George C. Bailey

Perinatal Outcomes with Tamsulosin Therapy for Symptomatic Urolithiasis

PURPOSE Medical expulsive therapy represents an effective adjunctive treatment for nonpregnant patients with symptomatic urolithiasis. Tamsulosin is classified by the FDA (Food and Drug Administration) as a category B medication. However, to our knowledge no published data exist for human pregnancy. We explored the safety and efficacy of tamsulosin therapy for symptomatic urolithiasis occurring during pregnancy. MATERIALS AND METHODS We retrospectively identified patients treated with tamsulosin for stone disease during pregnancy at the Mayo Clinic during 2000 to 2014. This medical expulsive therapy cohort was matched 2:1 to pregnant women with symptomatic urolithiasis during pregnancy who did not receive medical expulsive therapy. Groups were compared using linear mixed models for continuous variables and exact conditional logistic regression models for nominal variables to take into account correlation due to matching. RESULTS A total of 27 patients receiving medical expulsive therapy comprised the study cohort. Median duration of antepartum tamsulosin exposure was 3 days (range 1 to 110), occurring during the first, second and third trimester in 3 (11%), 11 (40.7%) and 18 (67%) patients, respectively. Mean gestational age at delivery was 38.1 weeks (SD 2.4) and 6 (22%) infants were born preterm. All infant birthweights were considered appropriate for gestational age, and no cases of spontaneous abortion, intrauterine demise or neonatal congenital anomalies were encountered. Comparison between the medical expulsive therapy and control groups demonstrated no significant differences in maternal or infant outcomes for any of the examined variables. CONCLUSIONS Tamsulosin medical expulsive therapy does not appear to be associated with adverse maternal or fetal outcomes and may be considered as adjunctive therapy for urolithiasis during pregnancy.

A practical overview of considerations for penile prosthesis placement

Penile prostheses have remained the gold-standard therapy for medically refractory erectile dysfunction (ED) since their popularization. Advances in device design and surgical techniques have yielded improved rates of infection, satisfaction, and mechanical survival of devices. Operative techniques in penile prosthesis surgery include the use of adjunctive procedures (such as ventral phalloplasty and release of the suspensory ligament), management of penile fibrosis, and manoeuvres to correct Peyronies-disease-related curvature. Complications include urethral and corporal perforation, crossover, infection, impending erosion, and/or supersonic transporter deformity. Long-term data regarding mechanical, overall, and infection-free survival demonstrate excellent results, and, given the consistently high satisfaction rates and limited alternatives for medically refractory ED, penile prostheses are likely to remain a relevant and important treatment strategy for the foreseeable future.

Heavy Testosterone Use Among Bodybuilders: An Uncommon Cohort of Illicit Substance Users.

OBJECTIVE To identify and characterize patterns of use among a contemporary cohort of current anabolic-androgenic steroid (AAS) users. PATIENTS AND METHODS An anonymous, self-administered, 49-item questionnaire was posted on message boards of Internet websites popular among AAS users and administered via SurveyMonkey from February 1, 2015, to June 1, 2015. Thirty-seven questions were analyzed for this study. RESULTS A total of 231 male respondents met the inclusion criteria. Most were white, were older than 25 years, were employed with above average income, and had received a formal education beyond high school. Ninety-three percent began using AAS after the age of 18 years, and 81% reported using 400 mg or more of testosterone per week. Factors associated with longer duration of use (>5 years) included higher incomes (≥

Renal fossa recurrence after nephrectomy for renal cell carcinoma: prognostic features and oncological outcomes.

75,000, P=.003), increased testosterone dosages (>600 mg per week, P=.007), older age (≥35 years, P<.001), being married (P<.001), and being self-employed (P<.001). The Internet was the most common source of testosterone (53%). Ninety-three percent used at least one additional performance-enhancing drug. Seventy-seven percent had routine laboratory tests performed, and 38% reported laboratory abnormalities at some point. Nearly all experienced subjective adverse effects while using and not using testosterone. Fifty-three percent reported use of other illegal substances, most commonly (90%) beginning before AAS initiation. Ten percent had a criminal conviction, 91% of which preceded AAS use. Fifty percent were felonies. CONCLUSION The population of AAS users is disparate from that of other drugs of abuse. Laboratory test abnormalities and adverse effects are common and should be taken into account when counseling patients who may be using AASs.

Urinary collecting system invasion is associated with poor survival in patients with clear-cell renal cell carcinoma.

To describe the clinicopathological features associated with increased risk of renal fossa recurrence (RFR) after radical nephrectomy (RN) and to describe the prognostic features associated with cancer‐specific survival (CSS) among patients with RFR treated with primary locally directed therapy, systemically directed therapy or expectant management.

Surgical patient selection and counseling

To evaluate the prognostic significance of urinary collecting system invasion (UCSI) in a large series of patients with clear‐cell renal cell carcinoma (RCC).

Current Diagnosis and Management of Premature Ejaculation

The objectives of patient selection and counseling are ultimately to enhance successful outcomes. However, the definition for success is often narrowly defined in published literature (ability to complete surgery, complications, satisfaction) and fails to account for patient desires and expectations, temporal changes, natural history of underlying diseases, or independent validation. Factors associated with satisfaction and dissatisfaction are often surgery-specific, although correlation with pre-operative expectations, revisions, and complications are common with most procedures. The process of appropriate patient selection is determined by the integration of patient and surgeon factors, including psychological capacity to handle unsatisfactory results, baseline expectations, complexity of case, and surgeon volume and experience. Using this model, a high-risk scenario includes one in which a low-volume surgeon performs a complex case in a patient with limited psychological capacity and high expectations. In contrast, a high-volume surgeon performing a routine case in a male with low expectations and abundant psychiatric reserve is more likely to achieve a successful outcome. To further help identify patients who are at high risk for dissatisfaction, a previously published mnemonic is recommended: CURSED Patient (compulsive/obsessive, unrealistic, revision, surgeon shopping, entitled, denial, and psychiatric). Appropriate patient counseling includes setting appropriate expectations, reviewing the potential and anticipated risks of surgery, post-operative instruction to limit complications, and long-term follow-up. As thorough counseling is often a time-consuming endeavor, busy practices may elect to utilize various resources including educational materials, advanced practice providers, or group visits, among others. The consequences for poor patient selection and counseling may range from poor surgical outcomes and patient dissatisfaction to lawsuits, loss of credibility, or even significant patient or personal harm.

The impact of androgen deprivation on artificial urinary sphincter outcomes.

Premature ejaculation (PE) is a common sexual dysfunction characterized by reduced intravaginal ejaculatory latency time (IELT), inability to delay ejaculation, and personal distress. Increasing understanding of pathophysiologic mechanisms has yielded diverse and effective therapies. The current review discusses contemporary evaluation and management of PE, with a review of all randomized, controlled trials (RCT) performed. Therapies with RCT data include behavioral modification/psychotherapy, topical anesthetics, narcotic-like pain relievers, phosphodiesterase-5 (PDE-5) inhibitors, selective serotonin/norepinephrine reuptake inhibitors and receptor antagonists, tricyclic antidepressants, and surgery. As data are insufficient to define optimal therapies, treatment decisions are based on clinical factors (comorbid conditions, PE mechanism and patient preference), trial outcomes, and adverse event profiles. Combination therapies demonstrate superior efficacy to single agents, with concomitant use of behavioral/psychosexual modifications with pharmacotherapy recommended. The role of surgery in PE remains undefined, with additional data required. Further comparative RCTs are required to define optimal treatment algorithms.

The Use of Patient Reported Outcome Questionnaires in the Diagnosis of Androgen Deficiency

Background Androgen deprivation therapy (ADT) causes systemic tissue atrophy. It is unclear if this tissue atrophy adversely impacts artificial urinary sphincter (AUS) outcomes. We sought to evaluate the effect of ADT on adverse AUS outcomes. Methods We retrospectively identified 518 men undergoing primary AUS placement at our institution between 1998 and 2014. Rates of device explant for infection/erosion, mechanical failure, and urethral atrophy in men with >6 months of ADT use within 2 years prior to AUS placement were compared to ADT naive men. Results Fifty of the patients (50/518, 9.7%) had >6 months of ADT use within 2 years prior to AUS placement while 442 were ADT naive. Multivariable survival analysis of AUS events by competing risks failed to show any effect of ADT on device explantation for infection/erosion (HR 1.12, P=0.68), replacement for mechanical failure (HR 0.92, P=0.77), or urethral atrophy (HR 0.77, P=0.46). Conclusions This study did not show evidence supporting differences in adverse AUS outcomes between men with ADT use and ADT naive men.

Restoration of Penile Function and Patient Satisfaction with Intralesional Collagenase Clostridium Histolyticum Injection for Peyronie’s Disease

As the proportion of elderly individuals in the population has increased so has awareness of testosterone deficiency syndrome (TDS). Testosterone deficiency is manifested in numerous ways including low libido, sexual dysfunction, impaired fertility, loss of muscle mass, fatigue, hot flashes, mood instability, and increased abdominal fat deposition. Patient reported outcome measures are useful for clinicians, researchers, and patients. For the patient, these outcome measures, often termed instruments, express what the patient is able to do and how they feel over time. Researchers use these instruments to compare similar populations in a reliable and valid manner, while clinicians find them useful for assessing aspects of health not assessed by TDS exam or laboratory testing. Multiple questionnaires have been designed to screen patients for testosterone deficiency and to follow symptom response during treatment. These instruments are reviewed in this chapter. Due to the significant symptom overlap with common comorbidities, testosterone deficiency symptom scales lack specificity. Each of the scales has significant limitations. Therefore, current guidelines do not support their clinical use in identifying patients with low testosterone levels.