Allison S. Glass

Urethroplasty after radiation therapy for prostate cancer

OBJECTIVE To report urethroplasty outcomes in men who developed urethral stricture after undergoing radiation therapy for prostate cancer. METHODS Our urethroplasty database was reviewed for cases of urethral stricture after radiation therapy for prostate cancer between June 2004 and May 2010. Patient demographics, prostate cancer therapy type, stricture length and location, and type of urethroplasty were obtained. All patients received clinical evaluation, including imaging studies post procedure. Treatment success was defined as no need for repeat surgical intervention. RESULTS Twenty-nine patients underwent urethroplasty for radiation-induced stricture. Previous radiation therapy included external beam radiotherapy (EBRT), radical prostatectomy (RP)/EBRT, EBRT/brachytherapy (BT) and BT alone in 11 (38%), 7 (24%), 7 (24%), and 4 (14%) patients, respectively. Mean age was 69 (±6.9) years. Mean stricture length was 2.6 (±1.6) cm. Anastomotic urethroplasty was performed in 76% patients, buccal mucosal graft in 17%, and perineal flap repair in 7%. Stricture was localized to bulbar urethra in 12 (41%), membranous in 12 (41%), vesicourethra in 3 (10%), and pan-urethral in 2 (7%) patients. Overall success rate was 90%. Median follow-up was 40 months (range 12-83). Time to recurrence ranged from 6-16 months. CONCLUSION Multiple forms of urethroplasty appear to be viable options in treating radiation-induced urethral stricture. Future studies are needed to examine the durability of repairs.

Pubic Hair Grooming Injuries Presenting to U.S. Emergency Departments

OBJECTIVE To describe the demographics and mechanism of genitourinary (GU) injuries related to pubic hair grooming in patients who present to U.S. emergency departments (EDs). MATERIALS AND METHODS The National Electronic Injury Surveillance System contains prospectively collected data from patients who present to EDs with consumer product-related injuries. The National Electronic Injury Surveillance System is a stratified probability sample, validated to provide national estimates of all patients who present to U.S. EDs with an injury. We reviewed the National Electronic Injury Surveillance System to identify incidents of GU injury related to pubic hair grooming for 2002-2010. The variables reviewed included age, race, gender, injury type, location (organ) of injury, hospital disposition, and grooming product. RESULTS From 2002 to 2010, an observed 335 actual ED visits for GU injury related to grooming products provided an estimated 11,704 incidents (95% confidence interval 8430-15,004). The number of incidents increased fivefold during that period, amounting to an estimated increase of 247 incidents annually (95% confidence interval 110-384, P = .001). Of the cohort, 56.7% were women. The mean age was 30.8 years (95% confidence interval 28.8-32.9). Shaving razors were implicated in 83% of the injuries. Laceration was the most common type of injury (36.6%). The most common site of injury was the external female genitalia (36.0%). Most injuries (97.3%) were treated within the ED, with subsequent patient discharge. CONCLUSION Most GU injuries that result from the use of grooming products are minor and involve the use of razors. The demographics of patients with GU injuries from grooming products largely paralleled observations about cultural grooming trends in the United States.

Transperineal Management for Postoperative and Radiation Rectourethral Fistulas

PURPOSE The rectal sphincter preserving transperineal approach has been increasingly used successfully. We analyzed our experience with this surgical approach. A secondary aim was to evaluate the surgical outcome of energy ablative rectourethral fistulas without a concomitant interposition muscle flap. MATERIALS AND METHODS We identified all patients with rectourethral fistula who underwent rectal sphincter preserving transperineal repair from 1998 to 2011. Re-approximation of the urethral mucosa, posterior anastomotic urethroplasty or partial/total prostatectomy with urethrovesical anastomosis was performed for urinary closure. The fistula cohort was divided into 2 groups, including postoperative and energy ablative fistulas, respectively. Success after perineal rectourethral fistula repair was defined as resolution after the first attempt at repair. RESULTS A total of 23 patients underwent rectal sphincter preserving, transperineal rectourethral fistula repair. In the postoperative fistula cohort the fistula was successfully resolved in all 10 patients. A dartos interposition muscle flap was used in 2 of 10 patients. In the energy ablative cohort the fistula was successfully closed in 8 of 13 patients. An interposition muscle flap was not placed in 8 patients with an energy ablative fistula, of whom success was achieved in 5. Two of the 5 patients with an energy ablative fistula and a successful outcome without a concomitant interposition muscle flap had urinary extravasation, necessitating temporary catheterization. CONCLUSIONS Rectal sphincter preserving transperineal repair is a successful surgical method to repair postoperative and energy ablative rectourethral fistulas. An interposition muscle flap should be considered in the setting of energy ablative rectourethral fistulas to increase successful outcomes.

Role of Active Surveillance in the Management of Localized Prostate Cancer

Active surveillance is an increasingly recognized treatment option for men with low-risk prostate cancer. Despite encouraging evidence for oncologic efficacy and reduction in morbidity, several barriers contribute to the underuse of this management strategy. Consistent selection criteria as well as identification and validation of triggers for subsequent intervention are essential. Incorporation of novel biomarkers as well as advanced imaging techniques may improve surveillance strategies by better defining eligibility as well as improving prompt detection of disease progression.

Active surveillance: does serial prostate biopsy increase histological inflammation?

Background:Active surveillance (AS) is an appropriate management strategy for men with low-risk prostate cancer. Most protocols recommend repeated prostate biopsy every 12–24 months. The purpose of this paper is to describe histological inflammation patterns in men on AS who underwent serial prostate biopsy for disease monitoring.Methods:We reviewed records of men on AS from January 1999 through February 2011 who had a diagnostic plus ⩾1 repeat transrectal ultrasound-guided biopsies performed at our institution. The type and degree of inflammatory infiltrate were grossly reviewed and scored for each patient’s biopsy by a single pathologist. Relationship of inflammation severity and number of serial biopsies was assessed using a repeated measures mixed model. Unpaired t-test and χ2-square analysis assessed variance in degree of inflammation and location of inflammation relative to cancer grade progression defined as Gleason sum increase.Results:Fifty-six men met study inclusion criteria. Mean age was 62.1 (6.5) years, 71% were stage cT1c, 79% had a PSA level <10 ng ml−1, and 98% had diagnostic Gleason sum ⩽6. A small, statistically significant increase in maximum chronic inflammation (CI) scores with greater number of repeat biopsies was observed. CI scores were not associated with number of biopsies based on upgrade status. The main limitation to our study is our small sample size. Potential unmeasured confounders, such as unreported antibiotic use or symptomatic prostatitis, may have also affected our findings.Conclusions:In this pilot study of 56 men on AS for localized prostate cancer, degree of chronic histological inflammation increased with greater number of prostate biopsies, but was not associated with subsequent risk of grade progression.

Acquired Male Urethral Diverticula: Presentation, Diagnosis and Management

PURPOSE We describe the etiology, presentation, treatment and outcomes of men diagnosed with an acquired urethral diverticulum. MATERIALS AND METHODS We retrospectively analyzed the records of men with an acquired urethral diverticulum in an 11-year period (2000 to 2011) at a tertiary care reconstructive practice. Patient demographics, history, presentation, anatomical details such as diverticulum size and location, management and outcomes were recorded. Technical success was defined as unobstructed urination without urinary tract infection. RESULTS A total of 22 men with an acquired urethral diverticulum were included in analysis. Median age at presentation was 48.5 years (range 18 to 86). Most commonly, patients presented with recurrent urinary tract infection, urinary dribbling, incontinence or a weak urinary stream. Of the 22 men 12 (54.5%) underwent urethral diverticulectomy and urethroplasty, 3 (13.5%) underwent ileal conduit urinary diversion and 7 (32%) were treated nonoperatively. Select cases were managed conservatively when the urethral diverticulum was confirmed in a nonobstructed urethra, it was small or asymptomatic and it could be manually emptied after voiding. At a mean followup of 2.3 years there was a 91% urethral diverticulum recurrence-free rate. CONCLUSIONS Acquired male urethral diverticula are rare but should be considered when there is recurrent urinary tract infection, obstructive voiding symptoms, a history of hypospadias, urethral stricture or trauma, or prolonged urethral catheterization. Treatment options may include surgical excision of the urethral diverticulum or urinary diversion. Some patients may be adequately treated nonoperatively with post-void manual decompression.

Risk-Based Prostate Cancer Screening: Who and How?

The purpose of this review is to identify clinical risk factors for prostate cancer and to assess the utility and limitations of our current tools for prostate cancer screening. Prostate-specific antigen is the single most important factor for identifying men at increased risk of prostate cancer but is best assessed in the context of other clinical factors; increasing age, race, and family history are well-established risk factors for the diagnosis of prostate cancer. In addition to clinical risk calculators, novel tools such as multiparametric imaging, serum or urinary biomarkers, and genetic profiling show promise in improving prostate cancer diagnosis and characterization. Optimal use of existing and future tools will help alleviate the problems of overdiagnosis and overtreatment of low-risk prostate cancer without reversing the substantial mortality declines that have been achieved in the screening era.

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

To describe the epidemiology of genitourinary (GU) injury from toilets that present to USA Emergency rooms (ERs).

Early Detection of Prostate Cancer: More Information, More Clarity

EUROPEAN UROLOGY 62 (2012) 753–756 available at www.sciencedirect.com journal homepage: www.europeanurology.com Platinum Priority – Editorial and Reply from Authors Referring to the article published on pp. 745–752 of this issue Early Detection of Prostate Cancer: More Information, More Clarity Allison S. Glass, Matthew R. Cooperberg, Peter R. Carroll * Department of Urology, University of California San Francisco, Helen Diller Comprehensive Cancer Center, San Francisco, CA, USA Screening for prostate cancer (PCa) is among the most controversial topics in the field of urology. The outcome of this increasingly strident debate will have considerable impact on the field in developed countries, where the detection and management of PCa constitutes a large portion of what urologists manage. Recently, the US Preventive Services Task Force (USPSTF) finalized a crisp recommendation that routine prostate-specific antigen (PSA)–based screening for PCa be stopped. This recommen- dation won praise from some and strong denunciation by others but left most men wondering what to do. There is truth on both sides of the debate for and against PSA testing. PCa mortality has declined considerably—by 40%—since the advent and widespread uptake of PSA testing in the late 1980s in North America. Large, highly powered, contemporary clinical trials have confirmed the impact of PSA testing in reducing metastasis and cancer-specific mortality [1,2], and projection models have attributed as much as one-half of the observed decline in mortality to PSA screening [3]. However, many overinterpret the absolute impact of this decline for an individual man and fail to acknowledge the considerable, well-documented problems of PCa overdetection and overtreatment. The debate can be resolved only with more granular data and careful interpretation divorced from the emotional positions that can erode the middle ground information all men deserve. The current article by Schro¨der and colleagues [4], a superb group of clinical scientists who have added much to what we know about both the risks and benefits of PSA screening, presents novel and important information about the impact of PSA testing on one very important end point: the risk of metastatic PCa, a harbinger of PCa death in most cases. The authors assessed information available for 76 813 men aged 55–69 yr from four centers of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Participants were randomized to either PSA screening every 2–4 yr or usual care. Metastatic (M+) disease was defined by positive lesion on imaging or PSA >100 ng/ml at time of diagnosis (defined as <3 mo after diagnosis) or during follow-up. Assuming that PSA higher than any given threshold denotes M+ disease is debatable, but the value selected is reasonable and is clearly associated with the M+ disease in the majority of cases. Participants’ disease risk was stratified using conventional descriptors. At a median follow-up of 12 yr, the rate ratio of M+ disease in the screening group compared with the control group was 0.70, which translates to a relative risk reduction of 30% and an absolute risk reduction of 3.1 lives saved within 12 yr per 1000 men. These results were based on the primary intent-to-screen analysis; in analysis adjusting for nonscreening in the intervention arm (but not for contami- nation with screening in the control arm), a relative risk reduction of 42% was noted for those men actually screened. Additionally, a 55.6% higher incidence of PCa was found in the screening group. The number needed to invite to screening to avert one case of M+ disease was 328, and the number needed to diagnose (NND) but not necessarily treat was 12. However, this study notably demonstrates that the impact of screening on the risk of M+ disease is primarily seen at or shortly after diagnosis but attenuates during follow-up. The relative risk reduction at diagnosis was 50% but fell to 30% overall after accounting for the follow-up M+ cases. The authors suggested this finding may be due to increasing rates of M+ disease identified in those screened after 7-yr follow-up. In fact, the rate of M+ disease was DOI of original article: http://dx.doi.org/10.1016/j.eururo.2012.05.068 * Corresponding author. Department of Urology, University of California San Francisco, Helen Diller Comprehensive Cancer Center, 1600 Divisadero, San Francisco, CA 94115, USA. Tel. +1 415 353 7098; Fax: +1 415 885 7443. E-mail address: PCarroll@urology.ucsf.edu (P.R. Carroll). 0302-2838/

PD03-02 FREQUENCY OF DNA REPAIR GENE MUTATIONS IN LOCALIZED AND METASTATIC PROSTATE CANCER

– see back matter # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.