Courtney M.P. Hollowell

TECHNIQUE OF HAUTMANN ILEAL NEOBLADDER WITH CHIMNEY MODIFICATION: INTERIM RESULTS IN 50 PATIENTS

PURPOSE We report our 4-year experience with the chimney modification of the Hautmann ileal neobladder. This modification involves use of an 8 to 12 cm. tubularized isoperistaltic ileal chimney for the ureterointestinal anastomosis. MATERIALS AND METHODS Between April 1995 and March 1998, 50 men and women with invasive bladder cancer underwent radical cystectomy and creation of a Hautmann neobladder with chimney modification. Complications were assessed, divided as early and late, and subdivided as those related or unrelated to the neobladder. Continence was evaluated using a detailed patient questionnaire. RESULTS There were no intraoperative deaths. Early complications in 11 of the 50 patients were neobladder related in 5 (10%) and unrelated to the neobladder in 6 (12%). The early reoperation rate was 6%. Late postoperative complications in 10 patients (20%) were neobladder related in 8 (16%) and unrelated to the neobladder in 2 (4%). After 1 year 93% and 86% of patients achieved good day and nighttime continence, respectively. In 2 patients (4%) clean intermittent catheterization is performed and 1 required placement of an artificial urinary sphincter. Ureterointestinal anastomotic strictures were detected in 6 of 100 ureteral units (6%), including 2 with failed initial endoscopic management. Open surgical revision of the ureterointestinal anastomotic site was easier due to the anterior position of the ureters, and identification and mobilization of the isoperistaltic limb. CONCLUSIONS Our experience with the chimney modification of the Hautmann neobladder compares favorably to other forms of orthotopic urinary diversion in regard to ureteral stenosis, early and late postoperative complications, urinary continence and simplification of the ureterointestinal anastomosis.

Use of new technology in endourology and laparoscopy by American urologists: Internet and postal survey

OBJECTIVES To assess the use of new technology by American urologists. METHODS Using the American Urological Association directory, surveys were sent via the U.S. postal service to 1000 randomly selected American urologists and 3065 urologists who had an Internet address listed in the directory. RESULTS Responses were received from 601 urologists (415 postal, 186 Internet). Overall, 81% of survey respondents reported performing fewer or the same number of percutaneous procedures as compared with 3 to 4 years ago and 84% reported carrying out more or the same number of ureteroscopic procedures in the treatment of patients with stone disease. Open dismembered pyeloplasty (43%) and Acucise endopyelotomy (42%) were most frequently reported as the preferred treatment for adult patients with symptomatic ureteropelvic junction obstruction. Although 60% of respondents reported that they have taken a laparoscopy course, 67% currently do not perform any laparoscopy in their practice. In addition, only 7% of urologists stated that laparoscopy comprises more than 5% of their practice. When stratified by the number of years in practice, those in practice less than 10 years were more likely than those in practice 10 to 20 years and those in practice longer than 20 years to have performed an endopyelotomy (77%, 60%, and 48%, respectively, P <0.001) and to be currently performing laparoscopy (49%, 36%, and 18%, respectively, P <0.001). CONCLUSIONS Compared with 3 to 4 years ago, American urologists are performing more ureteroscopy and fewer percutaneous stone procedures. Although most urologists have taken laparoscopy courses, this modality has not been widely incorporated into their practices at present.

Practice patterns in the treatment of female urinary incontinence: a postal and internet survey

OBJECTIVES To survey American urologists to assess practice patterns in treating female incontinence. Advances in the treatment of female incontinence have changed the way urologists practice. METHODS Postal and e-mail surveys were sent to 2502 members of the American Urological Association. RESULTS From the postal group (n = 1000), 419 (42%) responses were obtained; from the e-mail group (n = 1502), 160 (11%) responses were obtained. For types I, II, and III stress urinary incontinence (SUI), 239 (44%) of 546, 388 (68%) of 570, and 512 (94%) of 547 urologists, respectively, recommended a sling procedure. For type I SUI, 75 (53%) of the 143 respondents in practice for less than 10 years recommended a sling procedure. The sling was recommended by 62 (35%) of the 176 respondents in practice for longer than 20 years (P <0.001). Most urologists (75%, 358 of 480) referred patients with significant vaginal prolapse to a gynecologist; however, urologists in full-time academic practice were more likely to offer surgical treatment (56%, 29 of 52). Most urologists recommended medical treatment for urge incontinence (94%, 461 of 491), and the medications most commonly selected were tolterodine (41%, 202 of 491), oxybutynin (26%, 129 of 491), and extended-release oxybutynin (25%, 125 of 491). CONCLUSIONS Overall, a sling procedure was the most commonly recommended surgical procedure for all types of SUI. Most urologists referred patients with significant vaginal prolapse to a gynecologist. For type I SUI, older urologists were more likely than younger urologists to perform needle bladder neck suspension.

INTERNET AND POSTAL SURVEY OF ENDOUROLOGIC PRACTICE PATTERNS AMONG AMERICAN UROLOGISTS

PURPOSE We determine endourological practice patterns among American urologists for the management of distal ureteral calculi, ureteropelvic junction obstruction, staghorn calculi and the use of ureteral stents with extracorporeal shock wave lithotripsy (ESWLdagger). MATERIALS AND METHODS Surveys were mailed by the United States postal service to 1,000 American urologists selected randomly from the American Urological Association membership roster. The same survey was sent via the Internet to 3,065 American urologists with an electronic mail address listed in the roster. RESULTS Responses were received from 1,029 urologists (postal 601, Internet 428). Ureteroscopy was the preferred treatment for all distal ureteral calculi less than or equal to 10 mm. Acucisedouble dagger endopyelotomy was the most frequently selected therapy for adults with ureteropelvic junction obstruction (50.3%, 514 of 1,022). Open pyeloplasty was recommended by a significantly greater percentage of urologists in practice longer than 15 years compared with the remaining survey respondents (166 of 485, 34.2% versus 92 of 427, 21.5%). For patients with renal pelvic stones 10, 15 or 20 mm. who are treated with ESWL routine stent placement was preferred by 25.3% (259 of 1,022), 57.1% (584 of 1,022) and 87.1% (888 of 1, 019) of urologists, respectively. Percutaneous nephrolithotomy was preferred for patients with staghorn calculi by 80.5% (828 of 1,028) of survey respondents. CONCLUSIONS Most urologists follow the American Urological Association practice guidelines for patients with distal ureteral calculi and staghorn stones. There is a significant difference of opinion regarding the use of stents with ESWL. No clear consensus has been reached concerning the management of adults with ureteropelvic junction obstruction. These data may be useful in designing physician education programs and/or future investigations to help define standard treatment practices for urological diseases.

Smoking cessation assistance for patients with bladder cancer: a national survey of American urologists.

PURPOSE Cigarette smoking is a known risk factor for bladder cancer. How urologists address smoking cessation among patients with bladder cancer is not well-known. We assessed the practice patterns of American urologists regarding smoking cessation assistance for patients with bladder cancer. MATERIALS AND METHODS A questionnaire regarding smoking cessation practice patterns was sent to 1,821 American urologists in the 2008 American Urological Association membership directory. Responses were summarized with frequency and percent. Statistical comparison was made using chi-square tests. Multiple logistic regression was used to detect significant predictors of providing smoking cessation assistance. RESULTS Responses were received from 601 urologists who collectively treated an estimated 14,713 patients with bladder cancer in the last year. More than half (55.6%) of urologists never discuss smoking cessation while only 19.8% always discuss smoking cessation with patients with bladder cancer. Of urologists who never discuss smoking cessation 40.7% believe that smoking cessation may not alter the course or outcome of the disease and 37.7% do not feel qualified giving smoking cessation counseling. Most urologists (93.7%) have never had formal smoking cessation training. Urologists with smoking cessation training were more likely to always provide smoking cessation assistance compared to those without training (20.6% vs 6.0%, p = 0.0011). Number of patients with bladder cancer treated (OR 3.96) and formal smoking cessation training (OR 13.49) were significant predictors of providing smoking cessation assistance. CONCLUSIONS American urologists demonstrate a low rate of providing smoking cessation assistance to patients with bladder cancer. Urologists who are trained in smoking cessation most commonly provide smoking cessation assistance. We recommend integrating formal smoking cessation instruction into courses that address bladder cancer and strongly encourage the American Urological Association to adopt practice pattern guidelines.

Localization of prostate cancer metastasis-suppressor activity on human chromosome 17

Prostate cancer is the most commonly diagnosed malignancy in American men. Currently, it is difficult to accurately predict the clinical course of histologically localized prostatic cancer in the individual patient. Identification of markers for metastatic potential of prostate cancer may improve the diagnosis and treatment of this disease. We have previously demonstrated that human chromosome 17 (17pter–q23) suppresses the metastatic ability of AT6.1 rat prostatic cancer cells. In this study we report on the further localization of the metastasis suppressor activity encoded by human chromosome 17.

Vitamin D deficiency predicts prostate biopsy outcomes

Purpose: The association between vitamin D and prostate biopsy outcomes has not been evaluated. We examine serum vitamin D levels with prostate biopsy results in men with an abnormal prostate-specific antigen and/or digital rectal examination. Experimental Design: Serum 25-hydroxyvitamin D (25-OH D) was obtained from 667 men, ages 40 to 79 years, prospectively enrolled from Chicago urology clinics undergoing first prostate biopsy. Logistic regression was used to evaluate the associations between 25-OH D status and incident prostate cancer, Gleason score, and tumor stage. Results: Among European American (EA) men, there was an association of 25-OH D <12 ng/mL with higher Gleason score ≥ 4+4 [OR, 3.66; 95% confidence interval (CI), 1.41–9.50; P = 0.008] and tumor stage [stage ≥ cT2b vs. ≤ cT2a, OR, 2.42 (1.14–5.10); P = 0.008]. In African American (AA) men, we find increased odds of prostate cancer diagnosis on biopsy with 25-OH D < 20 ng/mL [OR, 2.43 (1.20–4.94); P = 0.01]. AA men demonstrated an association between 25-OH D < 12 ng/mL and Gleason ≥ 4+4 [OR, 4.89 (1.59–15.07); P = 0.006]. There was an association with tumor stage ≥ cT2b vs. ≤ cT2a [OR, 4.22 (1.52–11.74); P = 0.003]. Conclusions: In AA men, vitamin D deficiency was associated with increased odds of prostate cancer diagnosis on biopsy. In both EA and AA men, severe deficiency was positively associated with higher Gleason grade and tumor stage. Clin Cancer Res; 20(9); 2289–99. ©2014 AACR.

DISTAL URETERAL REPLACEMENT WITH TUBULARIZED PORCINE SMALL INTESTINE SUBMUCOSA

Extensive ureteral injury can result from renal stone disease, iatrogenic injury, or penetrating trauma. A significant ureteral stricture can be repaired using various techniques, including the psoas hitch, Boari flap, transureteroureterostomy, ileal ureter, or renal autotransplantation. We describe a woman with a 5-cm, ischemic uretero-Indiana pouch stricture that developed after cystectomy and urinary diversion. Severe pelvic fibrosis prevented adequate mobilization of the ureter and Indiana pouch and would not permit any of the above-mentioned procedures. We report the first human use of tubularized small intestine submucosa to successfully replace a 5-cm strictured segment of distal ureter.

Brief smoking cessation intervention: A prospective trial in the urology setting

PURPOSE Urologists have an important role in the treatment of tobacco related diseases, such as kidney and bladder cancer. Despite this role, urologists receive little training in promoting tobacco cessation. We prospectively evaluated a brief smoking cessation intervention offered by a urologist at an outpatient clinic. MATERIALS AND METHODS Between 2009 and 2011 adult smokers from a single institution urology clinic were enrolled in a prospective, brief intervention trial or in usual care as controls. All patients were assessed by the validated Fagerström test for nicotine dependence and the readiness to quit questionnaire. Trial patients received a 5-minute brief smoking cessation intervention. The primary outcome was abstinence at 1 year and the secondary outcome was the number of attempts to quit. Multivariate logistic regression was used to identify factors associated with the quit rate and quit attempts. RESULTS A total of 179 patients were enrolled in the study, including 100 in the brief smoking cessation intervention, 41 in the brief smoking cessation intervention plus nicotine replacement therapy and 38 usual care controls. Of the participants 81.0% were 40 years old or older with a mean ± SD 11.26 ± 7.23 pack-year smoking history. Mean readiness to quit and tobacco dependence scores were similar in the 2 arms (p = 0.25 and 0.92, respectively). The 1-year quit rate in the brief smoking cessation intervention group was 12.1% vs 2.6% in the usual care group (OR 4.44, p = 0.163) Adding nicotine replacement therapy increased the quit rate to 19.5% (vs usual care OR 9.91, p = 0.039). Patients who received the brief smoking cessation intervention were significantly more likely to attempt to quit (OR 2.31, p = 0.038). Increased readiness scores were associated with an increased quit rate and increased quit attempts. CONCLUSIONS Urologists can successfully implement a brief smoking cessation intervention program. Our study highlights the role of the urologist in providing smoking cessation assistance and the significant impact of brief, simple advice about quitting smoking on the smoker quit rate.

Double-blind randomized comparison of single-dose ciprofloxacin versus intravenous cefazolin in patients undergoing outpatient endourologic surgery

OBJECTIVES To compare the efficacy of single-dose oral ciprofloxacin with intravenous cefazolin as a prophylactic agent in patients undergoing outpatient endourologic surgery. METHODS One hundred patients were enrolled in a double-blind, randomized study to receive either ciprofloxacin (500 mg) or cefazolin (1 g) before surgery. A postoperative clinical evaluation and urine cultures were performed 5 to 10 days after surgery. Patients undergoing ureteral stent insertion or exchange, ureteroscopy, bladder biopsy, retrograde pyelography, collagen injection, and internal urethrotomy were included. RESULTS Postoperative urinary tract infection occurred in 7 (9.1%) of 77 patients, including 3 (8.1%) of 37 and 4 (10.0%) of 40 of those who received ciprofloxacin and cefazolin, respectively (P = 0.77). There were no episodes of sepsis, and no patient with infection required hospitalization. The total cost associated with the administration of prophylactic antibiotics in the study population was