The Null Effect of Bladder Neck Size on Incontinence Outcomes after Radical Prostatectomy.

PURPOSE: We sought to determine whether bladder neck size is associated with incontinence scores after robot-assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS: Consecutive eligible patients undergoing robot-assisted laparoscopic radical prostatectomy between July 19 and December 28, 2016 were enrolled in a prospective, longitudinal, observational cohort study. The primary outcome was patient reported urinary incontinence on the EPIC (Expanded Prostate Cancer Index Composite) scale 6 and 12 weeks postoperatively. The relationship between the EPIC score of urinary incontinence and bladder neck size was evaluated by multiple regression. Predicted EPIC scores for incontinence were displayed graphically after using restricted cubic splines to model bladder neck size. RESULTS: A total of 107 patients were enrolled. The response rate was 98% and 87% at 6 and 12 weeks, respectively. Bladder neck size was not significantly associated with incontinence scores at 6 and 12 weeks. Comparing the 90th percentile for bladder neck size (18 mm) with the 10th percentile (7 mm) revealed no significant difference in adjusted EPIC scores for incontinence at 6 weeks (ß coefficient 0.88, 95% CI -10.92-12.68, p = 0.88) or at 12 weeks (ß coefficient 5.80, 95% CI -7.36-18.97, p = 0.39). CONCLUSIONS: These findings question the merit of creating an extremely small bladder neck during robot-assisted laparoscopic radical prostatectomy. We contend that doing so increases the risk of positive margins at the bladder neck without facilitating early recovery of continence.

Variation in the Diagnostic Evaluation among Persons with Hematuria: Influence of Gender, Race and Risk Factors for Bladder Cancer.

PURPOSE: We sought to determine whether race, gender and number of bladder cancer risk factors are significant predictors of hematuria evaluation. MATERIALS AND METHODS: We used self-reported data from SCCS (Southern Community Cohort Study) linked to Medicare claims data. Evaluation of subjects diagnosed with incident hematuria was considered complete if imaging and cystoscopy were performed within 180 days of diagnosis. Exposures of interest were race, gender and risk factors for bladder cancer. RESULTS: Of the 1,412 patients evaluation was complete in 261 (18%). On our adjusted analyses African American patients were less likely than Caucasian patients to undergo any aspect of evaluation, including urology referral (OR 0.72, 95% CI 0.56-0.93), cystoscopy (OR 0.67, 95% CI 0.50-0.89) and imaging (OR 0.75, 95% CI 0.59-0.95). Women were less likely than men to be referred to a urologist (OR 0.59, 95% CI 0.46-0.76). Also, although all patients with 2 or 3 risk factors had 31% higher odds of urology referral (OR 1.31, 95% CI 1.02-1.69), adjusted analyses indicated that this effect was only apparent among men. CONCLUSIONS: Only 18% of patients with an incident hematuria diagnosis underwent complete hematuria evaluation. Gender had a substantial effect on referral to urology when controlling for socioeconomic factors but otherwise it had an unclear role on the quality of evaluation. African American patients had markedly lower rates of thorough evaluation than Caucasian patients. Number of risk factors predicted referral to urology among men but it was otherwise a poor predictor of evaluation. There is opportunity for improvement by increasing the completion of hematuria evaluations, particularly in patients at high risk and those who are vulnerable.

Incidence and predictors of understaging in patients with clinical T1 urothelial carcinoma undergoing radical cystectomy.

OBJECTIVE: To evaluate predictors of understaging in patients with presumed non-muscle-invasive bladder cancer (NMIBC) identified on transurethral resection of bladder tumour (TURBT) who underwent radical cystectomy (RC) with attention to the role of a restaging TURBT. PATIENTS AND METHODS: We retrospectively evaluated 279 consecutive patients with clinically staged T1 (cT1) disease after TURBT who underwent RC at our institution from April 2000 to July 2011. In all, 60 of these cT1 patients had undergone a restaging TURBT before RC. The primary outcome measure was pathological staging of ≥T2 disease at the time of RC. RESULTS: In all, 134 (48.0%) patients were understaged. Of the 60 patients who remained cT1 after a restaging TURBT, 28 (46.7%) were understaged. Solitary tumour (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.25-0.76, P = 0.004) and fewer prior TURBTs (OR 0.84, 95% CI 0.71-1.00, P = 0.05) were independent risk factors for understaging. CONCLUSIONS: Despite the overall improvement in staging accuracy linked to restaging TURBTs, the risk of clinical understaging remains high in restaged patients found to have persistent T1 urothelial carcinoma who undergo RC. Solitary tumour and fewer prior TURBTs are independent risk factors for being understaged. Incorporating these predictors into preoperative risk stratification may allow for augmented identification of those patients with clinical NMIBC who stand to benefit most from RC.

Operative considerations for late-presenting persistent Müllerian duct syndrome.

Persistent Müllerian duct syndrome (PMDS) is a condition in which a 46, XY male displays masculine external genitalia, but internally retains developed Müllerian duct structures (uterus, fallopian tubes, and upper two-thirds vagina). Thoughtful operative consideration is needed to maximize the therapeutic benefit while minimizing the risk of hypogonadism, infertility, and erectile dysfunction. We report a 53-year-old male with a pelvic mass incidentally discovered on routine ultrasound, intra-operatively discovered to be PMDS. PMDS is a rare condition that may present late in life. The primary operative consideration is performing orchiopexy for cancer surveillance or orchiectomy if orchiopexy is not possible. Additional considerations include surveillance and counseling of infertility, hypogonadism, and assessment of the potential need for involvement of psychiatry. Removal of Müllerian remnants is a subject to debate. If possible, discuss with the patient their risks and options in the preoperative setting to guide operative planning.

Use of Contrasted Computerized Tomography as a Surrogate for Nuclear Medicine Renogram to Categorize Renal Function in the Setting of Ureteropelvic Junction Obstruction.

OBJECTIVE: To use basic measurements on contrasted computerized tomography (CT) to reliably determine whether a kidney with ureteropelvic junction obstruction (UPJO) is definitively functional (≥30% differential renal function [DRF]) or nonfunctional (≤10% DRF), obviating the need for nuclear medicine renogram (RG) to determine DRF. METHODS: This is a single institution, retrospective cohort of patients diagnosed with UPJO who underwent either pyeloplasty or nephrectomy between December 2004 and December 2014. Included patients had both preoperative mercaptoacetyltriglycine RG and contrasted CT within 180 days of each other. Patients with stents or nephrostomy tubes were excluded. RESULTS: A total of 49 patients were included. The strongest correlation between differential CT measurements and DRF on RG existed by multiplying the cortical area by the average cortical Hounsfield units (Pearson's r = 0.90, P < .001). Using an equation derived from linear regression and cutoff values generated by receiver operator curve (ROC) analysis, CT equation-estimated DRF values of ≥40% and ≤10% correlated with "definitively functional" RG values of ≥30% (100% specificity) and with "definitively nonfunctional" RG values of ≤10% (100% specificity), respectively. In 30 out of 49 cases, CT could have replaced RG. CONCLUSION: RG is the gold standard in determining quantitative DRF. However, the treatment algorithm for a kidney with symptomatic UPJO hinges on categorized function: "functional" (repair) or "nonfunctional" (remove). Appropriate measurements on contrasted CT can categorize definitively functional or nonfunctional kidneys with UPJO, negating the need for RG to obtain DRF in a majority of cases. This study design favors real-world application with potential to reduce medical expenditure and delay in definitive treatment.

Prolonged maintenance of water balance by adult females of the American spider beetle, Mezium affine Boieldieu, in the absence of food and water resources.

Moisture requirements were evaluated for female adults of spider beetles Mezium affine Boieldieu and Gibbium aequinoctiale Boieldieu to determine how they are differentially adapted for life in a dry environment. Features showing extreme desiccation resistance of M. affine were an impermeable cuticle wherein activation energies (43kJ/mol) were suppressed, daily water losses as little as 0.3%/day with an associated group effect, a low 64% water content and an impressive ability to survive nearly 3 months with no food and water. Behaviorally, the extended period of water stress and fasting was marked by long intervals of physical inactivity (quiescence), as though dead. These characteristics emphasizing water retention rather than gain are shared by G. aequinoctiale and reflect a typical xerophilic water balance profile. Water uptake was restricted to imbibing liquid, as evidenced by uptake of dye-stained droplets of free water and a critical equilibrium activity of 1.00a(v), where the inability to absorb water vapor from the air fails to equilibrate declining water levels (gain not equal to loss) except at saturation. Four-fold reduction in survival time within dry air and accelerated water loss rates with high activation energies for female adults of the closely related winged Prostephanus truncatus (Say) suggest that the enhanced water conservation of spider beetles is due, in part, to fusion of their elytra supplemented by entering into quiescence.