to incorporate this new procedure into clinical practice. MATERIALS AND METHODS: From July 2003 to July 2006, 47 urologists participated in the robot assisted laparoscopic prostatectomy mini fellowship program. The 5-day course had a 1:2 faculty-to-attendee ratio. The curriculum included lectures, tutorials, surgical case observation, and inanimate, animate and cadaveric robotic skill training. Questionnaires assessing practice patterns 1, 2 and 3 years after the mini fellowship program were analyzed. RESULTS: One, 2 and 3 years after the program the response rate to the questionnaires was 89% (42 of 47 participants), 91% (32 of 35) and 88% (21 of 24), respectively. The percent of participants performing robot assisted laparoscopic prostatectomy in years 1 to 3 after the mini fellowship was 78% (33 of 42), 78% (25 of 32) and 86% (18 of 21), respectively. Among the surgeons performing the procedure there was a progressive increase in the number of cases each year with increasing time since the mini fellowship training. In the 3 attendees not performing the procedure 3 years after the mini fellowship training the reasons were lack of a robot, other partners performing it and a feeling of insufficient training to incorporate the procedure into clinical practice in 1 each. One, 2 and 3 years following the mini fellowship training program 83%, 84% and 90% of partnered attendees were performing robot assisted laparoscopic prostatectomy, while only 67%, 56% and 78% of solo attendees, respectively, were performing it at the same followup years. CONCLUSIONS: An intensive, dedicated 5-day educational course focused on learning robot assisted laparoscopic prostatectomy enabled most participants to successfully incorporate and maintain this procedure in clinical practice in the short term and long term.

Preliminary study of virtual reality and model simulation for learning laparoscopic suturing skills.

PURPOSE: Repetitive practice of laparoscopic suturing and knot tying can facilitate surgeon proficiency in performing this reconstructive technique. We compared a silicone model and pelvic trainer to a virtual reality simulator in the learning of laparoscopic suturing and knot tying by laparoscopically naïve medical students, and evaluated the subsequent performance of porcine laparoscopic cystorrhaphy. MATERIALS AND METHODS: A total of 20 medical students underwent a 1-hour didactic session with video demonstration of laparoscopic suturing and knot tying by an expert laparoscopic surgeon. The students were randomized to a pelvic trainer (10) or virtual reality simulator (10) for a minimum of 2 hours of laparoscopic suturing and knot tying training. Within 1 week of the training session the medical students performed laparoscopic closure of a 2 cm cystotomy in a porcine model. Objective structured assessment of technical skills for laparoscopic cystorrhaphy was performed at the procedure by laparoscopic surgeons blinded to the medical student training format. A video of the procedure was evaluated with an objective structured assessment of technical skills by an expert laparoscopic surgeon blinded to medical student identity and training format. The medical students completed an evaluation questionnaire regarding the training format after the laparoscopic cystorrhaphy. RESULTS: All students were able to complete the laparoscopic cystorrhaphy. There was no difference between the pelvic trainer and virtual reality groups in mean +/- SD time to perform the porcine cystorrhaphy at 40 +/- 15 vs 41 +/- 10 minutes (p = 0.87) or the objective structured assessment of technical skills score of 8.8 +/- 2.3 vs 8.2 +/- 2.2 (p = 0.24), respectively. Bladder leak occurred in 3 (30%) of the pelvic trainer trained and 6 (60%) of the virtual reality trained medical student laparoscopic cystorrhaphy procedures (Fisher exact test p = 0.37). The only significant difference between the 2 groups was that 4 virtual reality trained medical students considered the training session too short compared to none of those trained on the pelvic trainer (p = 0.04). CONCLUSIONS: There is no significant difference between the pelvic trainer and virtual reality trained medical students in proficiency to perform laparoscopic cystorrhaphy in a pig model, although both groups require considerably more training before performing this procedure clinically. The pelvic trainer training may be more user-friendly for the novice surgeon to begin learning these challenging laparoscopic skills.

Preliminary evaluation of a genitourinary skills training curriculum for medical students.

PURPOSE: Basic urology training in medical school is considered important for many medical and surgical disciplines. We developed a 2-day intensive genitourinary skills training curriculum for medical students beginning their clinical clerkship training years and evaluated the initial experience with this program. MATERIALS AND METHODS: All 94 third-year medical students at the University of California, Irvine were required to participate in a 5.5-hour genitourinary examination skills training program. The teaching course included 1.5 hours of didactic lecture and video presentation with questions and answers, followed by 5, 45-minute hands-on stations including male Foley catheter placement, female Foley catheter placement, testicular examination and digital rectal examination training with a standardized patient, virtual reality cystourethroscopy and, lastly, a urologist led tutorial of abnormal genitourinary findings. The students completed questionnaires before and after the course concerning their experience. At the end of the course the students rated the usefulness of each part of the curriculum and evaluated the faculty. In addition, they were required to complete a multiple choice examination that included 4 genitourinary specific questions. RESULTS: All 94 medical students completed the genitourinary skills training course. Before the course less than 10% of students reported comfort with genitourinary skills, including testicular examination (5%), digital rectal examination (10%), male Foley catheter placement and female Foley catheter placement (2%). Following the course the comfort level improved in all parameters of digital rectal examination (100%) and testicular examination, male Foley catheter placement and female Foley catheter placement (98%). The students rated in the order of most to least useful training 1) standardized patient for testicular examination and digital rectal examination teaching, 2) male Foley catheter placement and female Foley catheter placement training, 3) didactic lecture, 4) tutorial of abnormal genitourinary examination findings and 5) virtual reality cystourethroscopy. On the examination questions following the course 80% to 98% of the class answered each urology content question correctly. CONCLUSIONS: An intensive skills training curriculum significantly improved medical student comfort and knowledge with regard to basic genitourinary skills including testicular examination, rectal examination, and Foley catheter placement in the male and female patient. Further followup will be performed to determine the application of these skills during clinical clerkship rotations.

Body image in women with HIV: a cross-sectional evaluation.

BACKGROUND: HIV lipodystrophy syndrome is a recognized complication of potent antiretroviral therapy and is characterized by often dramatic changes in various body fat stores, both central and peripheral. Given prior findings of heightened body image dysphoria among HIV-infected men with lipodystrophy as compared to HIV-infected men without lipodystrophy, we sought to determine body image among HIV-infected and HIV-negative women and to determine the relationship of HIV and lipodystrophy with body image. Our a priori hypothesis was that women with HIV and lipodystrophy would have significantly poorer body image as compared to women without HIV and to women with HIV without lipodystrophy. RESULTS: 116 women responded to two previously validated self-report instruments (Body Image Quality of Life Index (BIQLI) and the Situational Inventory of Body-Image Dysphoria-Short Form (SIBID-S)) on body image. 62 (53% subjects) HIV-infected women were recruited at the university-based HIV clinic. 54 (47% subjects) HIV-negative female controls were recruited from another study evaluating bone density in otherwise healthy controls. 96% identified their sexual orientation as women having sex with men. Among the HIV-infected group, 36 reported the presence of lipodystrophic characteristics and 26 reported no lipodystrophic changes. Agreement regarding the presence of lipodystrophy between physician and subject was 0.67 as measured by the kappa coefficient of agreement. Compared to HIV-negative women, HIV-positive women demonstrated poor body image as measured by BIQLI (p = 0.0009). Compared with HIV-infected women who denied lipodystrophy, HIV-infected women with self-reported lipodystrophy demonstrated poor body image as measured by BIQLI (p = 0.02) and SIBID-S scales (p = 0.001). CONCLUSION: We demonstrate that HIV and lipodystrophy status among women is associated with poor body image. Universal efforts should be made in the HIV medical community to recognize body image issues particularly among persons affected by lipodystrophy so that appropriate intervention and support may be provided.

Body image in men with HIV.

OBJECTIVE: To determine body image among HIV-infected men and to determine the relationship of lipodystrophy on body image. METHODOLOGY: Self-report questionnaires on body image were distributed to HIV-infected men at the university-based HIV clinic. Two previously validated instruments, the Body Image Quality of Life (BIQLI) scale and the Situational Inventory of Body Image Dysphoria Short Form (SIBID-S) were used to measure body image effects. The presence of lipodystrophy was determined by both self-report and physician examination. Demographic characteristics, disease stage, health status, and quality of life were also ascertained. Analysis of responses was performed via both group comparisons and linear regression analyses. RESULTS: One hundred ten men responded. Seventy-one percent identified their sexual orientation as men having sex with men (MSM). Forty-eight reported the presence of lipodystrophic characteristics; 62 reported no lipodystrophic changes. Agreement regarding the presence of lipodystrophy between physician and subject was 0.80 as measured by the kappa coefficient of agreement. Compared to HIV-infected men who denied lipodystrophy, HIV-infected men with self-reported lipodystrophy demonstrated poor body image as measured by BIQLI (p < 0.0001) and SIBID-S scales (p = 0.0001). Similarly, physician rated lipodystrophy was significantly associated with both body image subscale scores. CONCLUSIONS: We demonstrate that lipodystrophy among HIV-infected men is associated with poor body image.

A novel enrichment program using cascading mentorship to increase diversity in the health care professions.

The authors describe an innovative summer enrichment program based on a cascading mentorship model to transfer knowledge and skills from faculty to medical students to undergraduate students and finally to high school students. The program was designed to give high school students a glimpse of life in medical school and enhance the teaching and leadership skills of underrepresented undergraduate and medical students. Started in 2010 with 30 high school students and 9 college and medical student coaches, the University of California, Irvine, School of Medicine Summer Premed Program expanded rapidly over the next two summers and enrolled a total of 253 high school students, 48 college students, and 12 medical students. The college and medical student coaches, the majority of whom were underrepresented in medicine (URIM), reported that the program enhanced their teaching and leadership skills and self-confidence, motivated them toward careers in academic medicine, and raised their awareness about the importance of cultural diversity. The authors present the details of this interactive, structured program and describe how URIM student empowerment, near-peer teaching, science socialization, and support from the institution's leadership and faculty members provided a climate that fostered belonging, a sense of personal transformation, and professional development among students from different levels of education and diverse backgrounds. Long-term follow-up of the participants' career choices is needed.

Hypothermic robotic radical prostatectomy: impact on continence.

INTRODUCTION: Radical prostatectomy undoubtedly causes inflammatory damage to surrounding neuromuscular tissues (i.e., bladder, urethra, and nerves) that may contribute to urinary incontinence. We report the use of local hypothermia during robot-assisted laparoscopic prostatectomy to attenuate this injury. METHODS: Regional pelvic cooling was achieved using cold intracorporeal irrigation and an endorectal cooling balloon (ECB). In all, 115 men undergoing hypothermic robot-assisted laparoscopic radical prostatectomy (hRLP) (case #667-782) were prospectively compared with a historical cohort (case #1-666). Intracorporeal rectal and neurovascular bundle temperatures (T) and intrarectal temperatures were measured. Continence was defined as zero urinary pads. Kaplan-Meier analysis of time to zero pads and multivariate Cox proportional hazards regression was used. RESULTS: Hypothermia was achieved in 112/115 patients; 6 were excluded (3 ECB malfunction, 2 prior radiation, and 1 completion prostatectomy). Median endorectal T = 18.7 degrees C (range 9.1-29.5 degrees C). Mean intracorporeal T = 25.58 degrees C (ECB + irrigation, range 19.4-34.0 degrees C). Three and 12-month hRLP zero pad rates were 81% to 89% and 100% for initial and extended cooling groups versus 65% and 89% for controls. Return to continence was significantly faster for hRLP versus controls: median time to zero pad use was 39 days for hRLP versus 62 days for controls. Multivariate analysis adjusting for American Urological Association (AUA) symptom score, nerve-sparing surgery, learning curve, international index of erectile function-5, age, and prostate weight demonstrated a significantly faster return to continence (hazard ratio = 1.526; 95% CI 1.11, 2.09). Trends toward improved continence were observed with colder temperatures and older patients. CONCLUSIONS: Local hypothermia during prostatectomy resulted in a significant improvement in early postoperative zero pad continence rates. Longer and deeper cooling appears to be associated with improved continence, particularly among older patients.