Danuta Dynda

Robotic-assisted minimally invasive surgery; a useful tool in resident training—the Peoria experience, 2002–2009

The purpose of this study was to review the use of robotic‐assisted general surgery at our institution. We evaluated the 8 year experience of one minimally invasive surgery (MIS) fellowship‐trained surgeon in Peoria, IL, performing 240 cases of foregut, colon, solid organ and biliary surgery using the da Vinci system, with resident assistance. Foregut and colon procedures are the fifth and sixth most commonly performed procedures of the senior author annually.

Impact of County Rurality and Urologist Density on Urological Cancer Mortality in Illinois

PURPOSE The urology work force is contracting at a time when service demand is increasing due to demographic changes, especially in rural areas. We investigated the impact of rural status and urologist density on kidney and renal pelvis, bladder and prostate cancer mortality at the county level in Illinois. MATERIALS AND METHODS We stratified the 102 Illinois counties by 2003 RUCCs as urban (36, RUCCs 1 to 3) and rural (66, RUCCs 4 to 9). Area Health Resource Files were used for county demographic data and urologist density. County level age adjusted mortality rates from 1990 to 2010 were derived from National Center for Health Statistics data using SEER*Stat. We examined the associations of urological cancer mortality rates with rural status and urologist density. RESULTS Average urologist density significantly differed between rural and urban counties (1.9 vs 3.4/100,000 population, p < 0.01). The kidney and renal pelvis cancer mortality rate in rural counties was higher than in urban counties while that of prostate cancer was lower (4.9 vs 4.3 and 28.7 vs 32.2/100,000 population, respectively, each p < 0.01). Urologist density correlated with the mortality rate of kidney and renal pelvis cancer (Pearson coefficient -0.33, p < 0.01) but not with the bladder or prostate cancer mortality rate. Multiple regression analysis revealed that rurality and lower urologist density (p = 0.01 and < 0.05) were significantly associated with higher kidney and renal pelvis cancer mortality. CONCLUSIONS Rural residence and low urologist density were associated with increased kidney and renal pelvis cancer mortality on the county level in Illinois. Further expansion and testing of evidence-based telemedicine is warranted because remote technical consultation is now technologically feasible, effective, inexpensive and satisfactory to patients.

Delivering kidney cancer care in rural Central and Southern Illinois: a telemedicine approach

There is a growing body of experience and research suggesting that telemedicine (video conferencing, smart phones and online patient portals) could be the solution to addressing gaps in the provision of specialised healthcare in rural areas. The proposed role of telemedicine in providing needed services in hard to reach areas is not new. The United States Telecommunication Act of 1996 provided the initial traction for telemedicine by removing important economic and legal obstacles regarding the use of technology in healthcare delivery. This initial ruling has been supplemented by the availability of federal funding to support efforts aimed at developing telemedicine in underserved areas. In this paper, we explore one aspect of disease disparity pertinent to rural Illinois (kidney cancer incidence and mortality) and describe how we are planning to use an existing telemedicine program at Southern Illinois University School of Medicine (SIUSOM) to improve kidney cancer (Kca) care in rural Illinois. This represents an example of the possible role of telemedicine in addressing healthcare disparities in rural areas/communities and provides a description of general challenges and barriers to the implementation and maintenance of such systems.

Immune Characterization of the Programmed Death Receptor Pathway in High Risk Prostate Cancer

Micro‐Abstract The objective of this study was to determine the expression of programmed cell death‐1 (PD‐1) and programmed cell death ligand‐L1 (PD‐L1) in high‐grade prostate cancer tissues, and correlate the expression with disease and patient characteristics. Of the 25 samples, 2 (8%) scored high for PD‐1 expression, 2 (8%) scored high for PD‐L1 expression, and 18 (72%) scored high for CD3 expression. Background: Programmed cell death‐1 (PD‐1), a T‐cell inhibitory receptor, and its ligand, PD‐L1, have been reported to be expressed in many tumor types, and this expression has led to the development of many drugs targeting the PD‐1 pathway. The objective of this study was to determine the expression of PD‐1 and PD‐L1 in high‐grade prostate cancer tissues, and correlate the expression with disease and patient characteristics. Materials and Methods: Immunohistochemistry for PD‐1 (CD279), PD‐L1 (B7‐H1), and CD3 was performed and scored from 0 to 5 on prostatectomy/biopsy tissue samples taken from 25 men with high‐grade prostate cancer. Charts were then retrospectively reviewed for numerous patient and disease characteristics. Statistical analyses were done to investigate the association of these patient and disease characteristics with PD‐1, PD‐L1, and CD3 expression. Results: A score of 3 to 5 on the semiquantitative 0 to 5 score was deemed “high” expression whereas a score of 0 to 2 was deemed “low” expression. Of the 25 samples, 2 (8%) scored high for PD‐1 expression, 2 (8%) scored high for PD‐L1 expression, and 18 (72%) scored high for CD3 expression. There was no statistically significant difference between high and low expression groups of PD‐1, PD‐L1, or CD3 for any of the variables we collected. Conclusion: An overall low expression of PD‐1 and PD‐L1, and a concurrent high expression of CD3+ T cells was found in high‐risk prostate cancer tissue. No significant association was found between expression of PD‐1, PD‐L1, or CD3, and patient or disease characteristics. Because of this, one might be able to question the role of PD‐L1 in local immune suppression in prostate cancer.

A1 Adenosine Receptor-Mediated Inhibition of Parasympathetic Neuromuscular Transmission in Human and Murine Urinary Bladder

The potential role of A1 adenosine receptors in modulating neuromuscular transmission in the detrusor muscle of the urinary bladder has been tested in human and murine preparations with the intent to determine the viability of using adenosine receptor agonists as adjuncts to treat overactive bladder. In human detrusor muscle preparations, contractile responses to electrical field stimulation were inhibited by the selective A1 adenosine receptor agonists 2-chloro-N6-cyclopentyladenosine, N6-cyclopentyladenosine (CPA), and adenosine (rank order of potency: 2-chloro-N6-cyclopentyladenosine > CPA > adenosine). Pretreatment with 8-cyclopentyl-3-[3-[[4(fluorosulphonyl)benzoyl]oxy]propyl]-1-propylxanthine, an irreversible A1 antagonist, blocked the effects of CPA, thus confirming the role of A1 receptors in human detrusor preparations. In murine detrusor muscle preparations, contractions evoked by electrical field stimulation were reduced by CPA or adenosine. Amplitudes of the P2X purinoceptor–mediated excitatory junctional potentials (EJPs) recorded with intracellular microelectrodes were reduced in amplitude by CPA and adenosine with no effect on the spontaneous EJP amplitudes, confirming the prejunctional action of these agents. 8-Cyclopentyltheophylline, a selective A1 receptor antagonist, reversed the effects of CPA on EJP amplitudes with no effect of spontaneous EJPs, confirming the role of A1 receptors in mediating these effects.

3-year treatment outcomes of water vapor thermal therapy (Rezūm System) compared to doxazosin, finasteride and combination drug therapy for men with benign prostatic hyperplasia: cohort data from the Medical Therapy of Prostatic Symptoms (MTOPS) Trial

Purpose: We evaluated the long‐term outcomes of treatment of lower urinary tract symptoms due to benign prostatic hyperplasia to compare a 1‐time water vapor thermal therapy procedure with daily medical therapy in cohorts from the MTOPS (Medical Therapy of Prostatic Symptoms) study. Materials and Methods: Results in the treatment arm of a randomized, controlled trial of thermal therapy using the Rezum® System were compared to MTOPS subjects treated with doxazosin and/or finasteride. Evaluations were restricted to medical therapy subjects, representing 1,140 of the original 3,047 (37.4%), with a prostate volume of 30 to 80 cc and an International Prostate Symptom Score of 13 or greater to include men who met key criteria of the Rezum and MTOPS trials. Outcomes were compared during 3 years for symptom changes and clinical progression rates. Results: Thermal therapy improved symptom scores by approximately 50% throughout 36 months (p <0.0001). Symptom improvement was greater than with either drug alone but similar to that of combination drugs (p ≤0.02 and 0.73, respectively). The peak flow rate improved 4 to 5 ml per second after thermal therapy and doxazosin while thermal therapy was superior to finasteride and combination drugs for 24 and 12 months (p <0.001 and <0.01, respectively). Observed rates of clinical progression during 3 years corroborate these outcomes with approximately 5 times greater progression for any medical therapy vs a single thermal therapy procedure. Conclusions: A single water vapor thermal therapy procedure provided effective and durable improvements in symptom scores with lower observed clinical progression rates compared to daily long‐term use of pharmaceutical agents.

Antibiotics prophylaxis before prostate biopsy in practice: Review of online clinical guidelines.

Sir, The inaugural American Urologic Association (AUA) Quality Improvement Summit on January 25, 2014 introduced the directive to compile a white paper on the incidence, prevention, and treatment of complications related to prostate needle biopsy. We believe this summit brings to the urologic community’s attention the critical fact that published guidelines in antibiotic prophylaxis do not reflect the escalating danger of post prostate needle biopsy infections. The known infectious complication rates range from 0.1% to 7%, depending on the antimicrobial agent used.[1] Even with prophylactic antibiotics, 5% of men will develop asymptomatic bacteriuria and 2–3% will develop symptomatic urinary tract infection.[2] The current AUA best practice policy statement on urologic surgery antimicrobial prophylaxis, last updated in February 2012, recommends fluoroquinolones or 1st through 3rd generation cephalosporins as the prophylactic antimicrobial agents of choice preceding prostate needle biopsy. This recommendation does not account for the fact that the overall risk of post-biopsy infections has risen over the past decade.[2-4] It also does not account for the increasing rate of quinolone resistance, as evidenced by the dramatic 22% of men found to have quinolone-resistant flora on prebiopsy rectal swab.[1] While the origin of this change in microbial sensitivity is likely complex and multifactorial, possibly related to increased, inappropriate, or repeated utilization of antibiotics, the fact remains that our guidelines for prophylaxis need to reflect these factors in order to effectively protect patients receiving prostate needle biopsies.

Conservative management and female gender are associated with increased cancer-specific death in patients with isolated primary urothelial carcinoma in situ

Our goal was to investigate the effect of patient and disease characteristics on the probability of cancer-specific death (CSD) in cases of isolated urothelial carcinoma in situ (CIS). We performed a retrospective analysis of patients diagnosed with isolated CIS between 1990 and 2010 identified from the Surveillance, Epidemiology, and End Results (SEER) database. Competing risk analysis using Cox proportional hazard model was used to examine the probability of CSD controlling for possible covariates. Overall (n = 1432), patients were mainly male (75%), mean age at diagnosis was 71 years, median survival 47 months, and 65% of the patients had CIS in their upper urinary tract. Caucasians were the predominant race (90%). CIS was the cause of death in 87/1432(6%) of the total cohort; 69/1239 (6%) of patients who underwent surgery, and 18/193 (9%) of the patients who were managed conservatively (CM). On multivariate analysis, CM [hazard ration (HR) = 2.019, CI: 1.189-3.429, P = 0.009] and female gender (HR = 1.690, CI: 1.041-2.741, P = 0.033) were associated with CSD, while age, site, race and year of diagnosis were non-significant predictors. Female gender and conservative management were positively associated with CSD. Multi-institutional collaboration is needed to validate markers for poor prognosis in cases of isolated CIS.

Project PROMIS: Peoria Regional Outpatient Medical Imaging Study.

BACKGROUND Abdominal aortic aneurysm (AAA) accounts for > 15,000 reported deaths annually. Early screening in high-risk populations is important to decrease morbidity and mortality from rupture. METHODS A prospective, population-based study of free ultrasound-based AAA screening was conducted from July 2004 to December 2006. Before examination, subjects completed surveys asking their medical history, including known AAA risk factors. Incidence rates and comparison analyses were performed. RESULTS The final analysis included 979 patients, of whom AAA was discovered in 27 (2.8%). AAA was found in only male patients > 60 years old (4% of the male population). AAA size ranged from 3 to 10 cm. Of patients diagnosed with AAA, 85% were current or past smokers, and 70% had hypercholesterolemia. There was a 6% incidence of AAA in male smokers > or = 60 years old who had hypercholesterolemia. CONCLUSIONS Four factors were predominant in our population of patients with AAA: patient age, male sex, smoking history, and hypercholesterolemia.

A prospective study to examine the association of the urinary and fecal microbiota with prostate cancer diagnosis after transrectal biopsy of the prostate using 16sRNA gene analysis

There is accumulating evidence that variations in the human microbiota may promote disease states including cancer. Our goal was to examine the association between urinary and fecal microbial profiles and the diagnosis of prostate cancer (PC) in patients undergoing transrectal biopsy of the prostate.