Francesco Del Giudice

Racial Disparities in Postoperative Complications After Radical Nephrectomy: A Population-based Analysis

OBJECTIVE To perform a population-based study that evaluates contemporary racial disparities in the morbidity profile of patients undergoing radical nephrectomy in the United States. METHODS Using the Premier hospital database (Premier Inc, Charlotte, NC), which collects data from over 600 nonfederal hospitals throughout the United States, we identified patients undergoing a total nephrectomy as their primary procedure and also had a concurrent diagnosis of a kidney mass or cancer from 2003 to 2010. The primary outcome was 90-day major complication rates, based on the Clavien classification system. Multivariate logistic regression models were performed, adjusting for clustering by hospitals and survey weighting to ensure nationally representative estimates. RESULTS The study population included 25,517 patients translating into a weighted sample of 185,135 radical nephrectomies. In a multivariate model including patient, hospital, and surgical characteristics, blacks were more commonly associated with a major complication (odds ratio, 2.1; P <.0001). When we incorporated Charlson comorbidity score into the model, the racial disparity in major complications was attenuated by 36% (odds ratio, 1.7; P <.0001). Adjusting for annual surgical volume in the multivariate model did not alter results. CONCLUSION Our contemporary evaluation of patients undergoing radical nephrectomy in the United States demonstrates that blacks are associated with a markedly elevated rate of major complications as compared to whites. This disparity is possibly a result of unequal access to routine health care.

Inflatable Penile Prosthesis Placement, Scratch Technique and Postoperative Vacuum Therapy as a Combined Approach to Definitive Treatment of Peyronie’s Disease

Purpose: Peyronies disease is a devastating condition resulting in penile malformation, erectile dysfunction, pain and emotional distress. In this prospective, 2 institution study we evaluated a multimodal surgical and mechanical combined approach to the definitive treatment of Peyronies disease and concomitant erectile dysfunction. Materials and Methods: A total of 145 select patients underwent endocavernous disruption of Peyronies disease plaques via the scratch technique, followed by inflatable penile prosthesis insertion. Postoperatively patients were assigned to vacuum device therapy for 3 minutes twice daily to continue penile curvature correction. Followup continued for 1 year after surgery. Anatomical and functional results were assessed. Results: Patients with plaques in the proximal third, middle third and subcoronal areas of the penis had a mean ± SD postoperative residual curvature of 21.5 ± 4.5, 17.3 ± 4.8 and 14.1 ± 3.1 degrees, respectively. After 24 weeks of vacuum therapy the mean penile curvature deviation decreased to 8.7 ± 2.5, 9.1 ± 2.9 and 7.7 ± 0.9 degrees, respectively. The mean IIEF‐5 (International Index of Erectile Function) score was 9.8 ± 2.3 preoperatively, 18.9 ± 3.1 at 6 months (p <0.001) and 24.1 ± 3.6 at 1 year (p <0.001). The mean EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) score at the end of followup was 64.6 ± 11.8. Operative and postoperative complications were minimal. Conclusions: Our novel combination of intraoperative and postoperative therapies in the treatment of patients with Peyronies disease and an inflatable penile prosthesis was safe and efficacious with excellent functional outcomes. Penile curvature corrections were statistically significant and complications were negligible.

The Prognostic Role of Circulating Tumor Cells (CTC) in High-risk Non–muscle-invasive Bladder Cancer

Introduction The purpose of this study was to evaluate the impact of circulating tumor cells (CTCs) as a prognostic marker in patients with high‐risk non–muscle‐invasive bladder cancer (NMIBC) and assess the efficacy and reliability of 2 different CTC isolation methods. Materials and Methods Globally, 155 patients with a pathologically confirmed diagnosis of high‐risk NMIBC were included (pT1G3 with or without carcinoma in situ) and underwent transurethral resection of bladder tumor (TURB) after a blood withdrawal for CTC evaluation. A total of 101 patients (Group A) had their samples analyzed with the CellSearch automated system, and 54 (Group B) had their samples analyzed with the CELLection Dynabeads manual system. Results Patients were followed for 28 months, and during this interval, there were a total of 65 (41.9%) recurrences, 27 (17.4%) disease progressions, and 9 (5.8%) lymph node and/or bone metastasis. In our CTC analysis, there were 20 (19.8%) positive patients in Group A and 24 in Group B (44.4%). In our analysis, we found a strong correlation between CTC presence and time to first recurrence; in Group A, we observed an incidence of recurrence in 75% of CTC‐positive patients and in Group B of 83% of CTC‐positive patients. The time to progression was also strongly correlated with CTCs: 65% and 29%, respectively, of those patients who progressed in those with CTCs in Group A and B. Conclusion The study demonstrates the potential role of CTCs as a prognostic marker for risk stratification in patients with NMIBC, to predict both recurrence and progression. Micro‐Abstract Circulating tumor cells (CTCs) could represent a promising, noninvasive prognostic and predictive marker in high‐risk patients with non–muscle‐invasive bladder cancer. We retrospectively evaluated 155 patients with pT1G3 bladder cancer who underwent transurethral resection of bladder tumor after a blood withdrawal for CTC evaluation. In our analysis, the presence of CTCs was significantly associated with time to first recurrence and time to progression.

Hyperhomocysteinemia as an Early Predictor of Erectile Dysfunction: International Index of Erectile Function (IIEF) and Penile Doppler Ultrasound Correlation With Plasma Levels of Homocysteine.

AbstractErectile dysfunction (ED) is inability to achieve and maintain an erection to permit satisfactory sexual activity. Homocysteine (Hcys) is a sulfur-containing amino acid synthesized from the essential amino acid methionine. Experimental models have elucidated the role of hyperhomocysteinemia (HHcys) as a strong and independent predictor for atherosclerosis progression and impaired cavernosal perfusion.The aim of this study is to investigate the serum levels of Hcys in our cohort of patients with ED, to compare these values with these of control population and to examine Hcys as a predictive marker for those patients who are beginning to complain mild–moderate ED.A total of 431 patients were enrolled in the study. The whole cohort was asked to complete the International Index of Erectile Function (IIEF) questionnaire. The study population was divided in 3 main groups: Group A: 145 patients with no ED serving as a control group; Group B: 145 patients with mild or mild–moderate ED; Group C: 141 patients with moderate or severe ED. Each participant underwent blood analysis. All patients underwent baseline and dynamic penile Doppler ultrasonography.We found in our cohort mean Hcys plasma concentrations significantly higher than the cut-off point in both groups B and C (18.6 ± 4.7 and 28.38 ± 7.8, respectively). Mean IIEF score was 27.9 ± 1.39, 19.5 ± 2.6, and 11.1 ± 2.5 for groups A, B, and C, respectively (P < 0.0001). In the penile Doppler ultrasonography studies, a high significant inverse correlation was detected between the mean values of the 10th minutes peak-systolic velocity (PSV) and Hcys levels for the groups B and C.This establishes a dose-dependent association between Hcys and ED. Furthermore, we showed that Hcys was an earlier predictor of ED than Doppler studies, as the Hcys increase was present in patients with mild ED even before abnormal Doppler values.

Short‐term pretreatment with a dual 5α‐reductase inhibitor before bipolar transurethral resection of the prostate (B‐TURP): evaluation of prostate vascularity and decreased surgical blood loss in large prostates

To investigate if short‐term treatment with dutasteride (8 weeks) before bipolar transurethral resection of the prostate (B‐TURP) can reduce intraoperative bleeding, as dutasteride a dual 5α‐reductase inhibitor (5‐ARI) blocks the conversion of testosterone into its active form dihydrotestosterone (DHT), and reduces prostate volume and prostate‐specific antigen (PSA) levels, while increasing urinary flow rate.

MP58-05 THE LONG-TERM PROGNOSTIC VALUE OF SURVIVIN EXPRESSING CIRCULATING TUMOR CELLS IN PATIENTS WITH HIGH-RISK NON-MUSCLE INVASIVE BLADDER CANCER (NMIBC)

genes in irradiated AR-positive cells, and HF antagonized the androgen effects. Finally, in xenograft-bearing mice, low-dose flutamide was found to enhance the cytotoxic effects of irradiation, and its tumor size was similar to that of AR knockdown line with radiation alone. CONCLUSIONS: These findings suggest that AR activity inversely correlates with sensitivity to radiotherapy in bladder cancer. Accordingly, anti-androgenic drugs may function as sensitizers of irradiation, especially in patients with AR-positive urothelial cancer.

Non-ischemic priapism following recurrent idiopathic ischemic priapism treated successfully with selective arterial embolization and postoperative vacuum therapy before delayed inflatable penile prosthesis placement: A single case report

Priapism is defined as a persistent tumescence or erection of the penis not associated to sexual desire and/or stimulation. Idiopathic recurrent priapism may also occasionally follow treatment of veno‐occlusive priapism and represents a diagnostic and therapeutic challenge.

Psychological impact of different primary treatments for prostate cancer: A critical analysis

Limited attention has been given to the psychological impact of primary treatments in patients with prostate cancer. Aim of our analysis was to critically analyse the current evidence on the psychological impact of different primary treatments (surgery, radiotherapy and active surveillance), in patients with prostate cancer, using validated questionnaires. We searched in the MEDLINE and Cochrane library database from the literature of the past 15 years (primary fields: prostate neoplasm, AND radical prostatectomy or radiotherapy or active surveillance AND psychological distress or anxiety or depression; secondary fields: urinary, sexual, bowel modifications, non‐randomised and randomised trials). Overall eighteen original and review articles were included and critically evaluated. Either radical prostatectomy or active surveillance and radiotherapy are well‐tolerated in terms of definite anxiety and depression during the post‐treatment follow‐up. A mutual influence between functional and psychological modifications induced by treatments has been demonstrated. Urinary symptoms related to incontinence more than sexual and bowel dysfunction are able to induce psychological distress worsening. In conclusion, patients and their clinicians might wish to know how functional and psychological aspects may differently be influenced by treatment choice.

Monopolar Transurethral Enucleation of Prostatic Adenoma: Preliminary Report

OBJECTIVE To describe preliminary results of our monopolar transurethral enucleation of prostatic adenoma (mTUEPA). MATERIALS AND METHODS A consecutive series of male patients treated with mTUEPA, a retrograde enucleation of the prostatic adenoma performed by means of a standard monopolar resectoscope, were prospectively enrolled. Symptoms, uroflowmetry parameters, and post-voiding residual were assessed at baseline and at 1, 6, and 12 months postoperatively. Prostate volume was evaluated at baseline by means of transrectal ultrasound. Antiplatelet and anticoagulant drugs were stopped at least 1 week before the operation. RESULTS Forty-seven patients were enrolled. Mean preoperative prostate volume was 64.9 ± 28.5 g. When assessed at baseline, the mean total International Prostatic Symptoms Score was 15.2 ± 3.9, peak flow rate (Qmax) was 8.4 ± 2.9 mL/s and the post-voiding residual was 103.2 ± 90.6 mL. Four weeks after surgery, patients reported a mean International Prostatic Symptoms Score of 5.3 ± 3. This lower urinary tract symptoms relief was further maintained at 6 and 12 months after surgery. A significant postoperative improvement in uroflowmetry parameters was described, being the 6 and 12 months mean Qmax of 23.4 ± 10.6 mL/s and 18.8 ± 9.2 mL/s, respectively (P < .001). Overall, 14 postoperative complications were reported by 13 of 47 (27.6%) patients: most of them were minor complications (Clavien-Dindo Grade I-II), whereas 1 patient reported capsule perforation during surgery, requiring interruption of the procedure and its further completion (Clavien-Dindo IIIb). CONCLUSION mTUEPA is a safe and effective technique, merging the principles of laser enucleation and the advantages of mechanical enucleation with standard monopolar transurethral resection of the prostate equipment.