The relationship of depression, alcohol and marijuana with treatment for LUTS/BPH.

INTRODUCTION: Despite widespread usage, research on the relationship of marijuana use to disease is sorely lacking. We sought to test the relationship of LUTS/BPH treatment and endocannabinoid agonist usage, as well as alcohol usage and depression, with treatment for LUTS/BPH in our health system. MATERIALS AND METHODS: We queried our hospital system database of nearly three million patients in a marijuana-legalized region for data from the electronic medical record between January 2011 and October 2018. Men over the age of 45 on medical therapy for LUTS (selective alpha blockade and/or finasteride) were included. Exclusions were diagnosis of bladder or prostate malignancy and men with only one visit. Alcohol and marijuana (MJ) use were found from diagnosis code and/or social history text. Medical diagnoses were based on ICD-9/10 codes. Multiple logistic regression was used to control for confounders. We considered all men over the age of 45 who had any of these features: depression, obesity or metabolic syndrome (MetS), hypertension (HTN), erectile dysfunction (ED), hypogonadism, diabetes (DM) and calculated the odds ratio of also receiving medical therapy for LUTS. Univariable and multivariable analyses were employed, multiple logistic regression was used to control for confounders. RESULTS: A total of 173,469 patients were identified meeting criteria with 20,548 (11.9%) on medical treatment for LUTS. After adjusting for confounding variables, MJ and depression remained associated with an increased risk of LUTS medication, within the context of verifying previously established relationships of ED, Obesity/MetS, DM, HTN and hypogonadism. CONCLUSIONS: Men with depression and MJ usage were more likely to be treated for LUTS/BPH in our system. Better understanding of the causality of this relationship and potential interaction of LUTS/BPH with the endocannabinoid system is desirable.

Sociodemographic index and global trends in prostate cancer: 1990-2017.

BACKGROUND: Considered globally, prostate cancer is a disease of the aging male that increases in prevalence with exposure to screening and diagnostic testing, and which requires a population with the health and longevity to encounter it. The Global Burden of Disease (GBD) dataset is an aggregation of worldwide registries and health data systems that reports global and regional assessment of disease impact. METHODS: Using the GBD database, 1171 worldwide registries and health registration systems from 1990 to 2016 were aggregated for prostate cancer disease codes and outcomes. Disease-Adjusted Life Years (DALYs) were calculated and segregated by sociodemographic index (SDI) quintile, and compared to other urologic diseases and tuberculosis (TB). RESULTS: Prostate cancer exerts a burden of disease that is vastly higher in the top quintile of SDI. The three lowest SDI quintiles represent the majority of global population but are currently less impacted by prostate cancer. Conversely, TB has its highest impact on the lowest SDI levels, although these rates are declining. CONCLUSIONS: As a global disease, prostate cancer predominantly affects high SDI men who enjoy a longer life expectancy in which to suffer from this disease and a greater exposure to screening and diagnosis. As lower SDI men are elevated in health and income, reallocation of DALYs will occur, and a greater burden of prostate cancer can be expected. These epidemiologic trends have great implications for the allocation of resources, as the population of men affected by prostate cancer outpaces urologic workforce growth.

The rising worldwide impact of benign prostatic hyperplasia.

OBJECTIVES: To describe the trend in the impact of lower urinary tract symptoms attributed to benign prostatic hyperplasia (LUTS/BPH) on a global scale using the Global Burden of Disease (GBD) database. MATERIALS AND METHODS: Using the GBD database, worldwide data aggregated from registries and health systems from 1990 to 2017 were filtered for LUTS/BPH diagnoses. Calculation of years lived with disability (YLD) were compared with other urological diseases. YLD were calculated by a standardized method using assigned disability weights. The GBD-defined sociodemographic index (SDI) was used to assess impact of LUTS/BPH by global SDI quintile. RESULTS: Global Burden of Disease data over the 1990-2017 study period were summarized and global numbers and trends noted with other urological diseases for comparison. A total of 2 427 334 YLD were attributed to BPH in 2017 alone, almost three times more than those attributed to the next highest urological disease, prostate cancer (843 227 YLD). When stratified by SDI quintile, a much lower impact of BPH was found in the bottom three quintiles, despite this subset representing 66.9% of the 2017 world population. CONCLUSIONS: Lower urinary tract symptoms attributed to benign prostatic hyperplasia exert a rapidly rising human burden far exceeding other urological diseases. As the population ages and men in a lower SDI enjoy increased life expectancy and decreased competing mortalities, a continually accelerating wave of LUTS/BPH can be forecast. These epidemiological trends have serious implications for the future allocation of resources and the global urological workforce.

Marijuana, Alcohol, and ED: Correlations with LUTS/BPH.

PURPOSE OF REVIEW: Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is a disease complex with enormous societal burden and yet the pathogenesis of LUTS/BPH is poorly understood. We set out to review the literature on the relationship between depression, marijuana usage, and erectile dysfunction (ED) to LUTS/BPH. RECENT FINDINGS: LUTS/BPH has independent associations with depression as well as with ED. In each case, the causality and mechanistic relationship is unknown. The impact of marijuana, as it increasingly pervades the general population, on the disease complex of LUTS/BPH is not well studied but recent results support short-term benefit and long-term caution. Depression, a form of central nervous dysfunction, and ED, which is likely mediated via endothelial dysfunction, are independently associated with LUTS/BPH. The presence of cannabinoid receptors in urologic organs, coupled with recent population studies, supports a modulatory effect of marijuana on voiding although an enormous knowledge gap remains.

Solitary brain metastasis after recurrent adenocarcinoma of the prostate.

Prostate cancer is rarely metastatic to visceral organs, and even less commonly to the brain. Recent data suggests brain metastasis from prostatic adenocarcinoma occur in 0.16% of patients, and almost universally in the setting of very high-volume disease. We present a man with an abruptly symptomatic brain lesion that developed at a PSA value of 1.5 ng/mL with no other known metastatic disease and required emergent neurosurgical resection. The patient had been initially treated with radiotherapy for Grade Group 4 prostate cancer in 2005 with a long period of PSA suppression.

Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms: What Is the Role and Significance of Inflammation?

PURPOSE OF REVIEW: The purpose of this review is to summarize the role and significance of inflammation as a putative additional factor contributing to lower urinary tract symptoms and the progression of benign prostatic hyperplasia. We review (1) the histologic definition of prostatic inflammation and its prevalence, (2) the effects inflammation in the prostate including on risk of acute urinary retention, and (3) the effects of systemic inflammation on the prostate and on voiding. RECENT FINDINGS: Inflammation is a highly prevalent finding in the prostate, both on a histological and biochemical level. Men with inflammation have higher IPSS scores and increased prostate size; however, these differences appear to be imperceptibly small. Men with inflammation do experience a significantly increased risk of developing acute urinary retention, an event that is associated with significant morbidity. Recently, attempts have been made to identify more specific biochemical markers of local inflammation, and to identify regional patterns of inflamed tissue within the prostate which may be associated with higher IPSS scores, accelerated progression, and AUR. The effects of systemic inflammatory states, most notably MetS, and their role in LUTS have also been examined. Inflammation is a common finding in prostates of aging men, but its contribution to lower urinary tract symptoms and benign prostatic hyperplasia progression appears to be small when considered as a clinically relevant entity. Advances in the understanding of different forms of inflammation, and their impact when experienced in different locations within the prostate, may refine this knowledge. Systemic inflammation affects voiding, including in the absence of a prostate, but again significant effects of systemic inflammation on the prostate itself are also difficult to demonstrate. Prostatic inflammation is associated with a significantly increased risk of acute urinary retention.

Novel Prostate Biopsy Technique Using Imaging Fusion in a Patient With Absent Rectum.

INTRODUCTION: A 70-year-old male with prior total colectomy for ulcerative colitis was referred for elevated prostate specific antigen (PSA) (8.01) with PIRADS 4 lesion on magnetic resonance imaging (MRI). Described is a novel technique using pre-operative multi-parametric prostate MRI and intraoperative computed tomography (CT) 3D/3D fusion for systematic and targeted prostate biopsy in a patient lacking a rectum. TECHNICAL CONSIDERATIONS: Under general anesthesia, an ultra-low-dose (ULD) cone beam CT was performed in supine position using a robotic-armed fluoroscopy system (Artis Zeego Care+Clear, Siemens). 3D/3D auto-registration of the femoral heads and prostate from the MRI and ULD CT was performed. The prostate edges and two areas of concern were marked. Then, reduced-dose fluoroscopy-guided prostate biopsy was performed transperineally using triangulation technique. 27 prostate biopsy cores were obtained. Grade group 5 (Gleason 4+5=9) prostate cancer was identified in two cores from the targeted lesion and one core from the prostate base. The remaining twenty-four biopsies were negative for malignancy. Surgical time was 81 minutes. PSMA scan demonstrated no metastasis or lymphadenopathy. Robotic-assisted laparoscopic radical prostatectomy was performed without complications. Final pathology demonstrated T3a, grade group 5 prostate adenocarcinoma involving 10% of the prostate volume with negative surgical margins. CONCLUSION: This is the initial report of fluoroscopy-guided prostate biopsy using imaging fusion techniques in a patient without a rectum. This technique allowed precise identification of localized, very high-risk prostate cancer with over three times the number of cores, and much lower radiation dose, than typical CT-guided biopsies. Our technique could provide a new paradigm in targeted prostate biopsy.

Age-Dependent Effects of Voluntary Wheel Running Exercise on Voiding Behavior and Potential Age-Related Molecular Mechanisms in Mice.

BACKGROUND: Older men frequently develop lower urinary tract symptoms attributed to benign prostatic hyperplasia (LUTS/BPH). Risk factors for LUTS/BPH include sedentary lifestyle, anxiety/depression, obesity, and frailty, which all increase with age. Although physical exercise may reduce the progression and/or severity of LUTS/BPH, the age-related mechanisms responsible remain unknown. METHODS: Voiding symptoms, body mass, and frailty were assessed after 4-weeks of voluntary wheel running in 2-month (n = 10) and 24-month (n = 8) old C57Bl/6J male mice. In addition, various social and individual behaviors were examined in these cohorts. Finally, cellular and molecular markers of inflammation and mitochondrial protein expression were assessed in prostate tissue and systemically. RESULTS: Despite running less (aged vs young X¯ = 12.3 vs 30.6 km/week; p = .04), aged mice had reduced voiding symptoms (X¯ = 67.3 vs 23.7; p < .0001) after 1 week of exercise, which was sustained through week 4 (X¯ = 67.3 vs 21.5; p < .0001). Exercise did not affect voiding symptoms in young mice. Exercise also increased mobility and decreased anxiety in both young and aged mice (p < .05). Exercise decreased expression of a key mitochondrial protein (PINK1; p < .05) and inflammation within the prostate (CD68; p < .05 and plasminogen activator inhibitor-1; p < .05) and in the serum (p < .05). However, a frailty index (X¯ = 0.17 vs 0.15; p = .46) and grip strength (X¯ = 1.10 vs 1.19; p = .24) were unchanged after 4 weeks of exercise in aged mice. CONCLUSIONS: Voluntary aerobic exercise improves voiding behavior and mobility, and decreases prostatic mitochondrial protein expression and inflammation in aged mice. This promising model could be used to evaluate molecular mechanisms of aerobic exercise as a novel lifestyle intervention for older men with LUTS/BPH.

Analysis of a large single-center experience with robot-assisted pyeloplasty.

OBJECTIVES: To report a single-center experience with robot-assisted pyeloplasty. METHODS: Medical records of 100 consecutive robot-assisted pyeloplasty cases carried out between May 2004 and August 2010 were retrospectively reviewed, and major perioperative parameters were recorded. Patients underwent functional (renal scan) and/or anatomical (ultrasound or computerized tomoghraphy) imaging at 6 months. RESULTS: The mean patient age was 39.8 years. A total of 12 patients underwent prior attempts at repair. Ureteral stents were placed in all patients except one, and closed-suction drains were placed in 59 patients. There were two intraoperative complications and two postoperative complications requiring surgical intervention. One patient with a complex prior surgical history developed a urine leak that was managed with prolonged drainage. A total of 42 patients were discharged on postoperative day 1, and 44 were discharged on postoperative day 2. Mean length of follow up was 22.8 months. The operative success rate was 96%. CONCLUSIONS: The majority of patients undergoing robot-assisted pyeloplasty can expect a short hospitalization with minimal morbidity. The operative success rate is high, even in patients with prior attempts at repair. Complication rates including urine leaks are quite low, and routine placement of a closed-suction drain is likely to be unnecessary.

A Novel Technique of Robotic-Assisted Simple Cystectomy During Urinary Diversion for Benign Indications.

BACKGROUND: When urinary diversion is necessary for benign indications, the defunctionalized bladder is at risk of a number of severe complications such as bleeding, pain, pyocystis and secondary urothelial carcinoma. These complications occur in 54%-80% of patients left with native bladder after diversion, and these patients go on to require completion cystectomy 20%-25% of the time. Rowley et al. at the University of Michigan reported their experience in open simple cystectomy in 2011 in a series of 23 patients. This operation, to our knowledge, has not been previously adapted to the robotic platform despite the growing prevalence of robotic surgery including for complex reconstruction and urinary diversion. Here we report our novel adapted technique of performing robotic simple cystectomy in 2 index patients. OBJECTIVE: To visually demonstrate and report our technique of simple cystectomy, utilizing the robotic platform, including outcomes in 2 index patients. METHODS: Two index patients are presented, including outcomes: One female with spinal cord injury, smoking and chronic infections in the setting of suprapubic catheter diversion, and one male with multiply failed local treatments including radiation and cryotherapy for prostate cancer that have resulted in chronic fistula, prior Fournier's gangrene, and sympheseal osteomyelitis. RESULTS: he operations were completed without difficulty, in an expedient fashion (35-48 minutes) and without significant blood loss (10cc or less). The technique is illustrated in the accompanying video. CONCLUSION: This novel adapted robotically-assisted operation appears to be a rapid and reproducible operation that recapitulates the principles of open surgery with little time or blood loss, thus avoiding the morbidity of radical cystectomy or of delayed secondary operations, while at the same time providing all the benefits inherent to a robotic operation. Outcomes appear excellent. Further study is needed.

Diagnostic yield of upper tract imaging performed for hematuria screening: Results from a national, privately-insured cohort.

OBJECTIVES: To increase the population-level understanding of upper tract imaging evaluation during risk-based hematuria assessment. Using a national, privately-insured cohort, we evaluated the rates of imaging and the diagnostic yield of each imaging modality. We hypothesized that the rate of upper tract disease would be low and that the benefit of computed tomography over renal ultrasound would be limited. METHODS: We identified patients with an incident diagnosis of microscopic or gross hematuria between 2010 and 2015 within the MarketScan database. Multivariable logistic regression was used to predict the adjusted likelihood of any upper tract finding, with a subset analysis limited to malignant outcomes. RESULTS: We identified 466,710 patients; 150,880 (32.3%) received ultrasound, 219,449 (47.0%) received computed tomography, and 96,381 (20.7%) received other imaging. Ultrasound detected 1,469 findings among 150,880 patients (1%); computed tomography detected 3,764 findings among 219,449 patients (1.7%); other imaging detected 2,612 findings among 96,381 patients (2.7%) (P < 0.0001). When adjusted for comorbidities, increased age, male sex, increased Elixhauser index, gross hematuria, and CT or other imaging were associated with upper tract findings, in the overall and subset analysis (all p < 0.0001). CONCLUSIONS: The diagnostic yield of imaging is higher than expected; however, the detection rate remained low. As supported by updated clinical practice guidelines, clinicians should pursue risk-based imaging strategies during hematuria evaluation, although these data may support increased utilization of ultrasound at the initial evaluation.

Renal trauma from recreational accidents manifests different injury patterns than urban renal trauma.

PURPOSE: The majority of blunt renal trauma is a consequence of motor vehicle collisions and falls. Prior publications based on urban series have shown that significant renal injuries are almost always accompanied by gross hematuria alone or microscopic hematuria with concomitant hypotension. We present a series of blunt renal trauma sustained during recreational pursuits, and describe the mechanisms, injury patterns and management. MATERIALS AND METHODS: Database review from 1996 to 2009 identified 145 renal injuries. Children younger than age 16 years, and trauma involving licensable motor vehicles, penetrating injuries and work related injuries were excluded from analysis. Grade, hematuria, hypotension, age, gender, laterality, mechanism, management, injury severity score and associated injuries were recorded. RESULTS: We identified 106 patients meeting the criteria and 85% of the injuries were snow sport related. Age range was 16 to 76 years and 92.5% of patients were male. There were 39 grade 1 injuries, 30 grade 2, 22 grade 3, 12 grade 4 and 3 grade 5 injuries. Gross hematuria was present in 56.7%, 77.2% and 83.3% of grade 2, grade 3 and grade 4 injuries, respectively. None of the patients with grade 2 or greater injuries and microscopic hematuria had hypotension except 1 grade 5 pedicle injury. The nephrectomy and renorrhaphy rate for grade 1 to grade 4 injuries was 0%. CONCLUSIONS: Compared to urban series of blunt renal trauma, recreationally acquired injuries appear to follow different patterns, including a paucity of associated injuries or hypotension. If imaging were limited to the presence of gross hematuria, or microscopic hematuria with hypotension, 23% of grade 2 to grade 4 injuries would be missed. Men are at higher risk than women. However, operative intervention is rarely helpful.

The Impact of Race, Ethnicity and Insurance Status on Surgery Rates for Benign Prostatic Hyperplasia.

OBJECTIVE: To determine whether patient race/ethnicity are associated with differences in likelihood of undergoing surgical treatment for LUTS/BPH. METHODS: Queried hospital network database between 1/2011 and 10/2018. Men over age 40 on medical therapy for LUTS (selective alpha blockade and/or 5-alpha-reductase inhibitor), with 2+ provider visits, and without bladder/prostate malignancy were included. Ethnicity/race determined by self-identification. Insurance status classified as public (Medicare/Medicaid/Tricare), private, self-pay, or other. Multivariable backwards step-wise logistic regression was performed to compare odds of undergoing a surgical procedure by race/ethnicity, controlling for patient age, insurance status, comorbidities, and type of medical therapy. RESULTS: 30,466 patients included, with White (n=24,443, 80.2%), Hispanic (n=2,715, 8.9%), Black (n=1,245, 4.1%), and other race/ethnicity (2,073, 6.8%) identified within the study population. After adjusting for age, insurance status, major comorbidities, and type of medical therapy, Black patients were less likely to undergo surgery than White patients (OR 0.57, 95% CI 0.37 - 0.88, P = .011), as were patients of other race/ethnicity (OR 0.67, 95% CI 0.49 - 0.92, P = .013). CONCLUSIONS: Adjusting for age, insurance status, major comorbidities and type of LUTS medication, men categorized as Black were significantly less likely to undergo surgical treatment for LUTS/BPH than White patients. It is unknown whether this difference results from differences in counseling, access, or other bias in therapy. Efforts to understand and respond to this disparity are necessary. Limitations include lack of IPSS data, additional comorbidity data, limited geographic area, and retrospective nature.

High-risk Disease and Poor Follow-up: The Importance of Renal Mass Biopsy in a Cohort of Veterans.

OBJECTIVE: To assess the clinical utility of renal mass biopsy (RMB) in our multistate system. RMB is useful in the management of masses ≤4 cm (T1a), but evaluation of RMB in the uniquely vulnerable Veteran population is lacking. METHODS: About 136 RMB in 130 patients performed between 06/2015 and 11/2020 were identified in this Quality Improvement analysis. Demographics, size, pathology, treatment, and biopsy complications were analyzed. Of 101 T1a masses, 89 were either diagnostic or not decompressed cysts and 77 met inclusion criteria for follow-up imaging compliance analysis. RESULTS: The median age was 66 years. The diagnostic rate was 94.1% (128/136) for all masses and 94.1% (95/101) for T1a renal masses, with a complication rate of 2.2%. Among solid T1a masses, unexpectedly aggressive lesions (Fuhrman Grade 4, Type 2 papillary or sarcomatoid features) were identified in 8/89 (9.0%). Fifty-seven (64%) patients were treated with cryoablation or surgery and 32 (36%) patients elected active surveillance (AS). A neoplastic finding (oncocytoma or renal cell carcinoma (RCC)) was present in 16 patients choosing AS (50%) compared to 52 patients choosing treatment (91%). Compliance with National Comprehensive Cancer Network-recommended imaging was 50% and 47% for AS and treatment groups, respectively. CONCLUSION: In this VA cohort, we found a significant incidence of high-risk lesions and poor compliance with follow-up imaging. Aggressive biopsy protocols with high consideration of treatment may be appropriate to limit risk in those lost to follow-up. Given that 9% of our small renal masses were highly aggressive, biopsy may be critical in the selection of AS candidates.

Perioperative Clerkship Design for Students with Physical Disabilities: A Model for Implementation.

OBJECTIVE: Disability inclusion is an important and growing area of focus for medical education that may be stymied by stereotypes about disabilities, lack of knowledge about accommodations for students with physical disabilities, or outdated technical standards that preclude participation of people with mobility disabilities. To support the inclusion of students with physical disability in surgical clerkships, we describe a proactive, progressive approach to the accommodations process for a student with a thoracic spinal cord injury entering a surgical clerkship. DESIGN: Working proactively, medical school leadership, disability professionals and the clerkship team collaborated on the development of reasonable accommodations for a student with a thoracic spinal cord injury entering a surgical clerkship. SETTING: University of Colorado, Department of Surgery and Department of Medical Education, Aurora, CO. PARTICIPANTS: A third-year medical student and faculty from the medical school and surgical clerkship leaders. RESULTS: An M3 student with a thoracic spinal cord injury successfully completed an 8-week surgical clerkship completing all required procedural and clinical skills utilizing reasonable accommodation. The student achieved a grade of honors for the rotation. CONCLUSIONS: Early communication and planning for disability-related adjustments are critical to ensure an accessible experience for students with physical disabilities. The addition of a student with a disability adds to a better understanding of inclusive practices for surgical education and adds to the diversity of thought and experience for the medical education community.

Is Your Career Hurting You? The Ergonomic Consequences of Surgery in 701 Urologists Worldwide.

Purpose: Our objective was to seek correlations between the type, volume, and duration of surgical work performed, surgeon habits and characteristics, and the prevalence of neck and back musculoskeletal complaint and intervention across career from training to retirement. Materials and Methods: An anonymous web-based multinational survey of urologists was conducted. The primary outcome measured was pain. Secondary outcomes included pain requiring intervention and surgery. Responses were subgrouped according to geography, practice patterns, and demographics. Student t test, Fisher's exact test, and chi-square test were used for analysis. Results: A total of 701 complete responses were received from this multinational survey. Gender, pain distribution, and private or academic practice did not correlate with pain, whereas exercise, lower weight, and body mass index (BMI) were protective. Dose-response of surgical type was assessed with high- and low-volume density quartiles and frequency of each pain severity; no correlation was found. Secondary analysis showed that female practitioners seek invasive therapy less than male counterparts, and practitioners of direct optical cystoscopy report no more neck trouble than others. Length of career since residency shows little relationship to pain or pain-free rates. Conclusions: In this, the largest surgical ergonomic study to date: surgical type, duration, volume, setting, and physician gender were unrelated to surgeon pain throughout career. Exercise was associated with lower prevalence of pain in a dose-related manner; increasing weight and BMI were positively associated with pain. Although 47% of urologists with spinal pain blame their career, we are unable to identify any dose-response relationship that supports that assumption.