Adam B. Shrewsberry

Exercise is Associated with Better Erectile Function in Men Under 40 as Evaluated by the International Index of Erectile Function

INTRODUCTION Studies have shown an association between erectile dysfunction and sedentary lifestyle in middle-aged men, with a direct correlation between increased physical activity and improved erectile function. Whether or not this relationship is present in young, healthy men has yet to be demonstrated. AIM The aim of this study was to assess the association between physical activity and erectile function in young, healthy men. MAIN OUTCOME MEASURES The primary end points for our study were: (i) differences in baseline scores of greater than one point per question for the International Index of Erectile Function (IIEF); (ii) differences in baseline scores of greater than one point per question for each domain of the IIEF; (iii) exercise energy expenditure; and (iv) predictors of dysfunction as seen on the IIEF. METHODS The participants were men between the ages of 18 and 40 years old at an academic urology practice. Patients self-administered the Paffenbarger Physical Activity Questionnaire and the IIEF. Patients were stratified by physical activity into two groups: a sedentary group (≤1,400 calories/week) and an active group (>1,400 calories/week). Men presenting for the primary reason of erectile dysfunction or Peyronies disease were excluded. RESULTS Seventy-eight patients had complete information in this study: 27 patients (34.6%) in the sedentary group (≤1,400 kcal/week) and 51 patients (65.4%) in the active group (>1,400 kcal/week). Sedentary lifestyle was associated with increased dysfunction in the following domains of the IIEF: erectile function (44.4% vs. 21.6%, P = 0.04), orgasm function (44.4% vs. 17.7%, P = 0.01), intercourse satisfaction (59.3% vs. 35.3%, P = 0.04), and overall satisfaction (63.0% vs. 35.3%, P = 0.02). There was a trend toward more dysfunction in the sedentary group for total score on the IIEF (44.4% vs. 23.5%, P = 0.057), while sexual desire domain scores were similar in both groups (51.9% vs. 41.2%, P = 0.37). CONCLUSIONS We have demonstrated that increased physical activity is associated with better sexual function measured by a validated questionnaire in a young, healthy population. Further studies are needed on the long-term effects of exercise, or lack thereof, on erectile function as these men age.

A unique benign mucinous cystadenoma of the retroperitoneum: a case report and review of the literature.

Primary retroperitoneal mucinous cysts are rare. Most often malignant, lesions present on a spectrum, fitting the histopathological categories of benign, borderline and malignant. The rarest form is the benign mucinous cystadenoma adenocarcinoma, of which only 20 cases have been reported. We present here the curious case of a 37-year-old woman with two large, fast growing, cystic, benign, primary retroperitoneal mucinous cystadenomas treated definitively by local resection.

Serum Testosterone May Be Associated with Calcium Oxalate Urolithogenesis

BACKGROUND The incidence of urolithiasis is twofold to threefold higher in men than in women. Several animal studies have suggested an association between testosterone levels and the formation of kidney stones. Specifically, castration has been shown to decrease stone formation in rat models. The association between testosterone and stone formation in humans, however, has not been well investigated. PATIENTS AND METHODS Early morning total and free testosterone levels were recorded for 55 male patients. Participants completed a demographics questionnaire, and clinical records of enrolled subjects were reviewed. When available, stone composition was determined in the stone formers. Mann-Whitney tests and logistic regression models were used to examine the data. RESULTS Of the 55 patients, 25 had no history of urolithiasis and 30 had a history of urolithiasis. Although the differences between the two groups were not statistically significant, the stone formers compared with stone-free controls tended to be older (median age 48.4 vs 36.5 years, P = 0.072) and have higher serum levels of testosterone (median serum concentration 384 vs 346 ng/dL, P = 0.112). In the multivariate analyses, after adjusting for age and body mass index, the testosterone-related odds ratio was 1.004 with a corresponding P value 0.051. CONCLUSIONS Male stone formers were found to have higher serum total testosterone levels compared with a similar cohort without stones. This result is consistent with several animal models that have demonstrated that testosterone is a risk factor for stone formation. Our findings warrant confirmation in a larger, prospective study. There are potential therapeutic implications if testosterone is found to be a risk factor in urolithogenesis.

Renal cell carcinoma in patients with end-stage renal disease has favorable overall prognosis

Patients with end‐stage renal disease (ESRD) demonstrate a greater risk for renal cell carcinoma (RCC) than the general population. This study compared pathological and clinical outcomes in patients with RCC with and without ESRD. Patients with ESRD who underwent nephrectomy and were found to have RCC at our institution since 1999 were identified. The control group was composed of patients from the general population with RCC. The primary outcome was risk of cancer recurrence. The study included 338 RCC patients: 84 with ESRD and 243 without ESRD. In the ESRD group, mean tumor size was smaller, there was decreased prevalence of advanced T category (>3) , and the average Karakiewicz nomogram score was lower. ESRD was associated with decreased tumor recurrence and clear cell pathology. No patients with ESRD had metastatic disease. There was no difference in overall or cancer‐specific mortality between the ESRD and control groups. Patients with ESRD who develop RCC have a better prognosis compared to RCC in patients without ESRD, which is likely secondary to favorable histopathologic phenotype as well as the likelihood of early diagnosis. Thus, the delay between nephrectomy and renal transplantation may not be necessary, especially in patients with asymptomatic, low grade tumors.

A +20% Adjustment in the Computed Tomography Measured Ureteral Length Is an Accurate Predictor of True Ureteral Length Before Ureteral Stent Placement

PURPOSE The correct length of a ureteral stent is important in minimizing postplacement discomfort and stent migration. We describe and validate a method to accurately measure the ureteral length. MATERIALS AND METHODS The ureteral length in 48 patients undergoing ureteral stent placement for urolithiasis was measured by computed tomography (CT) (total thickness of axial slices between the ureteropelvic junction and ureterovesical junction) and adjusted up by 20%. The adjusted CT measurement of ureteral length was compared with direct intraoperative measurement using scatter plot and Pearson correlation coefficient. Correlation coefficients were also calculated between intraoperative ureteral length and various body habitus measurements such as the height, weight, and waist circumference. RESULTS Median patient age was 62 years. The median stone diameter was 7.5 mm (1-20). The ratio of left- to right-sided stones was 2:1. The stone location was in the proximal ureter in 45.8%, distal ureter in 37.5%, kidney in 10.4%, and midureter in 6.3%. Symptoms included adnominal/flank pain (93.8%) followed by nausea/vomiting (39.6%) and gross hematuria (16.7%). Median creatinine was 1.4 (0.8-3.6 mg/dl) and median WBC was 8.6 (2.8-17.6). The median ureteral length was 25.8 cm (19.2-29.4) on the CT scan and 25.5 cm (19.0-29.0) on the intraoperative measurement (p=0.57). The Pearson correlation coefficient between the two measurements was 0.979. In contrast, the height, weight, and waist circumference correlated poorly with intraoperative ureteral length measurements (r=0.34, 0.19, and 0.40, respectively). CONCLUSION CT-measured ureteral length adjusted up by 20% is a reliable method to accurately measure the true ureteral length. This method is superior to traditional indirect methods that rely on body habitus measurements.

Recent Advances in the Medical and Surgical Treatment of Priapism

Priapism often is a urological emergency that requires prompt and aggressive therapy. Over the past several years, research has provided better understanding and new insights into the pathophysiology of this disorder. Subsequently, new treatments have been tried and developed. This report focuses on the latest review of therapy for ischemic and nonischemic priapism.

Ureteroscopy versus Shock Wave Lithotripsy: Factors Influencing Patient Treatment Preferences

Introduction: Shock wave lithotripsy and ureteroscopy are considered first line treatment options for patients with urolithiasis. However, these interventions have significant variation in rates of stone‐free success, procedure related complications and need for reoperation. We examined patient preferences in treatment selection for urolithiasis and factors associated with choice of treatment. Methods: Patients with a history of urolithiasis were self‐administered or mailed a questionnaire with a clinical scenario of a stone in the ureter and outcome statistics derived from a Cochrane Review for ureteroscopy and shock wave lithotripsy comparing stone‐free success rates, complication rates, need for ureteral stent placement and need for additional surgery. Subjects were asked to choose ureteroscopy or shock wave lithotripsy and to indicate the relative importance that each of the 4 outcome parameters had on their treatment selection. Results: A total of 163 patients returned complete surveys and a majority preferred ureteroscopy to shock wave lithotripsy (63% vs 37%, p=0.001) for the clinical scenario presented. For factors influencing procedure preference success was indicated as extremely important by 94% (152 of 163) of respondents, followed by complications, need for second surgery and, finally, need for stent. Conclusions: A majority of patients preferred ureteroscopy to shock wave lithotripsy after reviewing the evidence‐based rates of stone‐free success, complications and need for second surgery. Shared decision making and patient centered care should be the focus of surgical treatment selection when there is no consensus regarding a superior treatment for urolithiasis.

Outcomes Data in Pain Studies: In Reply to Barbul and colleagues

It is gratifying to see that these results were interesting to an authority like Dr Barbul and colleagues. We certainly agree that there are theoretical risks and concerns for increased surgical site infections with local cryotherapy application. We hope our study spurs future studies that are powered to sufficiently detect adverse events after cryotherapy as well as efficacy between different regimens of cryotherapy. Notably, of the 3 surgical site infections in our cryotherapy group, 1 occurred in a patient who underwent an abdominoperineal resection and had an infection only at the perineal wound. This portion of the wound did not have particular exposure to the ice packs. All wound infections were of Clavien-Dindo classification grade II and did not significantly alter the patient’s postoperative recovery. Additionally, although not formally studied, we have used cryotherapy routinely on virtually all surgical oncology and urologic oncology abdominal wounds at Emory University since accumulation of these data in 2011.Wehave not identified an increase in surgical site infections using ourNSQIP database. In a recent series of 67 cases abstracted byNSQIP, no wound infections were noted. Although not equal in wound-classification category, within the orthopaedic and obstetric literature there are multiple meta-analyses and systemic reviews providing evidence that cryotherapy does not increase rates of surgical site infections. Knee arthroplasty, which carries risk for hardware infection, a devastating complication, routinely is treated with postoperative cryotherapy at many facilities in the United States. Meta-analyses and systemic reviews of trials have not found an increased incidence of surgical site infections among the cryotherapy arms. Cryotherapy is also routinely used postoperatively in the field of orthopaedic sports medicine. A previous systematic review and a meta-analysis of randomized control trials on anterior cruciate ligament repair also do not demonstrate an increased incidence of surgical site infections among cryotherapy groups. A meta-analysis of cryotherapy use for perineal wounds after childbirth additionally did not find an increase in postoperative wound infections, although one of the trials analyzed noted increased edema and ecchymosis. Our patients were all normothermic, and this is another excellent point made by the reviewers. Perhaps patients who cannot maintain normothermia will be at increased risk for surgical site infections, and this issue needs to be further investigated. Our study group did not include any patients requiring postoperative ICU care. Patients in the ICU have more fluctuations in body temperature, hemodynamics, and blood glucose that can affect wound healing and tissue perfusion. This study certainly prompts numerous questions that need to be further examined in larger series with sufficient power to detect postoperative complications as well as patient quality of life. We look forward to additional feedback on our work and subsequent studies on the topic. We do believe that the decreased pain scores and patient satisfaction noted in our study combined with low risk profile of cryotherapy warrants our continued use of cryotherapy in our patients undergoing abdominal operations.

1983 URETEROSCOPY VERSUS SHOCK WAVE LITHOTRIPSY - FACTORS INFLUENCING PATIENT TREATMENT PREFERENCES

Methods: Patients with a history of urolithiasis were self-administered or mailed a questionnaire with a clinical scenario of a stone in the ureter and outcome statistics derived from a Cochrane Review for ureteroscopy and shock wave lithotripsy comparing stone-free success rates, complication rates, need for ureteral stent placement and need for additional surgery. Subjects were asked to choose ureteroscopy or shock wave lithotripsy and to indicate the relative importance that each of the 4 outcome parameters had on their treatment selection.

Laser Applications, Tumor, and Stricture

With improvements in technique and equipment, endoscopic treatment of both transitional cell carcinoma of the upper urinary tract and ureteral stricture disease has become more feasible. Patients with upper tract urothelial carcinoma who have bilateral disease, a solitary kidney, renal insufficiency, extensive comorbidities, or low-grade, low-stage disease may benefit from endoscopic management. The goals of treating ureteral strictures are ruling out malignancy, preserving renal function, and relieving symptoms. Herein, we present our step-by-step surgical approach to the endoscopic treatment of upper tract urothelial carcinoma and ureteral stricture disease, including surgical technique, pre- and postoperative considerations, instrumentation, and potential complications.