Emotional and behavioral problems in children and adolescents with lower urinary tract dysfunction: a population-based study.

BACKGROUND: An association has been found between lower urinary tract dysfunction (LUTD) and emotional and behavioral problems, particularly in cases of urinary incontinence. Other associated symptoms and the coexistence of functional constipation require further investigation. OBJECTIVE: To assess whether emotional and behavioral problems are more common in children and adolescents with LUTD. STUDY DESIGN: A multicenter, cross-sectional, population-based study conducted in public places. Parents answered questions on urinary and psychological symptoms in their children aged 5-14 years. Children/adolescents with neurological problems or anatomical urinary tract abnormalities were excluded. The Dysfunctional Voiding Scoring System was used for assessing urinary symptoms, the Rome III Diagnostic Criteria for evaluating bowel symptoms, and the Strengths and Difficulties Questionnaire (SDQ) for evaluating emotional and behavioral problems. RESULTS: Of the 806 children/adolescents included, 53% were female. The mean age was 9.1 ± 2.7 years. The prevalence of LUTD was 16.4%. Overall, 26.2% had abnormal scores in the overall SDQ scale, 29.2% in the emotional problems subscale, and 30% in the conduct problems subscale. Of the children with LUTD, 40.5% screened positive for emotional/behavioral problems, with a significant association being found for the overall SDQ scale (P < 0.001) and for the emotional problems (P < 0.001), conduct problems (P < 0.001), and hyperactivity (P = 0.037) subscales. Urinary urgency, urinary incontinence, and voiding postponement were significantly associated with a greater prevalence of abnormalities in the overall SDQ score (P = 0.05; P = 0.004, and P = 0.012, respectively). Bladder and bowel dysfunction was an aggravator of emotional and behavioral problems, with more intense symptoms, both in the overall SDQ scale and in the subscales. In the multivariate analysis, the factors independently associated with the presence of emotional and behavioral problems were LUTD (odds ratio [OR] = 1.91), constipation (OR = 1.7), studying in a government-funded school (OR = 2.2), and poor education of the head of the family (OR = 1.9). CONCLUSIONS: Children and adolescents with LUTD have more emotional and behavioral problems, with bladder and bowel dysfunction being an aggravating factor for this association.

Association between a constipation scoring system adapted for use in children and the dysfunctional voiding symptom score in children and adolescents with lower urinary tract symptoms.

INTRODUCTION: A presumed association between more severe lower urinary tract symptoms (LUTS) and more severe functional constipation (FC) remains unconfirmed. Because the Rome IV criteria do not quantify FC, an adult constipation scoring system was modified and adapted for use in children. OBJECTIVES: The objective of this study was to assess the correlation between FC severity as determined by the modified constipation scoring system and LUTS severity in children/adolescents and the correlation between this modified scoring system and the Rome IV criteria. STUDY DESIGN: This was a cross-sectional study including 5- to 17-year-old patients with LUTS, with or without FC. Patients with neurological and/or anatomical abnormalities of the genitourinary and/or gastrointestinal tract were excluded. Girls with Dysfunctional Voiding Symptom Score (DVSS) ≥6 and boys with DVSS ≥9 were diagnosed with lower urinary tract dysfunction (LUTD). Patients with at least two positive Rome IV criteria were considered constipated. The severity of FC according to the adapted constipation scoring system was classified as mild for scores of 1-10, moderate for scores 11-20, and severe for scores 21-30. RESULTS: Of 128 patients with LUTS, 71 (55.5%) were female. Lower urinary tract dysfunction was detected in 107 patients (83.6%) and was more common in girls. Functional constipation was present in 80 patients (62.5%). Constipated children had higher constipation scores and DVSS, with both scores increasing with the severity of FC. Correlation was moderate between the constipation score and the DVSS (þ = 0.5, p < 0.001) and was strong between positivity for a greater number of Rome IV criteria and the constipation score (þ = 0.7, p < 0.001). Most of the constipated patients had mild or moderate FC, while in 30 non-constipated patients, the constipation score indicated mild FC. DISCUSSION: Patients from a specialist center are more likely to have more severe medical problems, and this may have influenced the correlation between the scores. The modifications made to the constipation scoring system require a future validation study. Nevertheless, this study provides new data on urinary dysfunction and its association with FC and highlights the need to investigate occult bowel symptoms that could affect the treatment of urinary dysfunction. CONCLUSION: The intensity of FC as measured by the modified constipation scoring system correlated with the severity of the urinary symptoms in children/adolescents with LUTS/LUTD. In constipated patients, there was a correlation between the modified constipation scoring system and the Rome IV criteria. In non-constipated patients, the constipation scoring system identified symptoms/signs of bowel dysfunction not picked up by the Rome IV criteria. Finally, constipation score modified for use in children and adolescents could be important for research purpose and particularly having a prognostic importance.

Percutaneous electrical stimulation for overactive bladder in children: a pilot study.

PURPOSE: The purpose of this was to evaluate the efficacy (tolerance and safety) of once-a-week parasacral percutaneous electrical nerve stimulation (PENS) to treat overactive bladder (OAB) in children. MATERIALS AND METHODS: This is a prospective case series of children aged 4-14 years who underwent PENS for OAB. Acupuncture needles were used bilaterally and symmetrically at S3 for sacral nerve stimulation (Figure). Eighteen children with pure OAB underwent PENS weekly for 20 weeks. Frequency was 10 Hz. Intensity varied up to a maximum of 10 mA, as tolerated by the participant, but without reaching the motor threshold. Pulse width was 600 µs Patients' voiding history was assessed before treatment using a structured questionnaire. The dysfunctional voiding scoring system (DVSS) was used before and after treatment to quantify symptoms of lower urinary tract dysfunction. A visual analog scale (VAS) was used to evaluate treatment outcome. RESULTS: Seven boys and eleven girls (mean age, 7.82 ± 2.45 years) were included. According to the VAS, symptoms were resolved in 66% of patients. Urinary urgency, present in all children at baseline, was resolved in 84% (P = 0.001). The proportion of patients with involuntary loss of urine without urgency decreased from 77% before treatment to 27% (P = 0.04). Urge incontinence resolved in 13 of 16 patients after treatment (P = 0.001). Only one of the 12 children with frequent urination at baseline reported this complaint after treatment (P = 0.04). All cases of recurrent urinary tract infection were resolved (P = 0.001). Regarding nocturnal enuresis, treatment was successful in 9 of 14 children (P = 0.004). DISCUSSION: The theory behind this new method is that when skin impedance is overcome through the use of acupuncture needles and greater proximity is attained between the tip of the electrode and the sacral nerves, a more effective stimulus is achieved, with enough energy to provide the same benefits as parasacral transcutaneous electrical nerve stimulation with the advantage that treatment can be given only once a week. CONCLUSIONS: Percutaneous electrical nerve stimulation seems to be an effective and safe treatment for OAB over the short term. Furthers studies with a control group are needed.

Sexual orientation of 46, XX patients with congenital adrenal hyperplasia: a descriptive review.

BACKGROUND: Congenital adrenal hyperplasia (CAH) consists of a group of diseases characterized by an enzyme deficiency, particularly 21-hydroxylase deficiency. The condition may present in the simple virilizing form or in the salt-wasting form, with varying degrees of genital ambiguity. The non-heterosexual orientation is used in gender studies fields and includes bisexual, homosexual, Lesbians, gays, bissexuals, transgender, intersex, and others. OBJECTIVE: The objective of this study was to evaluate the frequency of non-heterosexual orientation in patients with CAH, in an attempt to identify biological factors possibly associated with this occurrence. METHODS: This was a descriptive review of observational studies on the sexual orientation of patients with CAH published between 1985 and 2016, as listed in PubMed. RESULTS: Various studies have been performed to establish the relationship between CAH and non-heterosexual orientation. Non-heterosexual orientation is more prevalent in patients with more advanced Prader stages and those with the null and I2-splice genotype. CONCLUSION: The prevalence of homosexuality and bisexuality is greater in patients with CAH in relation to the general population.

Gender identity in patients with 5-alpha reductase deficiency raised as females.

BACKGROUND AND OBJECTIVE: 5-Alpha reductase type 2 deficiency (5-ARD) is a rare disorder of sex development. The lack of 5-alpha reductase, an enzyme that converts testosterone into dihydrotestosterone, results in external genitalia that may appear female, or predominantly male, albeit undervirilized, or, more often, ambiguous. METHODS: This study describes a series of patients with 5-ARD raised as female, focusing on aspects related to gender identity. Following a retrospective chart review, patients with 5-ARD were invited to return to the clinic to enable their gender identity to be assessed using an 11-item structured in-house questionnaire. The Golombok-Rust Inventory of Sexual Satisfaction was applied to patients who had initiated their sexual life. RESULTS: Six patients aged >15 years with 5-ARD and raised as female were included. Most patients were diagnosed late: two before and four after puberty. The mean length of the phallus was 2.8 cm (0.5-5.0). Reasons for seeing a doctor included genital appearance (n = 3), amenorrhea/absence of breast development (n = 2), and changes in gender role attitudes (n = 1). According to the gender identity assessment, 4 patients identified as female, 1 as male, and 1 as both genders. Only the patient identified as male requested gender re-assignment. Of the two patients who had initiated their sexual life, sexual satisfaction was found to be good in one and poor in the other due to vaginal discomfort during intercourse. CONCLUSION: In the present series, the majority of undervirilized patients with a diagnosis of 5-ARD raised as female were in complete conformation with being female and described themselves as heterosexual. The more virilized patients were those least in conformity with their female-assigned gender.

Obesity and lower urinary tract dysfunction in children and adolescents: Further research into new relationships.

INTRODUCTION: Lower urinary tract dysfunction (LUTD) involves faults in the filling and emptying phases of bladder function in toilet-trained children with no previous infection or any other obvious pathology. Lower urinary tract dysfunction is associated with conditions such as vesicoureteral reflux, recurrent urinary infection, behavioral alterations and decreased quality of life. The literature suggests an association between LUTD and obesity; however, the association between each individual symptom and obesity has yet to be evaluated. OBJECTIVE: To evaluate the association between excess weight and LUTD in children and adolescents in a community-based sample. STUDY DESIGN: This cross-sectional study included 423 children and adolescents aged 5-17 years, and randomly selected in public places and schools between May and July 2015. The participants and their mothers completed the Dysfunctional Voiding Scoring System (DVSS) questionnaire, except for the questions on constipation and with the addition of a question on enuresis. They also completed the Rome III questionnaire, in which two positive responses defined the presence of constipation. Participants were classified as being of normal weight, overweight or obese, which was based on the BMI-for-age indicator. RESULTS: Mean age was 9.7 years (SD 2.9), with girls comprising 50.6% of the sample and adolescents 52.5%. The prevalence of LUTD was 7.1%, with 13.5% of participants being overweight and 12.1% obese (Figure). Constipation was present in 5.9% of participants and enuresis in 10.8%. In the multivariate analysis, three factors were independently and significantly associated with a positive DVSS: age <10 years (ß = 0.76; 95% CI: 0.34-1.18), constipation (ß = 1.79; 95% CI: 0.88-2.70) and obesity (ß = 0.89; 95% CI: 0.25-1.52). DISCUSSION: Only bladder filling symptoms were associated with obesity. This may be explained by the fact that both obese individuals and those with emptying symptoms were shown to have activation alterations in the same brain regions. One limitation of this study was the use of questionnaires alone to diagnose LUTD and constipation. CONCLUSION: Only the bladder-emptying symptoms of LUTD appear to be associated with obesity. This hypothesis may serve as a basis for future studies.

A two-day bladder diary for children: Is it enough?

INTRODUCTION: A bladder diary (BD) is a simple and non-invasive method of evaluating people with lower urinary tract symptoms (LUTS). Recently, the ICCS recommended a 48-h daytime frequency and volume chart (which does not need to be recorded on 2 consecutive days) to evaluate lower urinary tract (LUT) dysfunction. However, some studies on adults have demonstrated that a minimum of 3 days is required. It is believed that, to date, there are no studies in the literature that compare a 2-day BD with a 3-day BD. The advantages of a BD over a shorter period of time are the simplicity and possible better parent compliance. OBJECTIVE: The aim of this study was to evaluate if a 2-day BD is statistically and clinically comparable to a 3-day BD. STUDY DESIGN: A voiding diary was filled in over a 3-day period for 92 children (ages ranged from to 3-16 years, mean 7.9 ± 3.07) attending the present institution. By using the voiding diary, the following parameters were calculated: urination frequency, maximum and average volumes of urine (MVV and AVV) and fluid intake. The diary considered the 2 days as the first and second days of the 3-day diary. RESULTS: Out of the 92 children, eight (8.7%) did not properly complete the diary. The sample predominantly comprised females (n = 55, 59.8%). No differences were seen between 2-day and 3-day bladder diaries regarding fluid intake, maximum and average voided volume. The sensitivity, specificity, positive and negative predictive values of the 2-day bladder diary for detecting frequency were 83.4%, 91.7%, 80% and 93.2%, and for low bladder capacity they were 97.2%, 90.9%, 99% and 88%, respectively (Table). DISCUSSION: In a 2006 document, the ICCS recommended that a bladder diary be kept for 3 days, but in new documentation (2014) there is a reference stating that 2 days are enough. Bladder capacity is an important parameter in evaluating LUTS. Using a 2-day BD, the data showed that only a small percentage of reduced bladder capacity diagnosis would be lost. CONCLUSION: When using the 2-day diary, a 16% false negative rate for frequency should be expected. A 2-day bladder diary is sufficient to evaluate bladder capacity and fluid intake.

Outcome of ureteral reimplantation in children with the urge syndrome.

PURPOSE: While bladder dysfunction, particularly detrusor-sphincter incoordination, appears to be associated with a higher ureteral reimplantation failure rate, the potential effect of the urge syndrome or detrusor instability alone on surgical outcome remains unclear. We assessed the effect of the underlying urge syndrome on the outcome of ureteral implantation in cases of primary vesicoureteral reflux. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who underwent ureteral reimplantation for primary vesicoureteral reflux at our institution in an 11-year period. The urge syndrome was considered frequency, urgency or urge incontinence with absent urinary tract infection. Patients with and without the urge syndrome were compared with respect to the rate of urinary tract infection and renal scarring as well as postoperative outcome. RESULTS: We identified 25 patients (40 ureters) with and 67 (113 ureters) without the urge syndrome. Reimplantation was successful in all except 1 ureter in a patient without the urge syndrome. Postoperatively 2 patients without the syndrome had transient contralateral reflux and 1 in each group had transient ipsilateral reflux. No case required reoperation. Postoperatively patients with the syndrome had a significantly higher incidence of febrile (16% versus 1.5%, p <0.05) and afebrile (52% versus 12%, p <0.05) urinary tract infection. CONCLUSIONS: The results of ureteral reimplantation are excellent with 99.3% success irrespective of the presence or absence of the urge syndrome. Thus, when clinically indicated, reimplantation may be performed safely in such cases. The higher incidence of postoperative urinary tract infection in patients with the urge syndrome may require continuing antibiotic prophylaxis in addition to anticholinergics until voiding symptoms resolve.

Further experience with seromuscular colocystoplasty lined with urothelium.

PURPOSE: We report our continuing experience with seromuscular colocystoplasty lined with urothelium. This procedure is designed to preserve the urothelium and potentially decrease the incidence of complications associated with standard bladder augmentation. MATERIALS AND METHODS: We retrospectively reviewed the charts of 32 patients who underwent seromuscular colocystoplasty lined with urothelium between April 1994 and July 1999. Data were collected on patient demographics, surgical indications, previous and adjunctive surgical procedures, preoperative and postoperative urinary continence, upper urinary tract changes, urodynamic parameters, surgical complications and histological findings. RESULTS: Mean patient age at surgery plus or minus standard deviation was 11.1 +/- 4.8 years. Mean followup was 1.6 +/- 1 years. A mean of 1.5 +/- 0.9 years postoperatively urodynamic studies available in 28 cases showed that total and safe bladder capacity increased by 1.8 and 2.4-fold, respectively. Continence was achieved in 71% of patients after the initial procedure, increasing to 81% after secondary procedures. Hourglass deformity developed in 7 cases (22%), augmentation failed in 4 (12.5%) and there were bladder calculi in 2 (6%). New onset or increased hydronephrosis and reflux were present in 6 of 62 (10%) and 9 of 60 (15%) evaluated renal units, respectively. Of the 7 interpretable biopsies 5 revealed various degrees of repeat colonic mucosal growth. There was no bladder perforation or metabolic abnormalities, and mucous production was not clinically significant. CONCLUSIONS: Seromuscular colocystoplasty lined with urothelium is a viable alternative to standard bladder augmentation. The 2 procedures have a similar overall complication rate. Comparatively there appears to be a low incidence of bladder calculi, mucous production has not been clinically significant, metabolic disturbances have not developed and perforation has not occurred during short-term followup. We are enthusiastic about this technique and continue to apply it in select patients.

Further experience with the double onlay preputial flap for hypospadias repair.

PURPOSE: Severe hypospadias can be safely and reliably repaired in 1 stage using island flaps of preputial skin. However, problems with conventional techniques include penile asymmetry resulting from rotation of the vascular pedicle around 1 side of the penile shaft and at times doubtful viability of the Byars flaps used for ventral skin coverage. We describe how some of these problems can be resolved using the double onlay preputial flap for hypospadias repair. MATERIALS AND METHODS: We reviewed the records of 47 children who underwent 1-stage double onlay preputial flap hypospadias repair at our institution between June 1994 and July 1998. Patient age ranged from 6 months to 9 years (mean 12.2 months). The urethral meatus was at the midshaft in 12 patients (25%), penoscrotal in 30 (64%) and perineal in 5 (11%). Chordee repair required dorsal plication in 29 patients, 7 of whom required an additional ventral incision of the tunica albuginea and tunica vaginalis autograft with preservation of the urethral plate to complete the repair. Scrotal transposition and bifid scrotum were repaired at the time of hypospadias repair in 9 patients. RESULTS: Followup was 3 to 47 months (mean 15.2 months). Complications requiring reoperation occurred in 12 patients (25%). In 8 (17%) boys a fistula developed, of whom 6 had perineal and 2 had penoscrotal hypospadias. Fistula closure was required in all patients. Successful closure was achieved with 1 procedure in 6 patients, required an additional fistula repair in 1 and remains to be determined in 1. Diverticula, meatal recession and persistent penile curvature requiring repeat dorsal plication occurred in 4 (9%), 2 (4%) and 2 (4%) patients, respectively. Revision for a bulky ventral skin strip was required in 1 boy (2%). All complications occurred in patients with the more proximal hypospadias. CONCLUSIONS: The double onlay preputial flap technique for hypospadias repair offers good cosmetic and functional results. Given the high incidence of penoscrotal and perineal hypospadias (75%) in our series complication rates are comparable or better than those of other techniques.

Bladder calculi in children who perform clean intermittent catheterization.

OBJECTIVE: To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients. PATIENTS AND METHODS: The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed. RESULTS: Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months. CONCLUSION: These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions.

Severe combined immunodeficient-hu model of human prostate cancer metastasis to human bone.

Commonly used in vivo models of prostate cancer metastasis include syngeneic rodent cancers and xenografts of human cancer in immunodeficient mice. However, the occurrence of osseous metastases in these models is rare, and in xenograft models, species-specific factors may limit the ability of human cells to metastasize to rodent bones. We have modified the severe combined immunodeficient (SCID)-human model to test the ability of circulating human prostate cancer cells to home to macroscopic fragments of human bone and other organs previously implanted into SCID mice. We have also compared the growth of human prostate cancer cells in various human and mouse tissue microenvironments in vivo. Macroscopic fragments of human fetal bone, lung, or intestine (16-22 weeks gestation) or mouse bone were implanted s.c. into male CB.17 SCID mice. Four weeks later, human prostate cancer cells were injected either i.v. via the tail vein (circulating cell colonization assay) or directly into the implanted tissue fragments transdermally (end organ growth assay). Tumor growth was followed for 6 weeks by palpation and magnetic resonance imaging. After 6 weeks, tumors were enumerated in implanted human and mouse organ fragments and native mouse tissue. Tumors were characterized by histology, immunohistochemistry, and chromosomal analysis. After i.v. injection, circulating PC3 cells successfully colonized implanted human bone fragments in 5 of 19 mice. Tumors were easily followed by palpation and imaging and had an average volume of 258 mm3 at autopsy. Histological examination revealed osteolysis and a strong desmoplastic stromal response, which indicated intense stromal-epithelial interaction. Bone tumors were subcultured, and chromosomal analysis demonstrated that the tumors were derived from the parental prostate cancer cell line. Microscopic tumor colonies were also found in a few mouse lungs after i.v. injection of PC3, DU145, and LNCaP cells, however the volume of the lung nodules was less than 1 mm3 in all of the cases. No colonization of human lung or intestine implants, the mouse skeleton, or other mouse organs was detected, demonstrating a species- and tissue-specific colonization of human bone by PC3 cells. Direct injection of 10(4) prostate cancer cells into human bone implants resulted in large tumors in 75-100% of mice. PC3 and DU145 bone tumors were primarily osteolytic, whereas LNCaP bone tumors were both osteoblastic and osteolytic. PC3 and LNCaP bone tumors showed a desmoplastic stromal response, which indicated intense stromal-epithelial interaction. All three of the cell lines formed tumors in implanted human lung tissue; however, the tumors were all < or = 10 mm3 in volume and showed minimal stromal involvement. No tumors formed after either s.c. injection or injection of cells into implanted mouse bone demonstrating both species- and tissue-specific enhancement of growth of human prostate cancer cells by human bone. The severe combined immunodeficient-human model provides a useful system to study species-specific mechanisms involved in the homing of human prostate cancer cells to human bone and the growth of human prostate cancer cells in human bone.

Orthotopic urethral substitution in female patients using the mitrofanoff principle.

PURPOSE: We present our experience with orthotopic urethral substitution in female patients using the Mitrofanoff principle. MATERIALS AND METHODS: We performed orthotopic urethral substitution using the Mitrofanoff principle in 18 female patients 1 to 29 years old (mean age 10). The conduit was constructed with appendix in 13 cases, tapered ileum in 4 and fallopian tube in 1. The etiology of incontinence included exstrophy in 8 patients, neurogenic bladder in 3, urogenital sinus in 3, and bilateral ectopic ureter, ectopic ureterocele, the prune-belly syndrome and post-cystectomy undiversion in 1 each. RESULTS: Mean followup was 29 months (range 9 to 72). A total of 16 patients achieved continence following a program of clean intermittent catheterization. There were 2 unsuccessful operations. In 1 case the appendix become ischemic and in 1 a vesicoperineal fistula developed. One patient catheterizes every 2 hours to avoid leakage. Catheterization was temporarily difficult in 5 patients, of whom 2 had an appendiceal and 3 had a tapered ileal conduit. Two patients with an ileal conduit have had chronic difficult catheterization. CONCLUSIONS: Orthotopic replacement of the urethra using the Mitrofanoff principle is suitable in highly select female patients who need continent diversion or a catheterizable conduit but who will not accept an abdominal stoma. It is particularly suited to patients in whom exstrophy reconstruction has failed.

Population-based study of pelvic lymph node positivity in clinically localized prostate cancer: a study comparing African Americans and whites.

OBJECTIVES: To evaluate the correlation between race and lymph node metastasis for prostate cancer by analyzing which preoperative parameters may predict lymph node status in both races. METHODS: We analyzed a group of patients (552 American white men [AWM] and 423 African-American men [AAM]) who underwent radical prostatectomy plus modified pelvic lymphadenectomy between January 1991 and June 1997. Patients who received neoadjuvant radiation or hormone therapy were excluded. Univariate and multivariate analyses were performed to determine the influence of race on lymph node positivity, as well as to correlate the preoperative parameters (serum prostate-specific antigen [PSA], biopsy Gleason score, and clinical stage) with lymph node metastasis for each race separately. RESULTS: The AAM presented with significantly higher preoperative Gleason scores and PSA levels than AWM. However, comparing lymph node status by race, the difference of positivity (41 AWM [7.4% and 22 AAM [5.2%]) was not statistically significant (P = 0.16). The percentage of positive nodes was similar in both races for each subset of PSA, Gleason score, and clinical stage. Despite the statistical significance of the three preoperative parameters in univariate analysis, in multivariate analysis only PSA and Gleason score were independent predictors of positive lymph nodes. CONCLUSIONS: There is no influence of race on lymph node metastasis, despite AAM presenting with higher preoperative Gleason scores and PSA levels. In multivariate analysis, preoperative Gleason score and PSA were independent factors for positive nodes regardless of race.

Quality of life in patients undergoing salvage procedures for locally recurrent prostate cancer.

BACKGROUND AND OBJECTIVES: As patients are being treated for prostate cancer at a younger age, a significant number of them will ultimately fail the primary treatment and will be candidates for potentially curative salvage therapy. The purpose of this study was to evaluate the impact of salvage therapy for locally recurrent prostate cancer upon the patients' quality of life. METHODS: A cohort of 68 men with locally recurrent prostate cancer undergoing salvage treatment was included in this analysis. Data were collected for the study by mailing the subjects a self-administered questionnaire that included a General Functional Assessment of Cancer Therapy (FACT-G) and a Prostate Cancer Treatment Outcome Questionnaire (FACT-P). Group comparisons were conducted using one-way analysis of variance (ANOVA). RESULTS: Overall, 50% and 88.6% of patients were free of biochemical recurrence in the salvage surgery (SS) and salvage radiotherapy (SRt) group, respectively (P=0.4). The physical well-being (PWB) subscale of FACT-G was significantly higher for the SRt patients (P=0.008). Using the Trial Outcome Index Prostate subscale, the Trial Outcome Index Incontinence Urinary scores, and the Functional Assessment of Incontinence Therapy-Urinary score group comparisons, patients in the SRt group had a higher quality of life than patients in the SS group (P=0.038, P=0.001, and P=0.001, respectively). CONCLUSIONS: In the current study, patients with clinically localized prostate cancer who are at high risk for local disease recurrence may have a trend toward better disease-free survival and a better urinary continence rates if the primary treatment is radical prostatectomy rather than radiation therapy.