Dominique Thomas

Evidence of Human Papillomavirus in the Placenta

Human papillomavirus (HPV) is an epitheliotropic virus typically infecting keratinocytes but also possibly epithelial trophoblastic placental cells. In the present study, we set out to investigate whether HPV can be recovered from transabdominally obtained placental cells to avoid any confounding contamination by HPV-infected cervical cells. Thirty-five placental samples from women undergoing transabdominal chorionic villous sampling were analyzed, and we detected HPV-16 and HPV-62 in 2 placentas. This study suggests that HPV infection of the placenta can occur early in pregnancy. The overall clinical implication of these results remains to be elucidated.

α-Blockers, 5-α-Reductase Inhibitors, Acetylcholine, β3 Agonists, and Phosphodiesterase-5s in Medical Management of Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: How Much Do the Different Formulations Actually Matter in the Classes?

Many monotherapies are currently available to clinically treat and alleviate symptoms of lower urinary tract symptoms secondary to benign prostatic hyperplasia: α-blockers, 5ARIs, PDE5Is, β-3-andrenoceptor agonists, and anticholinergic agents. Current studies have evaluated the effective of these treatments in comparison to other groups or in combination therapies. The current review evaluates the effectiveness of class formulations. Based on the findings, α-blockers, specifically doxazosin and terazosin, were most effective in reducing IPSS scores and peak urinary flow rate, while being most cost-effective. However, further clinical investigations are required to evaluate the clinical implications of different formulations.

Histologic Inflammatory Response to Transvaginal Polypropylene Mesh: A Systematic Review

To evaluate the inflammatory response following transvaginal implantation of polypropylene (PP) mesh. A comprehensive literature search was performed in the following databases from inception in April 2017: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library (Wiley). The studies retrieved were screened for eligibility against predefined inclusion and exclusion criteria. Twenty-three articles were included in this review. Following the implantation of PP mesh, there are immediate and local inflammatory responses. PP mesh elicits an inflammatory response that decreases over time; however, no studies documented a complete resolution. Further studies are needed to determine if there is a complete resolution of inflammation or if it persists.

Clinical Trials in Benign Prostatic Hyperplasia: A Moving Target of Success

Benign prostatic hyperplasia (BPH) affects over 50% of men above the age of 50 yr. With half of these men having bothersome lower urinary tract symptoms, this area represents a hot bed of novel treatments. Many BPH therapies have favorable short-term outcomes but lack durability or well-defined adverse events (AEs). Clinical trials are a gold standard for comparing treatments. We characterized all BPH clinical trials registered worldwide from inception to 2017. A total of 251 clinical trials were included. Of the studies, 30.1% used patient-reported outcomes such as the American Urological Association Symptom Score. Approximately 70% of clinical trials studied medical interventions, while the remaining trials investigated surgical approaches. Seventy-nine percent of trials were industry sponsored, while a minority were funded without commercial interest. Only 42% of trials had 12-mo follow-up, with the majority with <3 mo of follow-up. No trials evaluated prevention, diet, behavior, or alternative methods Overall, only 23% of trials reported results. Management options for BPH need unified benchmarks of success, AEs, durability, and standard reporting for all clinical trials, regardless of outcomes.nnnPATIENT SUMMARYnWe found that the majority of clinical trials were medical intervention, with very few trials evaluating prevention, diet, behavior, or alternative methods Furthermore, a few trials reported results in peer-reviewed journals. All clinical trials need to report results regardless of outcome, and in conclusion, standardized methods are needed in order to document the successes, adverse events, and durability for all clinical trials.

Prevalence of and Risk Factors for Urinary Incontinence in Home Hospice Patients

Urinary incontinence (UI) is a debilitating and embarrassing condition that is prevalent among aging males and females. Little is known about UI in the home hospice setting. We sought to determine UI prevalence and risk factors in a cohort of 15432 home hospice patients over 4yr. Most of the study patients were female (59%) and aged ≥75yr. This was a retrospective observational study and no patients were excluded. The median length of service was 19 d. Approximately one-third of patients were diagnosed with UI during their hospice stay. Female sex and age were associated with a greater risk of UI. Diagnoses that increased the risk of UI included dementia and stroke. The risk of UI diagnosis was lower among those without a health care proxy, as well among those with higher Palliative Performance Scale scores. UI affects a substantial number of patients in home hospice and there are no guidelines for its diagnosis or mitigation. There is a pressing need to further understand the impact of UI on home hospice patients. PATIENT SUMMARY: We investigated the prevalence of urinary incontinence (UI) among home hospice patients. Approximately one-third of patients were diagnosed with UI during their hospice care. Female sex, age, dementia, and stroke were associated with a greater risk of UI. Guidelines are required for UI diagnosis and mitigation in home hospice care.

Commentary on “Solving the benign prostatic hyperplasia puzzle”

Benign prostatic hyperplasia (BPH) is a common condition affecting over 50% of men as they reach the 5th decade of their life [1]. While over half of these patients have symptoms, it is not clear why some of these men do while others do not. The article Solving the benign prostatic hyperplasia puzzle by Keong Tatt Foo [2], delves into the different conundrums urologists face when trying to treat their patients. The purpose of this commentary is to bring these issues to light to spur and guide further research efforts. First, why do some small prostates lead to bladder outlet obstruction while some large prostates do not? Sometimes the question is not how large the prostate is but what is its shape and anatomy. Although we tend to correlate lower urinary tract symptoms (LUTS) with benign enlargement of the prostate (BPE), in practice it is not uncommon to see patients with small prostates having severe LUTS [3]. The adenoma can affect two zones: the transitional and periurethral zone. The adenoma can then give rise to different degrees of obstruction depending on its location [3]. This can also occur with the subcervical adenoma in patients with a small prostate which is located below the bladder neck. This is not a bladder neck problem

Prevalence and Risk Factors for Fecal Incontinence in Home Hospice

Introduction: We sought to determine the prevalence and risk factors associated with fecal incontinence (FI) in the home hospice setting. Methods: We conducted a retrospective cohort study of patients served by a hospice agency. Data on patient characteristics were extracted from hospice medical records. The primary outcome, FI, was assessed routinely during clinical visits to the patient’s home. Descriptive statistics were used to summarize patient characteristics. A Cox proportional hazards regression model was estimated for FI to examine associations with sociodemographic and clinical characteristics of patients. Results: A total of 15 432 patients were eligible. Patients were female (59.0%) and 75 years or older (23.5% were 75-84; 39.9% were 85+). Most patients with FI indicated incontinence at the time of hospice admission (64.5%; n = 4314), with the average onset period being approximately 18 days from admission (mean = 17.9, standard deviation = 50.6). Increasing age represented a risk factor for FI (hazard ratio [HR] = 1.01 [confidence interval, CI = 1.01-1.01]). The absence of a health-care proxy was associated with an increased risk of FI (HR = 1.11 [CI = 1.04-1.19]). Greater risk of FI was observed among patients with dementia (HR = 1.34 [1.24-1.46]) and stroke (HR = 1.42 [1.26-1.60]) compared to patients with cancer. Patients referred to hospice from settings other than the hospital also had a greater risk of FI compared to those referred from the hospital (HR = 1.17 [1.11-1.23]). Conclusion: Fecal incontinence is a highly prevalent condition among home hospice patients and most patients indicated FI upon admission (median time to detection = 18 days). Further studies are needed to identify modifiable risk factors for FI detection and its symptom management in this patient population.

A Plea for the Development of New Benign Prostatic Obstruction Follow-up Guidelines.

Benign prostatic hyperplasia (BPH) affects more than 50% of men as they reach their fifth decade of life, with a linear increase in incidence to more than 80% for men 80 years of age and older. Similarly, the prevalence of lower urinary tract symptoms secondary to benign prostatic obstruction (BPO), as well as the need for surgical intervention, increases with age. Over the past 2 decades, the urologic community has been presented with a myriad of surgical options available for BPO, ranging from office-based therapies to ablative surgical therapies. Currently, clinical trials and reported surgical series have limited short-term data (ie 6 months) and not uncommonly are industry sponsored. In the era of cost-economics and surgical outcomes assessment measures, the surgical treatment of BPO has no guidelines in which to evaluate or assess men for the risk of BPH recurrence. The current American Urological Association BPH guidelines are similar to other global guidelines, and emphasize clinical work-up and investigations, medical therapy options, and a potpourri of surgical interventions. These guidelines, however, do not cover postsurgical management and long-term follow-up for BPH disease. If patients have symptomatic relief and are without adverse events, no further reassessment is suggested. This differs from renal stone disease and oncological processes, particularly with bladder, kidney, prostate, and testicular cancer, whereby the guidelines are well established for the recommended follow-up and surveillance protocols after surgical management with clear, objective measures and markers to identify disease recurrence and management. Currently, no available guideline mentions the need or type of follow-up required or suggested by the urologist or primary care physician, nor identifies any markers or measures of BPH surgery success or treatment durability. Typically, the initial assessment of medical BPH therapy is the International Prostate Symptom Score (IPSS). However, not all clinicians use IPSS routinely, especially postoperatively. There needs to be more objective parameters to assess follow-up, such as uroflowmetry, post void residual, and frequency volume charts. The use of uroflowmetry and post void residual is only an optional test by the American Urological Association guidelines in the initial and medical management of BPH; however, their use is not recommended in the ongoing evaluation of these patients. To further complicate matters, there is a paucity of data evaluating patients’ prostate regrowth and change in IPSS scores postoperatively over time, but it is well known prostate growth is common in aging men. Unfortunately, the long-term durability and retreatment rate after the surgical management of patients with BPO can vary wildly after surgical intervention. Depending on the intervention and population studied, retreatment rates for even the “gold standard” transurethal resection of the prostate have been reported between 8% and 12% at 4 years. In the few long-term studies on surgical intervention for BPH, the retreatment rate was substantial. After 5 years following surgical intervention, the retreatment rate was an astounding 26%. These analyses do not account for those patients who have restarted medical therapy owing to worsening symptoms or for those who ended up with intermittent or indwelling catheters; analyses account only for those who underwent repeat procedures. No such population-based study has been reported. With 1 in 10 patients who undergo a surgical BPH treatment needing retreatment, the urologic community should ensure these patients are adequately followed. We propose further research and a stratified approach to follow-up that are dependent on the known failure rates associated with the armamentarium of treatment options. Early identification of patients who may require retreatment may help decrease costly emergency room visits and the morbidity associated with Acute Urinary Retention. For example, reduction in Prostate-Specific Antigen by 50% or greater Financial Disclosure: Bilal Chughtai and Kevin C. Zorn are consultants for Boston Scientific. Vincent Misrai is a proctor and lecturer for Boston Scientific. The remaining authors declare that they have no relevant financial interests. From the Department of Urology, Weill Cornell Medical College—New York Presbyterian Hospital, New York, NY; the Department of Urology, Clinique Pasteur, Toulouse, France; the Department of Urology, Mount Sinai Hospital, New York, NY; and the Section of Urology, Department of Surgery, University of Montreal Hospital Center, Montreal, Canada Address correspondence to: Bilal Chughtai, M.D., Department of Urology, Weill Cornell Medical College—New York Presbyterian Hospital, 425 East 61st Street, 12th Floor, New York, NY 10065. E-mail: bic9008@med.cornell.edu Submitted: June 16, 2016, accepted (with revisions): August 16, 2016

Prostatic Urethral Lift: Worth the Hype?

IntroductionThe prostatic urethral lift (PUL) procedure is a minimally invasive, nonablative technique that opens the prostatic urethra via mechanical compression, without destruction or resection of prostatic tissue. We explore the safety, efficacy, and long-term durability of PUL and its ability to treat LUTS secondary to BPH. Furthermore, we will discuss the potential advantages and disadvantages of the procedure and how urologists can use this information when treating BPH. Lastly, we will critically evaluate how PUL can play a role in BPH management.MethodsA comprehensive literature search utilizing Medline and PubMed was conducted to identify literature pertaining to PUL for the management of BPH. Studies critically evaluated International Prostate Symptom Scores (IPSS) and post-void residual volume (PVR), while improving peak urinary flow (Qmax), sexual function, and quality of life (QoL).ResultsEarly clinical trials for PUL have considerable sexual function preservation in comparison to other treatments, specifically in ejaculatory function. Adverse events have been mild and easily treatable.ConclusionsTreatment with PUL appears to be promising for men suffering from LUTS secondary to BPH. Not only does it offer rapid relief, but it improves these patients quality of life, while minimizing the amount of adverse events.