Alex K. Wu

Health Related Quality of Life in Patients Treated With Multimodal Therapy for Prostate Cancer

PURPOSE Patients with prostate cancer and high risk disease characteristics may benefit from multimodal therapy. However, the effects of multimodal therapy on health related quality of life have not been comprehensively described. We further characterized health related quality of life in patients treated with multimodal therapy. MATERIALS AND METHODS Patient data were obtained from the CaPSURE database, a national disease registry of men with prostate cancer. Included patients received active primary therapy (ie surgery or various forms of radiation) for prostate cancer with or without adjuvant or neoadjuvant therapy, and had complete clinical data, including health related quality of life assessments at baseline and through 2 years after treatment. The association between health related quality of life outcomes and different primary therapies with and without adjuvant or neoadjuvant therapy over time was analyzed using a repeated measures mixed model for each primary therapy. RESULTS A total of 2,204 men met the study criteria. As primary therapy 1,427 patients received radical prostatectomy, 267 received external beam radiation therapy and 510 received brachytherapy. When androgen deprivation therapy was included with radical prostatectomy, brachytherapy or external beam radiation therapy, there was a transient loss of sexual function that improved within 9 months postoperatively. When external beam radiation therapy was given with brachytherapy there was continuous worsening of urinary function and bother through 21 months. CONCLUSIONS Multimodal therapy may lead to declines in health related quality of life especially in the domains of urinary function, urinary bother and sexual function. These effects must be considered and patients must be counseled appropriately before initiation of multimodal therapy.

Time costs of fertility care: the hidden hardship of building a family

OBJECTIVE To determine the time that infertile couples spend seeking and utilizing fertility care. DESIGN Prospective cohort. SETTING Eight community and academic infertility practices. PATIENT(S) A total of 319 couples presenting for a fertility evaluation. INTERVENTION(S) Face-to-face and telephone interviews and questionnaires. MAIN OUTCOME MEASURE(S) Participants recorded diaries of time spent on provider visits, travel, telephone, and miscellaneous activities. Participants also recorded time off from work due to the physical and mental stress related to fertility care. Linear regression was used to assess relationship between fertility characteristics and time spent pursuing care. RESULT(S) Diaries were completed by 319 subjects. Over an 18-month time period, the average time spent on fertility care was 125 hours, equating to 15.6 days, assuming an 8-hour workday. For couples utilizing cycle-based treatments (CBT), overall time spent pursuing care averaged 142 hours, versus 58 hours for couples using other therapies, with the majority of time spent on provider visits (73 hours). After multivariable adjustment for clinical and sociodemographic characteristics, possessing a college degree and intensity of fertility treatment were independently associated with increased time spent pursuing fertility care. Furthermore, couples that spent the most time on care were significantly more likely to experience fertility-related stress. CONCLUSION(S) Over the course of 18 months of observation, couples pursuing fertility treatment dedicated large amounts of time to attaining their family-building goals. This burden on couples adds to the already significant financial and emotional burdens of fertility treatment and provides new insight into the difficulties that these couples face.

National incidence and outcomes of postoperative urinary retention in the Surgical Care Improvement Project

BACKGROUND The national incidence of postoperative urinary retention (POUR), its risk factors, and associated outcomes are not well understood. METHODS We identified patients undergoing one of the Surgical Care Improvement Project surgeries using the National Inpatient Sample. By using International Classification of Diseases, 9th revision, Clinical Modification codes (ICD-9-CM), we identified POUR and the outcomes urinary tract infection, noninfectious catheter-related complications, length of stay, and posthospitalization care. Multivariable analysis identified predictors of POUR and its associated outcomes. RESULTS A total of 415,409 patients, representing 2,077,045 nationally, underwent one of the Surgical Care Improvement Project procedures with 43,030 (2.1%) developing POUR. Age, sex, type of surgery, and medical comorbidities were predictive of POUR with a .71 area under the curve. Patients with POUR had greater odds of having urinary tract infections (odds ratio [OR], 2.3; 95% confidence interval [CI], 2.2-2.5), suffering catheter-related complications (OR, 5.2; 95% CI, 3.8-7.0), and needing additional posthospitalization care (OR, 1.3; 95% CI, 1.25-1.4), and they had a greater length of stay (.24 extra days). CONCLUSIONS Patients at risk for POUR can be identified, and they may benefit from interventions to prevent POUR.

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.

Impact of urethral ultrasonography on decision-making in anterior urethroplasty

Study Type – Diagnostic (Exploratory cohort)

Differences in the clinical characteristics of primarily and secondarily infertile men with varicocele

OBJECTIVE To compare the clinical characteristics of primarily and secondarily infertile men with varicocele. DESIGN Cross-sectional analysis. SETTING Male infertility clinic, tertiary health care center. PATIENT(S) Two hundred ninety-five infertile men with palpable varicoceles. INTERVENTION(S) Clinical evaluation including patient reproductive history (including assessment of primary or secondary infertility), physical examination, hormonal assessment and at least two semen analyses. MAIN OUTCOME MEASURE(S) Differences in the characteristics of men with primary vs. secondary infertility. RESULT(S) Two hundred five subjects were identified with primary infertility and 90 with secondary infertility. Secondarily infertile men were older (39.6 years vs. 35.0 years), with older partners (35.4 years vs. 33.2 years), but had higher sperm densities (51.3 vs. 36.0 million/mL) and a greater percentage of morphologically normal sperm (30.6% vs. 24.1%). A lower proportion of secondarily infertile men had total motile sperm count (TMC) <20 million compared with primarily infertile men (31.1% vs. 46.5%). Groups did not differ regarding infertility duration, tobacco or alcohol use, varicocele grade or laterality, testis volumes, or hormonal parameters. In multivariate modeling, secondary infertility (vs. primary) was an independent predictor of TMC >20 million (odds ratio 1.9). CONCLUSION(S) Men with secondary infertility are older and have older partners than primarily infertile men, yet they have significantly better sperm concentrations. Infertility in this group may be influenced by maternal reproductive potential.

Bilateral but not Unilateral Testicular Hypotrophy Predicts for Severe Impairment of Semen Quality in Men with Varicocele Undergoing Infertility Evaluation

OBJECTIVES Varicocele is a common cause of infertility, and varicocele-associated testicular hypotrophy has been described as a potential cause of decreased semen quality. We investigated the relationship between testicular hypotrophy and poor semen quality in infertile men with varicoceles. We hypothesized that bilateral hypotrophy is required before the semen quality is severely impaired. METHODS We retrospectively identified consecutive patients with palpable varicoceles undergoing an infertility evaluation at a single academic center. Each patient was evaluated by the same clinician with history and physical examination. Testicular hypotrophy was defined as a size discrepancy of greater than 3 mL or an absolute size of less than 14 mL. Multivariate logistic regression analysis was used to determine the clinical predictors of total motile sperm count (TMC) of less than 20 million. RESULTS A total of 245 men with complete data were identified, and 103 men with a TMC of less than 20 million sperm (mean age 36.2 +/- 6.6 years) were compared with 142 men with normal TMCs (mean age 37.1 +/- 6.5 years). On multivariate analysis, men with bilateral hypotrophy were nearly nine times more likely to have a TMC of less than 20 million sperm than were men without hypotrophy (odds ratio 8.8, 95% confidence interval 2.4 to 32.1), and six times more likely than those with unilateral hypotrophy (odds ratio 6.0, 95% confidence interval 1.4 to 26.3). Unilateral hypotrophy alone did not predict for a low TMC. CONCLUSIONS Among men with varicoceles undergoing infertility evaluation, those with bilateral hypotrophy are at the greatest risk of impaired semen quality.

Novel Therapeutic Approach for Neurogenic Erectile Dysfunction: Effect of Neurotrophic Tyrosine Kinase Receptor Type 1 Monoclonal Antibody

BACKGROUND Erectile dysfunction (ED) is a major health issue in aged populations, and neurogenic ED is particularly difficult to treat. Novel therapeutic approaches are needed for treatment of neurogenic ED of peripheral origin. OBJECTIVE To investigate the therapeutic effects of a neurotrophic tyrosine kinase receptor type 1 monoclonal antibody (TrkA-mAb) on erectile function and sexual behavior in a rat model of cavernous nerve injury (CNI). DESIGN, SETTING, AND PARTICIPANTS In one experiment, 84 male rats were randomly assigned to seven groups. The groups underwent either CNI or sham surgery, subsequent injection into the major pelvic ganglion (IMPG) of phosphate-buffered saline (PBS), an immunoglobulin G (IgG) control, or TrkA-mAb, and then intracavernosal (IC) injection of either PBS or varying TrkA-mAb concentrations immediately after surgery and then 1 wk later. Erectile function was assessed and histologic/molecular analyses were performed at 6 wk after surgery. In a second experiment, 36 male rats were randomly divided into three groups. The groups underwent CNI or sham surgery and then IC injection of PBS, IgG, or TrkA-mAb immediately after surgery and for 5 wk thereafter. At 6 wk after surgery, the performance of the rats in sexual behavior tests was videotaped. INTERVENTION CNI or sham surgery; IMPG of PBS, IgG, or TrkA-mAb; IC injection of PBS or TrkA-mAb. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The intracavernous pressure response to cavernous nerve electrostimulation was measured and midpenile cross-sections were histologically examined. Western blotting (WB) of cavernous tissue protein was performed. Rats were assessed for chasing, mounting, intromission, and ejaculation behaviors during sexual behavior tests. The data were analyzed using one-way analysis of variance followed by the Tukey-Kramer t test. RESULTS AND LIMITATIONS Recovery of erectile function of varying degrees was observed in the TrkA-mAb groups. TrkA-mAb treatment significantly suppressed tyrosine hydroxylase-positive nerve fibers in the corpus cavernosum and enhanced neuronal nitric oxide synthase-positive fibers in the dorsal nerve. The ratio of smooth muscle to collagen in the corpus cavernosum was significantly improved in TrkA-mAb treatment groups compared to PBS vehicle and IgG control groups. WB confirmed these biological changes. There was a nonsignificant increase in the average number of intromissions and ejaculations in the TrkA-mAb group. The study limitations include small sample size, variability in sexual behavior, lack of data on the neuromuscular mechanism involved, and lack of information of the role of neurotrophins or cytokines in regeneration. CONCLUSIONS TrkA-mAb successfully inhibits sympathetic nerve regeneration, leads to parasympathetic nerve regeneration, and has therapeutic effects on ED and sexual behavior disorder in a rat model of CNI. PATIENT SUMMARY This report provides strong evidence that a neurotrophic tyrosine kinase receptor type 1 monoclonal antibody (TrkA-mAb) inhibits sympathetic nerve regeneration, leads to parasympathetic nerve regeneration, and has therapeutic effects on erectile dysfunction and sexual behavior disorder in a rat model of cavernous nerve injury. The results raise the possibility that human patients with neurogenic erectile dysfunction may respond to TrkA-mAb in a manner that parallels the response seen in our rodent study.

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

Whats known on the subject? and What does the study add?

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.