Rezum for retention-retrospective review of water vaporization therapy in the management of urinary retention in men with benign prostatic hyperplasia.

OBJECTIVE: Rezum vapor ablation is a minimally invasive treatment for benign prostatic hyperplasia (BPH) that uses injections of sterile water vapor directly into the prostate for tissue ablation. Although Rezum is currently indicated for use in men with prostate sizes ≥30 and ≤80 ml, it is unclear how effective Rezum is for men in urinary retention. We sought to determine whether Rezum is effective in the treatment of catheter-dependent urinary retention secondary to BPH. METHODS: A retrospective chart review was conducted on consecutive patients who presented for urinary retention and subsequently treated with Rezum. We evaluated procedural details and examined variables pre- and post-Rezum (at 6 months) including International Prostate Symptom Score (IPSS), IPSS quality of life (IPSS-QOL), maximum flow (Qmax ), post void residual volume (PVR), prostate specific antigen, rate of retention, and use of alpha blockers and 5-alpha reductase inhibitor (5ARI). RESULTS: Of the 49 patients included in this study, median age of was 73 years, median prostate volume was 73cc (Interquartile range [IQR]: 50, 103) and a median lobe was present in 80% of patients. All patients were in urinary retention before treatment with a median PVR of 900 ml (IQR: 566, 1146). Following Rezum, IPSS (17 pre-Rezum, 4 post-Rezum) and IPSS-QOL (4 pre-Rezum, 1 post-Rezum) both improved at 6 months (p < 0.01). Qmax increased from 3 to 6 ml/s (p = 0.03) and PVR decreased from 900 to 78 ml (p < 0.01). Only 17/38 patients taking alpha-blockers and 7/15 patients on 5ARIs continued therapy at 6 months following Rezum (p < 0.01). Of the 49 patients treated, 10 (20.4%) remained in catheter dependent urinary retention following the procedure, and 6 remained in retention at 6 months (12.2%) even after further surgical therapies for BPH (p < 0.01). CONCLUSION: Rezum is a safe and effective therapy for treating catheter dependent urinary retention in patients with BPH, including those with median lobes. As a minimally invasive therapy, it is a promising option in patient, particularly those who are not suitable for prolonged anesthesia.

Post-analysis follow-up and validation of microarray experiments.

Measurement of gene-expression profiles using microarray technology is becoming increasingly popular among the biomedical research community. Although there has been great progress in this field, investigators are still confronted with a difficult question after completing their experiments: how to validate the large data sets that are generated? This review summarizes current approaches to verifying global expression results, discusses the caveats that must be considered, and describes some methods that are being developed to address outstanding problems.

Prostate Cancer: Under-representation of African American Men in Research Studies Used in the Latest NCCN Guidelines.

OBJECTIVE: To evaluate racial data in studies used in current NCCN prostate cancer guidelines. These guidelines represent the latest information that informs clinical practice. Prostate cancer disproportionately affects mortality in Black patients compared to White patients at a 2.1-fold higher death rate. However, this racial disparity is not accounted for when including patients in research. METHODS: The studies referenced in the latest NCCN guidelines were evaluated for inclusion of racial demographics, and whether they properly account for the higher mortality rate of prostate cancer seen in Black patients. We then analyzed topics within prostate cancer. RESULTS: After application of exclusion criteria, 547 of 878 studies were included for analysis; of those, only 32.4% included demographic data. Overall, Black patients accounted for 472,476 (12.8%) of total patients, while 3,023,007 (81.7%) patients were White. These findings were consistent with specific areas including risk stratification (12% vs 75%), imaging and staging (11% vs 80%), treatment (16% vs 81%), recurrence (15% vs 73%), castration-sensitive prostate cancer (9% vs 84%), castration-resistant prostate cancer (8% vs 73%), and metastatic bone disease (7% vs 84%). CONCLUSION: Our analysis showed consistently that although the guidelines utilize the best research, such studies often do not report racial demographics or have patient populations that do not reflect racial differences in mortality of prostate cancer. Our study questions the generalization of these studies to Black patients. Future research should emphasize inclusion of racial demographics and recruit appropriately representative study cohorts.

Effect of Gene 33/Mig6/ERRFI1 on hexavalent chromium-induced transformation of human bronchial epithelial cells depends on the length of exposure.

Hexavalent chromium (Cr(VI)) compounds are environmental and occupational lung carcinogens. The present study followed the chronic effect of Cr(VI) on the neoplastic transformation of BEAS-2B lung bronchial epithelial cells with or without deletion of Gene 33 (Mig6, EFFRI1), a multifunctional adaptor protein. We find that Gene 33-deleted cells exhibit increased anchorage-independent growth compared to control cells after transformed by 8-week but not 24-week Cr(VI) exposure. Gene 33-deleted cells show a higher level of cell proliferation and are more resistant to acute Cr(VI) toxicity compared to control cells after transformed by 8-week but not 24-week Cr(VI) exposure, despite that 24-week-transformed cells have increased resistance to acute Cr(VI) toxicity. However, Gene 33-deleted cells show increased migration after transformed by both 8-week and 24-week Cr(VI) exposures. Furthermore, only cells transformed by 24 weeks of Cr(VI) exposure can form subcutaneous tumors in nude mice. Although no significant difference in the size of tumors formed by the two cell types, there is a marked difference in the histological manifestation and more MMP3 expression in tumors from Gene 33-deleted cells. Our results demonstrate progressive neoplastic transformation of BEAS-2B cells and the adaptation of these cells to Gene 33 deletion during chronic exposure to Cr(VI).

Optic disc edema, globe flattening, choroidal folds, and hyperopic shifts observed in astronauts after long-duration space flight.

PURPOSE: To describe the history, clinical findings, and possible etiologies of ophthalmic findings discovered in 7 astronauts after long-duration space flight, and document vision changes in approximately 300 additional astronauts. DESIGN: Retrospective, observational examination of ophthalmic findings in 7 astronauts and analysis of postflight questionnaires regarding in-flight vision changes in approximately 300 additional astronauts. PARTICIPANTS: Seven astronauts with ophthalmic anomalies upon return from long-duration space missions to the International Space Station and 300 additional astronauts who completed postflight questionnaires regarding in-flight vision changes. METHODS: Before and after long-duration space flight, all 7 subjects underwent complete eye examinations, including cycloplegic and/or manifest refraction and fundus photography. Six underwent postmission optical coherence tomography (OCT) and magnetic resonance imaging (MRI); 4 had lumbar punctures (LP). Approximately 300 astronauts were queried regarding visual changes during space missions. MAIN OUTCOME MEASURES: Refractive change, fundus photograph examination, retina OCT, orbital MRI, LP opening pressures, and examination of visual acuity data. RESULTS: After 6 months of space flight, 7 astronauts had ophthalmic findings, consisting of disc edema in 5, globe flattening in 5, choroidal folds in 5, cotton wool spots (CWS) in 3, nerve fiber layer thickening by OCT in 6, and decreased near vision in 6 astronauts. Five of 7 with near vision complaints had a hyperopic shift ≥+0.50 diopters (D) between pre/postmission spherical equivalent refraction in 1 or both eyes (range, +0.50 to +1.75 D). These 5 showed globe flattening on MRI. Lumbar punctures performed in the 4 with disc edema documented opening pressures of 22, 21, 28, and 28.5 cm H(2)O performed 60, 19, 12, and 57 days postmission, respectively. The 300 postflight questionnaires documented that approximately 29% and 60% of astronauts on short and long-duration missions, respectively, experienced a degradation in distant and near visual acuity. Some of these vision changes remain unresolved years after flight. CONCLUSIONS: We hypothesize that the optic nerve and ocular changes we describe may result from cephalad fluid shifts brought about by prolonged microgravity exposure. The findings we report may represent parts of a spectrum of ocular and cerebral responses to extended microgravity exposure. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Small lymphocytic lymphoma of the prostate mimicking a PIRADS 5 lesion that resolved after systemic treatment.

Prostatic PIRADS 4 and 5 lesions on multiparametric MRI typically represent adenocarcinoma with small lymphocytic lymphoma being a rare pathological finding. We report a case of small lymphocytic lymphoma masquerading as PIRADS 4 and 5 lesions with associated lymphadenopathy in a 69-year-old male on active surveillance for low-risk prostate cancer that was subsequently confirmed on targeted and systematic prostate biopsy. Following treatment of lymphoma with ibrutinib, there was complete resolution of the PIRADS lesions on follow-up mpMRI.

The Two-Point Technique for Fluoroscopic-Guided Endoscopic Procedures in Urology: A Validation Study.

Introduction: The widespread use of diagnostic and therapeutic ionizing radiation raises concerns regarding excessive occupational and patient exposure. In this study, we test a novel fluoroscopic technique that has the potential to minimize radiation dose during urologic procedures. Materials and Methods: A prospective evaluation of all patients undergoing endoscopic urologic procedures in our institution was conducted. A "two-point technique (TPT)" is described in which the fluoroscope image intensifier (c-arm) is shifted between caudal and cephalad set points of the operative field. We wished to determine whether patient radiation exposure was lower with TPT than with a non-structured conventional technique, referred to as the cognitive fluoroscopic technique (CFT), in which the manipulation of the c-arm was at the discretion of the user. We obtained all clinical, radiographic, and fluoroscopic data of patients in the study period and used unpaired nonparametric statistical analysis of univariates entered stepwise into a logistic regression model. Results: A total of 106 endoscopic urologic procedures from January 2016 to November 2018 were reviewed. Forty-four (41.5%) cases were performed using TPT and 62 (58.5%) using CFT. The mean fluoroscopy time of TPT vs CFT was 71.1 (±60.8) seconds vs 104.5 (±91.6) seconds, respectively (p = 0.04), and the mean radiation dose on TPT vs CFT was 11.6 (±10.6) mGy vs 20.3 (±24.3) mGy, respectively (p = 0.03). TPT was an independent predictor of reduced operative room (OR) time and fluoro time (p < 0.05), while body mass index, age, and operator were not. Conclusion: The "TPT" helps reducing radiation dose and fluoroscopic time during endoscopic urologic procedures. The TPT is useful to lower radiation exposure to patients and OR staff.

Contemporary Trends in Percutaneous Nephrolithomy Across New York State: A Review of the Statewide Planning and Research Cooperative System.

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a complex multistep surgery that has shown a steady increase in use for the past decade in the United States. We sought to evaluate the trends and factors associated with PCNL usage across New York State (NYS). Our goal was to characterize patient demographics and socioeconomic factors across high-, medium-, and low-volume institutions. Materials and Methods: We searched the NYS, Statewide Planning and Research Cooperative System (SPARCS) database from 2006 to 2014 using ICD-9 Procedure Codes 55.04 (percutaneous nephrostomy with fragmentation) for all hospital discharges. Patient demographics including age, gender, race, insurance status, and length of hospital stay were obtained. We characterized each hospital as a low-, medium-, or high-volume center by year. Patient and hospital demographics were compared and reported using chi-square analysis and Student's t-test for categorical and continuous variables, respectively, with statistical significance as a p-value of <0.05. Results: We identified a total of 4576 procedures performed from 2006 to 2014 at a total of 77 hospitals in NYS (Table 1). Total PCNL volume performed across all NYS hospitals increased in the past decade, with the greatest number of procedures performed in 2012 to 2013. Low-volume institutions were more likely to provide care to minority populations (21.4% vs 17.3%, p < 0.001) and those with Medicaid (25.5% vs 21.5%, p < 0.001). High-volume institutions provided care to patients with private insurance (42.1% vs 34.0%, p < 0.001) and had a shorter length of stay (3.3 days vs 4.1 days, p < 0.001). Conclusion: Our data provide insight into the patient demographics of those treated at high-, medium-, and low-volume hospitals for PCNL across NYS. Significant differences in race, insurance status, and length of stay were noted between low- and high-volume institutions, indicating that racial and socioeconomic factors play a role in access to care at high-volume centers.

Detection of lymph node metastases in penile cancer.

Penile cancer (PC) is a relatively rare malignancy in the United States (US) but a greater concern in developing nations. Lymph node imaging remains critical to the staging and treatment of this disease as metastases develop in a predictable, anatomic fashion. Early surgical intervention remains a mainstay in treatment and imaging often aids in decision making. This review highlights the indications for imaging in both low-stage and advanced disease. Furthermore, we discuss the benefits and limitations of currently available imaging for staging of inguinal and pelvic lymph nodes in PC and novel modalities in development.

Prostate Cancer Screening Trends After United States Preventative Services Task Force Guidelines in an Underserved Population.

Purpose: Prostate cancer screening is a controversial topic. We examined trends in Prostate Specific Antigen (PSA) testing in an underserved population before and after the United States Preventative Services Task Force (USPSTF) recommendation against screening. Methods: Data were collected on all PSA and cholesterol screening tests from 2008 to 2014. We examined the trend of these tests and prostate biopsies while comparing this data to lipid panel data to adjust for changes in patient population. Results: A decrease in PSA screening was observed from 2010 through 2014, with the greatest decline in 2012. The age group most affected was patients aged 55-69 years. The amount of prostate biopsies during this period decreased as well. Conclusions: Decreased rates of PSA screening were observed in our urban hospital population that preceded the publication of the USPSTF guidelines. The incidence of prostate biopsies decreased in this timeframe. It now remains to be demonstrated whether decreased PSA screening rates impact the diagnosis of and ultimately the survival from prostate cancer.

Hyper IgE Syndrome and Renal Cell Carcinoma.

Hyper IgE Syndrome (HIES) is an immunodeficiency disorder characterized by increased serum levels of IgE, eczema, and recurrent cutaneous and pulmonary infections. In this report, we present, to our knowledge, the first documented case of renal cell carcinoma (RCC) found in a patient with HIES. The patient received infectious disease clearance prior to obtaining a partial nephrectomy which revealed clear cell histology. Both HIES and RCC have an immunological basis for their pathophysiology and may involve common pathways. Further studies may provide insight into any possible link and clinicians should be mindful of immunocompromised patients who present with risk factors for genitourinary malignancy.

Device-Related Adverse Events During Percutaneous Nephrolithotomy: Review of the Manufacturer and User Facility Device Experience Database.

INTRODUCTION AND OBJECTIVES: Percutaneous nephrolithotomy (PCNL) is an established technique for removal of large stones from the upper urinary tract. It is a complex multistep procedure requiring several classes of instruments that are subject to operator misuse and device malfunction. We report device-related adverse events during PCNL from the Manufacturer and User Facility Device Experience (MAUDE) database using a recently developed standardized classification system. MATERIALS AND METHODS: The MAUDE database was queried for "percutaneous nephrolithotomy" from 2006 to 2016. The circumstances and patient complications associated with classes of devices used during PCNL were identified. We then utilized a novel MAUDE classification system to categorize clinical events. Logistic regression analysis was performed to identify associations between device classes and severe adverse events. RESULTS: A total of 218 device-related events were reported. The most common classes included: lithotripter 53 (24.3%), wires 43 (19.7%), balloon dilators 30 (13.8%), and occlusion balloons 28 (12.8%). Reported patient complications included need for a second procedure 12 (28.6%), bleeding 8 (19.0%), retained fragments 7 (16.7%), prolonged procedure 4 (9.5%), ureteral injury 2 (4.8%), and conversion to an open procedure 3 (7.1%). Using a MAUDE classification system, 176 complications (81%) were Level I (mild/none), 26 (12%) were Level II (moderate), 15 (7%) were Level III (severe), and 1 (0.5%) was Level IV (life threatening). On univariate analysis, balloon dilators had the highest risk of Level II-IV complications compared with the other device classes [odds ratio: 4.33, confidence interval: 1.978, 9.493, p < 0.001]. The device was evaluated by the manufacturer in 93 (42.7%) cases, with 54.8% of reviewed cases listing the source of malfunction as misuse by the operator. CONCLUSIONS: PCNL is subject to a wide range of device-related adverse events. A MAUDE classification system is useful for standardized, clinically-relevant reporting of events. Our findings highlight the importance of proper surgeon training with devices to maximize efficiency and decrease harm.

Solid renal tumor severity in von Hippel Lindau disease is related to germline deletion length and location.

von Hippel Lindau disease (VHL) is an autosomal dominant familial cancer syndrome linked to alteration of the VHL tumor suppressor gene. Affected patients are predisposed to develop pheochromocytomas and cystic and solid tumors of the kidney, CNS, pancreas, retina, and epididymis. However, organ involvement varies considerably among families and has been shown to correlate with the underlying germline alteration. Clinically, we observed a paradoxically lower prevalence of renal cell carcinoma (RCC) in patients with complete germline deletion of VHL. To determine if a relationship existed between the type of VHL deletion and disease, we retrospectively evaluated 123 patients from 55 families with large germline VHL deletions, including 42 intragenic partial deletions and 13 complete VHL deletions, by history and radiographic imaging. Each individual and family was scored for cystic or solid involvement of CNS, pancreas, and kidney, and for pheochromocytoma. Germline deletions were mapped using a combination of fluorescent in situ hybridization (FISH) and quantitative Southern and Southern blot analysis. An age-adjusted comparison demonstrated a higher prevalence of RCC in patients with partial germline VHL deletions relative to complete deletions (48.9 vs. 22.6%, p=0.007). This striking phenotypic dichotomy was not seen for cystic renal lesions or for CNS (p=0.22), pancreas (p=0.72), or pheochromocytoma (p=0.34). Deletion mapping revealed that development of RCC had an even greater correlation with retention of HSPC300 (C3orf10), located within the 30-kb region of chromosome 3p, immediately telomeric to VHL (52.3 vs. 18.9%, p <0.001), suggesting the presence of a neighboring gene or genes critical to the development and maintenance of RCC. Careful correlation of genotypic data with objective phenotypic measures will provide further insight into the mechanisms of tumor formation.

The genetic basis of renal cell carcinoma.

The recognition of hereditary forms of renal cancer and the development of high-throughput genetic analysis have led to the identification of genes responsible for familial renal epithelial tumors of differing histologies and cytogenetic features. Some of these genes (VHL) are known to have an important role in sporadic renal neoplasia. This article describes the various epithelial renal tumors most commonly encountered by the urologist, the molecular and cytogenetic distinctions between them, and the hereditary syndromes that predispose to these tumors. Consideration of these syndromes is important for proper treatment when one encounters patients with multiple renal tumors, tumors at an early age of onset, or patients with a positive family history of renal cell carcinoma.

Factors influencing residents' pursuit of urology fellowships.

OBJECTIVE: To assess the predictors of residents' pursuit of fellowship training by surveying current urology residents and recent graduates. Postgraduate fellowship training of urologists could be an important source of urologic physician-scientists and continued innovation in urologic care. METHODS: A Web-based survey was electronically mailed to urology residents and recent graduates of urologic residency. Variables concerning sex, marital status, debt load, research and clinical exposure, publications, and postgraduate careers were recorded. RESULTS: Of the 71 respondents, 46 (65%) were married and 45% had children/dependents. Of the 69% who applied for fellowship, the "most important" factors influencing the pursuit of fellowship were intellectual appeal (82%), mentors (79%), the desire for an additional point of view for surgical training (58%), and the desire to pursue a career in academics (52%). Forty of those completing a fellowship (87%) versus two of those completing residency alone (13%) would pursue a career in academics. Residents with a mentor were 20 times more likely to pursue a urology fellowship. A shorter residency (5 years), encouragement by a program director, and manuscript publication during residency were also independent predictors. CONCLUSION: Mentorship, a shorter residency, and manuscript publication during residency were independent predictors of pursuing fellowship training. Debt load, age, marital status, and a desire to pursue a career in academic medicine were not significant factors.

What is the "true" incidence of active surveillance and brachytherapy candidates in men undergoing robot-assisted radical prostatectomy?

PURPOSE: To correlate clinical low-risk prostate cancers with pathologic outcomes in men who are considered for active surveillance (AS), interstitial radiation therapy, or radical prostatectomy (RP). PATIENTS AND METHODS: Clinical and pathologic data of 76 consecutive patients who underwent RP by a single surgeon between October 2001 and July 2008 were reviewed. The retrospective review identified men with clinical low-risk disease--defined as a prostate-specific antigen (PSA) level <10 ng/mL, no Gleason pattern >3, no >2 cores positive, and no core >50%--who would also have been considered for AS and/or brachytherapy based on these features. Pathologic specimens were examined for Gleason primary, secondary, and tertiary patterns, perineural invasion, capsular involvement, margins, nodal disease, and seminal vesicle involvement. RESULTS: Of the patients who underwent RP, 42/76 (55%) had low-risk clinical staging; 8/76 (19%) had low-risk features on final pathologic staging. Fifty-four of 76 (71%) were pT2c; 10% were pT3. Gleason 6 was seen in 41/76 (53%) of RP specimens; Gleason 7 and 8 in 41% and 4%, respectively. Favorable brachytherapy parameters were identified in 63% of those who underwent surgery, but 39 of 48 (81%) would have been inappropriately selected based on features of the pathologic specimen. CONCLUSION: Clinical staging based on PSA level and biopsy findings correlates poorly with pathologic outcome when stratifying for low-risk features in men who may be candidates for brachytherapy and/or AS.