Effect of elective inguinal hernia repair on urinary symptom burden in men.

BACKGROUND: Our study sought to examine the prevalence of urinary symptoms in men undergoing hernia repair and whether there is an association between symptoms and short-term outcomes. METHODS: This is a prospective cohort study of male veterans consenting to inguinal hernia repair. The American Urological Association Symptom Score (AUASS) was administered preoperatively at 48 hours and again at 30 days after surgery. RESULTS: Median preoperative AUASS was 6 (interquartile range [IQR]: 3 to 12); at 48 hours, the median score increased significantly to 10 (IQR: 4 to 16, P < .01) and at 30 days, the median score dropped below baseline to 3 (IQR: 1 to 8, P < .0001). Multivariable linear regression modeling revealed that the use of an intraoperative urinary catheter was significantly associated with an increase in AUASS from preop to both 48 hours and 30 days. CONCLUSION: Elective repair of an inguinal hernia is associated with reduction in urinary symptom burden at 30 days, whereas the use of an intraoperative foley catheter is associated with no improvement at 30 days.

Retrograde renal cooling to minimize ischemia.

OBJECTIVE: During partial nephrectomy, renal hypothermia has been shown to decrease ischemia induced renal damage which occurs from renal hilar clamping. In this study we investigate the infusion rate required to safely cool the entire renal unit in a porcine model using retrograde irrigation of iced saline via dual-lumen ureteral catheter. MATERIALS AND METHODS: Renal cortical, renal medullary, bowel and rectal temperatures during retrograde cooling in a laparoscopic porcine model were monitored in six renal units. Iced normal saline was infused at 300 cc/hour, 600 cc/hour, 1000 cc/hour and gravity (800 cc/hour) for 600 seconds with and without hilar clamping. RESULTS: Retrograde cooling with hilar clamping provided rapid medullary renal cooling and significant hypothermia of the medulla and cortex at infusion rates ≥ 600 cc/hour. With hilar clamping, cortical temperatures decreased at -0.90 C/min. reaching a threshold temperature of 26.90 C, and medullary temperatures decreased at -0.90 C/min. reaching a temperature of 26.10 C over 600 seconds on average for combined data at infusion rates = 600 cc/hour. The lowest renal temperatures were achieved with gravity infusion. Without renal hilum clamping, retrograde cooling was minimal at all infusion rates. CONCLUSIONS: Significant renal cooling by gravity infusion of iced cold saline via a duel lumen catheter with a clamped renal hilum was achieved in a porcine model. Continuous retrograde irrigation with iced saline via a two way ureteral catheter may be an effective method to induce renal hypothermia in patients undergoing robotic assisted and/or laparoscopic partial nephrectomy.

Efficacy of adding behavioural treatment or antimuscarinic drug therapy to α-blocker therapy in men with nocturia.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Nocturia is a common and bothersome lower urinary tract symptom, particularly in men. Many single drug therapies have limited benefit. For men who have persistent nocturia despite alpha-blocker therapy, the addition of behavioural and exercise therapy is statistically superior to anticholinergic therapy. OBJECTIVE: To compare reductions in nocturia resulting from adding either behavioural treatment or antimuscarinic drug therapy to α-adrenergic antagonist (α-blocker) therapy in men. PATIENTS AND METHODS: Participants were men who had continuing urinary frequency >8 voids/day) and urgency after 4 weeks of α-blocker therapy run-in and who had ≥1 nightly episode of nocturia. Participants received individually titrated drug therapy (extended-release oxybutynin) or multicomponent behavioural treatment (pelvic floor muscle training, delayed voiding and urge suppression techniques). Seven-day bladder diaries were used to calculate reductions in mean nocturia. RESULTS: A total of 127 men aged 42-88 years with ≥1 nocturia episode per night were included in the study. There were 76 men who had a mean of ≥2 nocturia episodes. Among those with ≥1 nocturia episode, behavioural treatment reduced nightly nocturia by a mean of 0.97 episodes and was significantly more effective than drug therapy (mean reduction = 0.56 episodes; P = 0.01). Participants with ≥2 episodes nocturia at baseline also showed larger changes with behavioural treatment compared with antimuscarinic therapy (mean reduction = 1.26 vs 0.61; P = 0.008). CONCLUSIONS: Both behavioural treatment and drug therapy reduced nocturia in men with ≥1 episode of nocturia/night when added to α-blocker therapy. These results were similar even when only those with ≥2 episodes of nocturia were considered. The addition of behavioural treatment was statistically better than bladder-relaxant therapy for nocturia.

Retrograde Renal Cooling to Minimize Ischemia

Objective: During partial nephrectomy, renal hypothermia has been shown to decrease ischemia induced renal damage which occurs from renal hilar clamping. In this study we investigate the infusion rate required to safely cool the entire renal unit in a porcine model using retrograde irrigation of iced saline via dual-lumen ureteral catheter. Materials and Methods: Renal cortical, renal medullary, bowel and rectal temperatures during retrograde cooling in a laparoscopic porcine model were monitored in six renal units. Iced normal saline was infused at 300 cc/hour, 600 cc/hour, 1000 cc/hour and gravity (800 cc/hour) for 600 seconds with and without hilar clamping. Results: Retrograde cooling with hilar clamping provided rapid medullary renal cooling and significant hypothermia of the medulla and cortex at infusion rates ≥ 600 cc/hour. With hilar clamping, cortical temperatures decreased at -0.9° C/min. reaching a threshold temperature of 26.9° C, and medullary temperatures decreased at -0.90 C/min. reaching a temperature of 26.1° C over 600 seconds on average for combined data at infusion rates ≥ 600 cc/hour. The lowest renal temperatures were achieved with gravity infusion. Without renal hilum clamping, retrograde cooling was minimal at all infusion rates. Conclusions: Significant renal cooling by gravity infusion of iced cold saline via a duel lumen catheter with a clamped renal hilum was achieved in a porcine model. Continuous retrograde irrigation with iced saline via a two way ureteral catheter may be an effective method to induce renal hypothermia in patients undergoing robotic assisted and/or laparoscopic partial nephrectomy. .

Isoprostane: quantitation of renal ischemia and reperfusion injury after renal artery clamping in an animal model.

BACKGROUND AND PURPOSE: Laparoscopic and robotic partial nephrectomy involves temporary clamping of the renal artery, making the kidney susceptible to ischemic damage. Isoprostane represents one potential marker of oxidative injury. The objective was to determine if renal interstitial isoprostane levels can quantitate renal damage secondary to warm ischemia. A second goal is to investigate allopurinol for renoprotective abilities using this model. We chose to investigate potential renoprotection of allopurinol because previous studies have demonstrated transplant kidneys pretreated with allopurinol to have less damage from ischemia. MATERIALS AND METHODS: A microdialysis probe was inserted into the renal parenchyma of rats to allow continuous dialysis and collection of the effluent for isoprostane levels. After clamping of the renal vessels for predefined intervals of ischemia, the interstitial effluent from the probe was collected and subsequently analyzed for isoprostane levels with and without allopurinol pretreatment. RESULTS: Clamping of the renal artery and vein produced increases in isoprostane levels during the ischemic period and larger increases during reperfusion. There was a trend for increased postclamp isoprostane levels as clamp times increased. When comparing isoprostane levels in rats that did not receive allopurinol, there were significant differences between the clamp and postclamp levels of isoprostane, with allopurinol offering protection to the kidney from ischemic changes caused by clamping the renal hilum. CONCLUSIONS: Our data have demonstrated that isoprostane levels are a potential real-time marker of renal ischemia and reperfusion injury. We also found allopurinol administration demonstrated a trend toward renoprotective abilities in the hilar occluded kidney.

Urothelial cancers after renal transplantation.

OBJECTIVE: After solid organ transplantation, risk of cancer varies significantly based on cancer type. In this study, we determine the incidence of urothelial cancers (bladder and kidney) after renal transplantation from a single high-volume transplantation institution. In addition, we analyze the risk factors and review outcomes from the patients. MATERIALS AND METHODS: We performed a retrospective review of all patients in the University of Alabama at Birmingham (UAB) transplant database to identify all patients who received renal transplants at UAB between January 1, 1990, and January 1, 2010. We further identified transplant patients diagnosed with bladder, urothelial of other cancers in the same time period. We also examined tumor-specific variables such as presentation, clinical and pathologic staging, treatment type, recurrence, progression, interval to recurrence and progression, cancer-specific mortality, and interval from time to diagnosis to death. RESULTS: Review of the transplant database confirmed 5,920 renal transplants. Thirteen patients underwent the diagnosis of urothelial cancer, providing an incidence of 0.2%. Eight patients had bladder cancer for an incidence of 0.13%, compared to an incidence of 0.02% among the general population. Patients diagnosed with bladder cancer after renal transplantation were younger than those in the general population and frequently present with more advanced and aggressive disease. CONCLUSIONS: Patients are at an elevated risk of urothelial cancers after renal transplantation probably from immune suppression.

Characterizing changes in kidney and renal pelvis cancer incidence from 1998 to 2006 in the United States.

In this study, we characterize the changes in kidney and renal pelvis cancer (RCC) from 1998 to 2006 in the United States. The goal is to examine variations in stage and treatments. In addition, we explore changes in risk factors that have occurred over the same period. Data on over 20,000 patients diagnosed with RCC in National Cancer Data Base were used for the study. We investigated the changes in stage and treatment rates based on race, gender and age at diagnosis from 1998 to 2006. Changes in smoking, obesity and hypertension rates over the period were examined for comparison. The increase in RCC incidence rates from 1998 to 2006 was almost entirely a result of increases in stage I. Increases for blacks were proportionally higher than whites. Obesity and hypertension increased over the period but smoking declined. In terms of treatment, there was an increase in surgery cases primarily for stage I. There were no significant differences in trends based on gender, although rates in men were 65% greater than in women. The mean age at diagnosis was stable for stages I-IV. There are increased incidences of renal tumors, particularly stage I renal cancer among blacks and whites from 1998 to 2006. Patients were more likely to undergo surgical therapy for these tumors.

The effect of prostate cancer screening on stage IV disease in America.

OBJECTIVE: Some studies have found that prostate cancer (PCa) screening provides little or no change in PCa-related mortality during the 7-10 years following diagnoses. However, most men are diagnosed with PCa at low-stage disease and die of unrelated causes during this period. Men diagnosed at stage IV are at much higher risk of dying of the disease. Therefore, stage IV rates at first diagnoses may be a surrogate marker of PCa-related mortality over a time span less than 10 years. The study objective is to examine the association between PCa screening and stage IV disease rates in new cases to explore potential benefits for PCa screening. MATERIALS AND METHODS: The percent of stages I, II, III, IV and unclassified PCa diagnosed in white males in 2005 was compared to PCa screening rates on a state-by-state basis. To consider access to medical care and socioeconomic status, median family income, degree of urbanization, urologist population density and health insurance status were included in the analysis. RESULTS: PCa stage IV disease correlated inversely with PCa screening rates (r = -0.42, P = 0.006) where r is the correlation coefficient and P is the probability. Stage I PCa correlated with lack of health insurance (r = 0.37, P = 0.02). CONCLUSIONS: The results of this study suggest that with PCa screening may be associated with reduced rates of stage IV disease.

Bladder cancer incidence and mortality rates compared to ecologic factors among states in America.

PURPOSE: Smoking, inadequate vitamin D and pesticide exposure have been linked to bladder cancer (BCa) in past studies. The objective of this study is to explore associations between BCa rates and these risk factors. MATERIALS AND METHODS: BCa incidence and mortality rates among states were compared to smoking; solar ultraviolet (UV) radiation levels and drinking water from a surface water supply (which has greater residual pesticide contamination than groundwater and both are used as sources for drinking water). Lack of health insurance, median family income and urbanization were included to adjust for access to health care and socioeconomic status. RESULTS: BCa incidence and mortality correlated directly with smoking and inversely with solar UV radiation for males and females. BCa mortality correlated directly with drinking surface water for both sexes. Lack of health insurance correlated inversely with BCa incidence for females and trended toward significance for males. Multivariable analyses identified solar UV radiation as the best predictor of BCa incidence in males and solar UV radiation and smoking in females. Solar UV radiation, smoking and drinking surface water were the best predictors of BCa mortality in males, while smoking and drinking surface water were the best predictors of mortality in females. CONCLUSIONS: BCa incidence and mortality for both sexes correlated directly with smoking and inversely with solar UV radiation levels. BCa mortality for both sexes correlated with drinking water from a surface water source. It is hypothesized that BCa mortality risks may increase from drinking water contaminated with low levels of pesticides.

Chemoprevention of prostate cancer: what can be recommended to patients?

Prostate cancer is third to lung and colon cancer as the cause of cancer-related deaths in American men. It is estimated that there will have been more than 28,000 deaths and 186,000 new cases in 2008 that will impose a significant burden on national health care costs. Chemoprevention aims to reduce both incidence and mortality through the use of agents to prevent, reverse, or delay the carcinogenic process. This study provides clinicians with information on some chemoprevention agents that have been considered to reduce prostate cancer risks, including 5-alpha-reductase inhibitors; statins (a class of compounds used to reduce cholesterol); NSAIDs; selenium; vitamins E and D; lycopene; allium vegetables (garlic, scallions, onions, chives, and leeks); soy/isoflavones; and green tea polyphenols. The evidence to support prostate cancer risk reduction benefits for each chemoprevention agent based on a review of the literature is provided.

Renal cell carcinoma rates compared with health status and behavior in the United States.

OBJECTIVES: To explore the relationship between renal cell carcinoma rates and health status and behavior in the United States. METHODS: The renal cell carcinoma incidence (2003-2004) and mortality rates (2000-2003) for males and females were compared with the levels of current smokers, obesity, physical inactivity, hypertension, diabetes, high fruit/vegetable diet, and excessive alcohol consumption on a state-by-state basis. Family income, lack of health insurance, urbanization, and urologist population density among the states were included to adjust for access to healthcare and socioeconomic status. RESULTS: The renal cell carcinoma incidence and mortality rates for both males and females correlated directly with the levels of smoking, obesity, and physical inactivity. The incidence rates correlated directly with hypertension for both sexes and the urologist population density for males. The mortality rates correlated inversely with high fruit/vegetable consumption, family income, and urbanization for both sexes. Multivariate analysis identified best-fit models for predicting renal cell carcinoma rates. Physical inactivity and urologist population density were the strongest variables for predicting the incidence rates in males; smoking for predicting the incidence rates in females; and smoking and high fruit/vegetable diet for predicting mortality in both sexes. CONCLUSIONS: In the present study, we found that smoking, obesity, and physical inactivity correlated directly with the renal cell carcinoma incidence and mortality and hypertension correlated directly with the incidence rates. A high fruit/vegetable diet, family income, and urbanization correlated inversely with renal cell carcinoma mortality rates. The prevalence of urologists correlated directly with the incidence rates for males but not for females.

High cholesterol levels are associated with reduced prostate cancer mortality rates during periods of high but not low statin use in the United States.

OBJECTIVE: Some studies suggest that cholesterol may promote prostate cancer development. High serum cholesterol levels are commonly treated with statins, which have been associated with decreased prostate cancer risks. Statin use has increased in this country during the 1990s while prostate mortality rates have gone down. In this study, we compare high cholesterol levels to prostate cancer mortality rates among states over time periods in which statin use has changed. We hypothesize that prostate cancer risks from high cholesterol may be reduced when statin use is high. METHODS: State-specific, high cholesterol levels for white males (2001-2003) were compared with age-adjusted prostate cancer mortality rates for each year from 1992 to 2000. To control for medical care access and socioeconomic status, urbanization, family income, and health insurance status were considered. RESULTS: High cholesterol levels correlate inversely with prostate cancer mortality for: 2000 (R = -0.40, P < 0.01); 1999 (R = -0.37, P < 0.01); and 1998 (R = -0.32, P < 0.05), but there was no significant correlation from 1992 to 1997. Statin use was 46%, 47%, and 49% in 1998, 1999, and 2000, respectively, and ranged from 7% in 1992 to 42% in 1997. Urbanization correlated at the P < 0.05 level from 1994 to 2000 but family income and health insurance status did not correlate. CONCLUSIONS: High cholesterol levels were associated with lower prostate cancer mortality rates when statin use was high, but not low, suggesting that statins reduce prostate cancer mortality risks.

Exploring causes for declining prostate cancer mortality rates in the United States.

OBJECTIVES: Prostate cancer mortality rates in the U.S.A. increased in the late 1980s and declined from 1993 until 2003. The purpose of this study is to compare declining prostate cancer mortality rates among states with independent variables that may have an association to explore causes for the decline. METHODS AND MATERIALS: Annual rates of prostate cancer mortality for men over 50 were obtained from the National Vital Statistic System public use data file for states for individual years from 1993 to 2003. The annual rate of prostate cancer mortality decline for each state was calculated by the Joinpoint Regression Program (Statistical Research and Applications Branch of NCI). Annual rates of prostate cancer decline were cross-correlated to state levels of PSA screening, health insurance coverage, obesity, physical inactivity, diabetes, and high cholesterol for males from 45 to 64. RESULTS: Declining prostate cancer mortality rates for white males correlated with high cholesterol levels (R = -0.42, P = 0.002) and PSA screening levels (R = -0.28, P = 0.05). Declining prostate cancer mortality rates for black males correlated with health insurance coverage (R = -0.43, P = 0.03). CONCLUSIONS: Declining prostate cancer mortality rates are weakly associated with increased PSA screening for white males but there was no association for black males, possibly because blacks have less access to medical care. The strong inverse correlation between declining prostate cancer mortality rates and levels of white males with high cholesterol levels was unexpected but may be associated with the widespread use of cholesterol reducing medications (statins), which are hypothesized to reduce prostate cancer risk.

Solar ultraviolet B radiation compared with prostate cancer incidence and mortality rates in United States.

OBJECTIVE: To investigate whether the prostate cancer incidence and mortality rates in the United States correlate inversely with solar ultraviolet (UV) B radiation levels computed from a mathematical model using forecasted ozone levels, cloud levels, and elevation. Another objective was to explore whether the annual prostate cancer rates correlated more strongly with the cumulative UVB exposure for the year or for exposure during certain seasons. METHODS: The age-adjusted incidence and mortality cancer rates for black and white men in the continental United States were correlated with the mean UV index values averaged for the year and for each season. RESULTS: We found an inverse correlation between the UVB levels and prostate cancer incidence (R = -0.42, P <0.01) and mortality rates (R = -0.53, P <0.001) for white men and for incidence (R = -0.40, P <0.05) for black men, but the strength of the correlation depended on the season of UVB irradiance. No statistically significant results for black male mortality were found. The annual prostate cancer incidence and mortality rates for white men correlated most strongly with UVB exposure levels in the fall and winter, and incidence rates for black men correlated with UVB exposure levels in the summer. CONCLUSIONS: Increased solar UVB radiation might reduce the risk of prostate cancer, but the efficacy depends on the season of UVB irradiance.