The association of lower urinary tract symptoms, depression and suicidal ideation: data from the 2005-2006 and 2007-2008 National Health and Nutrition Examination Survey.

PURPOSE: We examine the association among depression, suicidal ideation and self-reported lower urinary tract symptoms using a large, cross-sectional, population based study. MATERIALS AND METHODS: The study included 2,890 men from the 2005-2006 or 2007-2008 cycles of the NHANES (National Health and Nutrition Examination Survey) who were 40 years old or older. Men were asked if they experienced nocturia, urinary hesitancy and/or incomplete bladder emptying. The PHQ-9 (Patient Health Questionnaire-9) was used to determine the likelihood of clinical depression and suicidal ideation. RESULTS: The prevalence of lower urinary tract symptoms was 33.7% and 10.3% for men reporting 1 and 2 or more symptoms, respectively. Moderate to severe depression (PHQ-9 score 10 or greater) and suicidal ideation were reported by 181 (6.3%) and 105 (3.6%) men, respectively. Men reporting moderate to severe depression (compared to those reporting minimal depression) had a higher odds of reporting lower urinary tract symptoms (adjusted odds ratio [AOR] 5.09, 95% CI 3.17-8.17 for PHQ-9 score 5 to 9 and AOR 7.62, 95% CI 3.90-14.87 for PHQ-9 score 10 or greater; p trend <0.0001). More lower urinary tract symptoms were associated with a significantly higher odds of moderate to severe depression (AOR 3.09, 95% CI 1.86-5.15 for 1 symptom and AOR 8.06, 95% CI 4.18-15.53 for 2 or more symptoms, p trend <0.0001) and a higher odds of suicidal ideation (AOR 1.70, 95% CI 0.85-3.42 and AOR 2.71, 95% CI 1.40-5.25, respectively, p trend = 0.004). CONCLUSIONS: A significant relationship was observed between lower urinary tract symptoms and depression/suicidal ideation. While the pathophysiology of the relationship and its significance in clinical practice remain unclear, clinicians may consider screening men with severe lower urinary tract symptoms for depression.

Artificial urinary sphincter placement in compromised urethras and survival: a comparison of virgin, radiated and reoperative cases.

PURPOSE: Although long-term outcomes after initial placement of artificial urinary sphincters are established, limited data exist comparing sphincter survival in patients with compromised urethras (prior radiation, artificial urinary sphincter placement or urethroplasty). We evaluated artificial urinary sphincter failure in patients with compromised and noncompromised urethras. MATERIALS AND METHODS: We performed a retrospective analysis of 86 sphincters placed at a single institution between December 1997 and September 2012. We assessed patient demographic, comorbid disease and surgical characteristics. All nonfunctioning, eroded or infected devices were considered failures. RESULTS: Of the 86 patients reviewed 67 (78%) had compromised urethras and had higher failure rates than the noncompromised group (34% vs 21%, p=0.02). Compared to the noncompromised group, cases of prior radiation therapy (HR 4.78; 95% CI 1.27, 18.04), urethroplasty (HR 8.61; 95% CI 1.27, 58.51) and previous artificial urinary sphincter placement (HR 8.14; 95% CI 1.71, 38.82) had a significantly increased risk of failure. The risk of artificial urinary sphincter failure increased with more prior procedures. An increased risk of failure was observed after 3.5 cm cuff placement (HR 8.62; 95% CI 2.82, 26.36) but not transcorporal placement (HR 1.21; 95% CI 0.49, 2.99). CONCLUSIONS: Artificial urinary sphincter placement in patients with compromised urethras from prior artificial urinary sphincter placement, radiation or urethroplasty had a statistically significant higher risk of failure than placement in patients with noncompromised urethras. Urethral mobilization and transection performed during posterior urethroplasty surgeries likely compromise urethral blood supply, predisposing patients to failure. Patients with severely compromised urethras from multiple prior procedures may have improved outcomes with transcorporal cuff placement rather than a 3.5 cm cuff.

Selective angioembolization for traumatic renal injuries: a survey on clinician practice.

PURPOSE: A variety of clinical and imaging findings are used by clinicians to determine utility of renal angioembolization (AE) in managing renal trauma. Our purpose was to investigate specific criteria that clinicians who manage high-grade renal trauma (HGRT) utilize in decision-making for primary or delayed AE. METHODS: A total of 413 urologists and interventional radiologists (IRs) who practice at level 1 or 2 trauma centers within the United States were provided an original survey via email on experience and opinions regarding the utility of AE for HGRT. We described overall practice patterns and assessed differences by clinician type, using the Fisher's exact test. RESULTS: A total of 79 (20 %) clinicians completed the survey. All clinicians had AE capability for HGRT management. A higher proportion of IRs reported using AE for grade I-II (33 vs. 3 %, p = 0.002), grade III (65 vs. 26 %, p = 0.001), and penetrating injuries (83 vs. 58 %, p = 0.02). A greater proportion of urologists reported using AE for grade V injuries (81 vs. 56 %, p = 0.03). Clinicians most commonly cited computed tomography evidence of active arterial bleeding (97 %), or arteriovenous fistula/pseudoaneurysm (94 %) as indications for primary AE, and 62 % identified concurrent visceral injury as factor that would necessitate surgical intervention. CONCLUSION: In a survey of clinicians, we report that IRs and urologists utilize AE differently when managing HGRT, as a higher proportion of IRs use AE to manage lower grade as well as penetrating injuries. Validation studies are needed to establish algorithms to identify patients with HGRT who would benefit from selective renal AE.

Reoperative urethroplasty. A systematic review.

OBJECTIVES: Limited articles are published on reoperative urethroplasty outcomes. We sought to perform a systematic review of re-operative urethroplasty articles over the past fifteen years. METHODS: A systematic review was performed on PubMed using the search terms "Urethra" AND "Surgical Procedures, Operative" OR "Urethroplasty". RESULTS: Five articles out of 3,541 articles identified between 1998 and 2012 specifically addressed re-operative urethroplasty patients. A total of 212 patients were included in these five studies. Re-operative urethroplasty success rates ranged from 35% to 84%. Success rates were higher in the two studies with over 40 patients and ranged from 78-84%. CONCLUSION: Limited studies address re-operative urethroplasty outcomes. Success rates for re-operation are lower than those for initial urethroplasty procedures. Overall, studies with a higher number of patients had an increased success rate.

Strontium substitution for calcium in lithogenesis.

PURPOSE: Strontium has chemical similarity to calcium, which enables the replacement of calcium by strontium in biomineralization processes. Incorporating strontium into human bone and teeth has been studied extensively but little research has been performed of the incorporation of strontium into urinary calculi. We used synchrotron based x-ray fluorescence and x-ray absorption techniques to examine the presence of strontium in different types of human kidney stones. MATERIALS AND METHODS: Multiple unique human stone samples were obtained via consecutive percutaneous nephrolithotomies/ureteroscopies. A portion of each stone was sent for standard laboratory analysis and a portion was retained for x-ray fluorescence and x-ray absorption measurements. X-ray fluorescence and x-ray absorption measurements determined the presence, spatial distribution and speciation of strontium in each stone sample. RESULTS: Traditional kidney stone analyses identified calcium oxalate, calcium phosphate, uric acid and cystine stones. X-ray fluorescence measurements identified strontium in all stone types except pure cystine. X-ray fluorescence elemental mapping of the samples revealed co-localization of calcium and strontium. X-ray absorption measurements of the calcium phosphate stone showed strontium predominately present as strontium apatite. CONCLUSIONS: Advanced x-ray fluorescence imaging identified strontium in all calcium based stones, present as strontium apatite. This finding may be critical since apatite is thought to be the initial nidus for calcium stone formation. Strontium is not identified by standard laboratory stone analyses. Its substitution for calcium can be reliably identified in stones from multiple calcium based stone formers, which may offer opportunities to gain insight into early events in lithogenesis.

Microcomposition of human urinary calculi using advanced imaging techniques.

PURPOSE: Common methods of commercial urolithiasis analysis, such as light microscopy and Fourier transform infrared spectroscopy, provide limited or no information on the molecular composition of stones, which is vital when studying early stone pathogenesis. We used synchrotron radiation based microfocused x-ray fluorescence, x-ray absorption and x-ray diffraction advanced imaging techniques to identify and map the elemental composition, including trace elements, of urinary calculi on a µm (0.0001 cm) scale. MATERIALS AND METHODS: Human stone samples were obtained during serial percutaneous nephrolithotomy and ureteroscopy procedures. A portion of each sample was sent for commercial stone analysis and a portion was retained for synchrotron radiation based advanced imaging analysis. RESULTS: Synchrotron radiation based methods of stone analysis correctly identified stone composition and provided additional molecular detail on elemental components and spatial distribution in uroliths. Resolution was on the order of a few µm. CONCLUSIONS: Knowledge of all elements present in lithogenesis at this detail allows for better understanding of early stone formation events, which may provide additional insight to prevent and treat stone formation.

The association of depression, anxiety and nocturia: a systematic review.

PURPOSE: This systematic review focuses on the relationship between nocturia and depression/anxiety. Our objective is to provide an overview of current data on the epidemiology, pathophysiology and patient management implications of the association between nocturia and depression/anxiety. MATERIALS AND METHODS: We queried PubMed®, Web of Science® and Embase™ in July 2012 to identify abstracts, and original, review and editorial articles on nocturia and mood disorders, specifically depression and anxiety. The search was done using the key words "nocturia," "depression" and "anxiety." We complied with the Assessment of Multiple Systemic Reviews (AMSTAR) instrument. We retrieved a total of 500 records, including 95, 81 and 324 from PubMed, Web of Science and Embase, respectively. RESULTS: Cross-sectional (level 3) data indicated that nocturia and depression/anxiety are strongly associated. One prospective study contended that depression leads to nocturia in a unidirectional relationship. Nocturia poses a greater risk for depression in men vs women. Results conflict on the effect of serotonin reuptake inhibitors on nocturia. CONCLUSIONS: The results of this systematic review suggest a bidirectional association between depression and nocturia. The relationship between anxiety and nocturia is less clear. Practicing clinicians should consider administering a brief self-administered scale to assess for depression in patients with nocturia.

De novo erectile dysfunction after anterior urethroplasty: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the likelihood of developing de novo erectile dysfunction (ED) after anterior urethroplasty and to determine if this likelihood is influenced by age, stricture length, number of previous procedures or timing of evaluation. MATERIALS AND METHODS: PubMed, Embase, Cochrane, and Google Scholar databases were searched for the terms 'urethroplasty', 'urethral obstruction', 'urethral stricture', 'sexual function', 'erection', 'erectile function', 'erectile dysfunction', 'impotence' and 'sexual dysfunction'. Two reviewers evaluated articles for inclusion based on predetermined criteria. RESULTS: In a meta-analysis of 36 studies with a total of 2323 patients, de novo ED was rare, with an incidence of 1%. In studies that assessed postoperative erectile function at more than one time point, ED was transient and resolved at between 6 and 12 months in 86% of cases. CONCLUSIONS: Men should be counselled regarding the possibility of transient or permanent de novo ED after anterior urethroplasty procedures. Increasing mean age was associated with an increased likelihood of de novo ED, but this was not statistically significant.

Zip-related genital injury.

OBJECTIVE: To describe the epidemiology of genital injuries caused by trouser zips and to educate both consumers and the caregivers of patients who sustain such injuries. PATIENTS AND METHODS: The National Electronic Injury Surveillance System, a dataset validated to provide a probability sample of patients who present to emergency departments (EDs) in the USA with injuries, was analysed to characterize zip-related genital injuries occurring between 2002 and 2010. A total of 523 cases were analysed to obtain national estimates. RESULTS: Between 2002 and 2010, an estimated 17,616 patients presented to US EDs with trouser zip injuries to the genitals. The penis was almost always the only genital organ involved. Zip injuries represented nearly one-fifth of all penile injuries. Amongst adults, zips were the most frequent cause of penile injuries. Annual zip-related genital injury incidence remained stable over the study period. CONCLUSIONS: Zip-related genital injuries affect both paediatric and adult cohorts. Practitioners should be familiar with various zip-detachment strategies for these populations.

No small slam: increasing incidents of genitourinary injury from toilets and toilet seats.

OBJECTIVE: To describe the epidemiology of genitourinary (GU) injury from toilets that present to USA Emergency rooms (ERs). MATERIALS AND METHODS: The National Electronic Injury Surveillance System (NEISS) is a stratified probability sample of hospital ER visits for USA consumer product-related injuries. NEISS was used to estimate total toilet- and toilet seat-related GU injury for the years 2002-2010, as well as to describe demographics and injury characteristics. Analyses were performed using strata, primary sampling units and sample weights to accommodate the complex sample survey design. Data are reported as national estimates with 95% confidence intervals (CIs) provided. RESULTS: In all, 13 175 (95% CI 10 185-16 165) GU injuries related to toilets presented to ERs during 2002-2010. The most common mechanism involved crush from accidental fall of toilet seat, described in 9011 (68.4%, 95% CI 6907-11 115) cases. Most crush injuries were isolated to the penis (98.1%). Of crush injuries, 81.7% occurred in children aged 2-3 years and 99.3% occurred in the home. Crush injuries increased over the period 2002-2010 (P = 0.017) by ≈100 per year, ending with an estimated 1707 (95% CI 1011-2402) by 2010. Most patients who sustained toilet- and toilet seat-related GU injuries were treated in the ER and then discharged. CONCLUSION: While penile crush injury related to a toilet seat is an uncommon mechanism of urological injury in children, the number of incidents appears to be rising. These findings support educational efforts and interventions, such as exchange of heavy toilet seats with slow-close toilet seat technology.

Molecular mechanisms of external genitalia development.

External genitalia development occurs through a combination of hormone independent, hormone dependent, and endocrine pathways. Perturbation of these pathways can lead to abnormal external genitalia development. We review human and animal mechanisms of normal and abnormal external genitalia development, and we evaluate abnormal mechanisms that lead to hypospadias. We also discuss recent laboratory findings that further our understanding of animal models of hypospadias.

A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury.

BACKGROUND: Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS: Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS: There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION: In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Repeat urethroplasty after failed urethral reconstruction: outcome analysis of 130 patients.

PURPOSE: Male urethral stricture disease accounts for a significant number of hospital admissions and health care expenditures. Although much research has been completed on treatment for urethral strictures, fewer studies have addressed the treatment of strictures in men with recurrent stricture disease after failed prior urethroplasty. We examined outcome results for repeat urethroplasty. MATERIALS AND METHODS: A prospectively collected, single surgeon urethroplasty database was queried from 1977 to 2011 for patients treated with repeat urethroplasty after failed prior urethral reconstruction. Stricture length and location, and repeat urethroplasty intervention and failure were evaluated with descriptive statistics, and univariate and multivariate logistic regression. RESULTS: Of 1,156 cases 168 patients underwent repeat urethroplasty after at least 1 failed prior urethroplasty. Of these patients 130 had a followup of 6 months or more and were included in analysis. Median patient age was 44 years (range 11 to 75). Median followup was 55 months (range 6 months to 20.75 years). Overall, 102 of 130 patients (78%) were successfully treated. For patients with failure median time to failure was 17 months (range 7 months to 16.8 years). Two or more failed prior urethroplasties and comorbidities associated with urethral stricture disease were associated with an increased risk of repeat urethroplasty failure. CONCLUSIONS: Repeat urethroplasty is a successful treatment option. Patients in whom treatment failed had longer strictures and more complex repairs.

The impact of serial prostate biopsies on sexual function in men on active surveillance for prostate cancer.

PURPOSE: NCCN Guidelines® recommend annual prostate biopsies for men with low risk prostate cancer on active surveillance. We determined whether erectile function decreases with the number of biopsies experienced. MATERIALS AND METHODS: During a median 3.2-year followup after prostate cancer diagnosis in 2003 to 2010 at our institution 427 men on active surveillance underwent a total of 1,197 biopsies and provided 1,398 erectile function evaluations via the Sexual Health Inventory for Men questionnaire. For analysis we decomposed the 25-point questionnaire responses into a 5-point erectile function score and a 3-level sexual activity status. We used separate models adjusted for patient characteristics to determine whether either outcome varied with biopsy exposure. RESULTS: At diagnosis the median age was 61 years and median prostate specific antigen was 5.3 ng/ml. Of the cases 70% were clinical stage cT1 and 93% were Gleason score less than 7. Of biopsies followed by evaluations 40% were the first undergone by the patient and 9% were the fifth to ninth. At the first erectile function evaluation 15% of men were inactive, 8% engage in stimulation and 77% engaged in intercourse. Sexual activity level changed in greater than 20% of respondents between evaluations. Adjusted erectile function scores were not associated with biopsy exposure cross-sectionally or longitudinally but they corresponded with the 50th, 63rd and 80th percentiles of erectile function by increasing sexual activity level. Similarly, sexual activity was not associated with biopsy exposure. Separated outcomes were more accurate and informative than Sexual Health Inventory for Men scores. CONCLUSIONS: Our study had high power to detect erectile function-biopsy associations but it estimated that the effects were negligible. We recommend erectile function scores over Sexual Health Inventory for Men scores to avoid biased assessment of erectile function.

Safer urethral catheters: how study of catheter balloon pressure and force can guide design.

OBJECTIVES: To better define urethral catheter balloon pressures and extraction forces during traumatic placement and removal of urethral catheters. To help guide design for safer urethral catheters. MATERIALS AND METHODS: Measurements of balloon pressure were made upon filling within the urethra vs the bladder. Extraction forces were measured upon removal of a catheter with a filled balloon from the bladder. Models for the bladder and urethra included an ex vivo model (funnel, 'bladder', attached to a 30 F tube, 'urethra') and fresh human male cadavers. The mean (SEM) balloon pressures and extraction forces were calculated. RESULTS: In the ex vivo model, the mean (SEM) pressures upon filling the balloon with 10 mL were on average three-times higher within the ex vivo'urethra' (177 [6] kPa) vs 'bladder' (59 [2] kPa) across multiple catheter types. In the human cadaver, the mean balloon pressure was 1.9-times higher within the urethra (139 [11] kPa) vs bladder (68 [4] kPa). Balloon pressure increased non-linearly during intraurethral filling of both models, resulting in either balloon rupture (silicone catheters) or 'ballooning' of the neck of the balloon filling port (latex catheters). Removal of a filled balloon per the ex vivo model 'urethra' and cadaveric urethra, similarly required increasing force with greater balloon fill volumes (e.g. 9.34 [0.44] N for 5 mL vs 41.37 [8.01] N for 10 mL balloon volume). CONCLUSIONS: Iatrogenic complications from improper urethral catheter use is common. Catheter balloon pressures and manual extraction forces associated with urethral injury are significantly greater than those found with normal use. The differences in pressure and force may be incorporated into a safer urethral catheter design, which may significantly reduce iatrogenic urethral injury associated with catheterization.

The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury. METHODS: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score. RESULTS: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001). CONCLUSION: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

National incidence and impact of noninfectious urethral catheter related complications on the Surgical Care Improvement Project.

PURPOSE: We defined the incidence and health outcomes related impact of noninfectious urethral catheter related complications for the 7 surgical procedures monitored by the Joint Commission as part of the Surgical Care Improvement Project. MATERIALS AND METHODS: We performed a cross-sectional analysis of the 2007 National Inpatient Sample (a 20% stratified sampling of nonfederal United States hospitals) using ICD-9-CM procedure and diagnostic codes to identify the incidence of catheter related complications for coronary artery bypass graft, and noncoronary artery bypass graft cardiac surgery, hysterectomy, colon, hip, knee and major vascular surgery. Univariate and multivariate analysis (with a significance level of less than 0.05) was performed to determine if these complications were associated with length of stay, urinary tract infections and/or deaths. RESULTS: A total of 1,420 cases of catheter related complications were identified nationally. The incidence of catheter related complications varied by surgical procedure (average 1 in 528 men and 1 in 5,217 women for all procedures). Univariate analysis revealed that in the presence of catheter related complications, mean length of stay (6 of 7 procedures, range 1.5 to 3.0 days, p <0.05) and urinary tract infection (5 of 7 procedures, absolute range 6.9% to 11.8%, p <0.05) were statistically increased for most procedures. Multivariate analysis demonstrated a significant association between catheter related complications, and increased length of stay (range 1.5 to 3.5 days, p <0.05) and urinary tract infection (OR 2.4-6.8, p <0.05) for 5 and 6 of 7 procedure types, respectively, but not mortality rate (0 of 7 procedures). CONCLUSIONS: Catheter related complications are reported rarely, but are associated with increased length of stay and urinary tract infection rates for patients in the Surgical Care Improvement Project.

Urology resident publication output and its relationship to future academic achievement.

PURPOSE: Scholarly research is considered by many to be an important component of residency training but little is known about the quantity and types of publications produced by urology residents. To our knowledge whether publication efforts during residency predict future academic publication performance is also unknown. We evaluated resident productivity, as measured by peer reviewed publication output, and determined its relation to future publication output as junior faculty. MATERIALS AND METHODS: We assembled a list of graduating residents from 2002 to 2004 who were affiliated with the top 50 urology hospitals, as ranked in 2009 by U.S. News&World Report. PubMed® was queried to determine the publication total in the last 3 years of residency of each individual and during years 2 to 4 after residency graduation. Resident publication output was stratified by research time and fellowship training. The relationship between resident productivity and future achievement was assessed. RESULTS: We assessed the publication output of 251 urologists from a total of 34 training programs affiliated with the top 50 urology hospitals. Subjects published a mean total of 3.5 and a mean of 2.0 first author papers during training. Greater research time during residency was associated with increased productivity during and after residency. Publication during training correlated with publication during the early academic career. CONCLUSIONS: Publication output correlated with increasing dedicated research time and was associated with the pursuit of fellowship training and an academic career. Publication during residency predicted future academic achievement.

Squamous cell carcinoma at the site of a Prince Albert's piercing.

INTRODUCTION: Medical practitioners should be aware of genital piercing and its potential complications. General piercings are associate with complications common to all piercings as well as some unique to urethral piercings. Specifically, the association between carcinoma and genital piercing is not well recognized. AIM: The present study is a report of two cases describing squamous cell carcinoma associated with genital piercing. METHODS: Case reports of two men admitted to an academic medical center. RESULTS: A 60-year-old man with a history of HIV and hepatitis C as well as a Prince Albert piercing presented for treatment of a urethrocutaneous fistula. A biopsy of indurated granulation tissue surrounding the fistula revealed invasive, moderately-differentiated squamous cell carcinoma. A 56-year-old man with a history of HIV, hepatitis C, and a Prince Albert piercing presented following a single episode of gross hematuria. He also reported splitting of his urinary stream. On physical examination, areas of necrosis were noted on the glans penis; biopsy revealed invasive, poorly-differentiated squamous cell carcinoma. CONCLUSIONS: The present study is the first to suggest a possible association between squamous cell carcinoma of the penis/urethra and genital piercing. Patients with genital piercings, especially those with concurrent risk factors such as HIV and HCV, should be counselled about this rare complication.

Ethnographic investigation of patient-provider communication among African American men newly diagnosed with prostate cancer: a study protocol.

INTRODUCTION: In the USA, African American men bear a disproportionate burden of prostate cancer (PCa) compared with all other groups, having a higher incidence and mortality, poorer quality of life and higher dissatisfaction with care. They are also less likely to receive guideline-concordant treatment (eg, undertreatment of aggressive disease). Inadequate patient-provider communication contributes to suboptimal care, which can be exacerbated by patients' limited health literacy, providers' lack of communication skills and time constraints in low-resource, safety net settings. This study is designed to examine the communication experiences of African American patients with PCa as they undertake treatment decision-making. METHODS AND ANALYSIS: Using an ethnographic approach, we will follow 25 African American men newly diagnosed with PCa at two public hospitals, from diagnosis through treatment decision. Data sources include: (1) audio-recorded clinic observations during urology, radiation oncology, medical oncology and primary care visits, (2) field notes from clinic observations, (3) patient surveys after clinic visits, (4) two in-depth patient interviews, (5) a provider survey, and (6) in-depth interviews with providers. We will explore patients' understanding of their diagnoses and treatment options, sources of support in decision-making, patient-provider communication and treatment decision-making processes. Audio-recorded observations and interviews will be transcribed verbatim. An iterative process of coding and team discussions will be used to thematically analyse patients' experiences and providers' perspectives, and to refine codes and identify key themes. Descriptive statistics will summarise survey data. ETHICS AND DISSEMINATION: To our knowledge, this is the first study to examine in-depth patient-provider communication among African American patients with PCa. For a population as marginalised as African American men, an ethnographic approach allows for explication of complex sociocultural and contextual influences on healthcare processes and outcomes. Study findings will inform the development of interventions and initiatives that promote patient-centred communication, shared decision-making and guideline-concordant care. This study was approved by the University of California San Francisco and the Alameda Health System Institutional Review Boards.