Gregory Murphy

Cycling, and Male Sexual and Urinary Function: Results from a Large, Multinational, Cross-Sectional Study

Purpose We explored the relation of cycling to urinary and sexual function in a large multinational sample of men. Materials and Methods Cyclists were recruited to complete a survey through Facebook® advertisements and outreach to sporting clubs. Swimmers and runners were recruited as a comparison group. Cyclists were categorized into low and high intensity cyclists. Participants were queried using validated questionnaires, including SHIM (Sexual Health Inventory for Men), I‐PSS (International Prostate Symptom Score) and NIH‐CPSI (National Institutes of Health Chronic Prostatitis Symptom Index), in addition to questions about urinary tract infections, urethral stricture, genital numbness and saddle sores. Results Of 5,488 complete survey responses 3,932 (72%) were included in our analysis. On multivariate analysis swimmers/runners had a lower mean SHIM score than low and high intensity cyclists (19.5 vs 19.9 and 20.7, p = 0.02 and <0.001, respectively). No significant differences were found in I‐PSS or NIH‐CPSI scores, or urinary tract infection history. Cyclists had statistically higher odds of urethral stricture compared to swimmers/runners (OR 2.5, p = 0.042). Standing more than 20% of the time while cycling significantly reduced the odds of genital numbness (OR 0.4, p = 0.006). Adjusting the handlebar higher or even with the saddle had lower odds of genital numbness and saddle sores (OR 0.8, p = 0.005 and 0.6, p <0.001, respectively). Conclusions Cyclists had no worse sexual or urinary functions than swimmers or runners but cyclists were more prone to urethral stricture. Increased time standing while cycling and a higher handlebar height were associated with lower odds of genital sores and numbness.

Outcomes of men on active surveillance for low-risk prostate cancer at a safety-net hospital

PURPOSE To characterize demographic, disease, and cancer outcomes of men on active surveillance (AS) at a safety-net hospital and characterize those who were lost to follow-up (LTFU). METHODS From January 2004 to November 2014, 104 men with low-risk prostate cancer (PCa) were followed with AS at Zuckerberg San Francisco General Hospital (ZSFG). Criteria for AS have evolved over time; however, patients with diagnostic prostate-specific antigen (PSA) 10ng/mL or less, clinical stage T1/2, biopsy Gleason score 3 + 3 or 3 + 4, 33% or fewer positive cores, and 50% or less tumor in any single core were potentially eligible for AS. Men were longitudinally followed with a PSA or digital rectal examination or both every 3 to 6 months, and repeat prostate biopsy every 1 to 2 years. Clinical staging and grading were based on a physical examination and at least a 12-core biopsy, respectively. LTFU was defined as failure to successfully contact patients with 3 phone calls or any urology visit recorded within 18 months from a prior visit or biopsy. A secondary chart review was performed using the electronic medical record at ZSFG as well as EPIC Systems CareEverywhere which allows access to select non-ZSFG institutions to confirm that patients were truly LTFU. RESULTS Among the 104 men on AS at ZSFG, the median age at diagnosis of PCa was 61.5 years (range: 44-81). The median follow-up period was 29 months (range: 0-186 months) during which 18 (17.3%) men were LTFU and 48 (46%) remained on surveillance. Men underwent a median of 7 (1-21) serum PSA measurements and an average of 2 prostate biopsies (1-5). In total, 22 (20.6%) men had definitive treatment with the median time from diagnosis to active treatment being 26 (range: 2-87) months. Radiation therapy was more common than radical prostatectomy (12.5% vs. 7.7%). There was 1 PCa-related death and 3 noncancer deaths. Initial adherence to AS was poor; however, men committed to AS initially were ultimately more compliant over time. CONCLUSION AS for low-risk PCa is challenging among a vulnerable population receiving care in a safety-net hospital, as rates of LTFU were high. Our findings suggest the need for AS support programs to improve adherence and follow-up among vulnerable and underserved populations.

Guidelines of guidelines: a review of urethral stricture evaluation, management, and follow-up

Background Our objective is to report a comparative review of recently released guidelines for the evaluation, management, and follow-up of urethral stricture disease. Methods This is an analysis of the American Urologic Association (AUA) and Société Internationale d’Urologie (SIU) guidelines on urethral stricture. Strength of recommendations is stratified according to letter grade that corresponds to the level of evidence provided by the literature. Results Although few, the discrepancies between the recommendations offered by the two guidelines can be best explained by varying interpretations of the literature and available evidence on urethral strictures. When comparing the AUA guidelines and the SIU guidelines on urethral stricture, there are very few discrepancies. Perhaps the most notable difference is in the use of repeat DVIU or urethral dilation after an initial failed attempt. SIU guidelines state that there are instances where repeat DVIU or urethral dilation can be indicated, and they give a range of time at which stricture recurrence post procedure mandates an urethroplasty (less than 3 to 6 months). The AUA guidelines definitively state that repeat endoscopic procedures should not be offered as an alternative to urethroplasty, and they do not mention time of stricture recurrence as a factor. SIU guidelines allow for management of urethral stricture with indwelling urethral stenting. Conclusions Overall there is a need for more high quality research in the work up, management, and follow up care of urethral stricture.

Postoperative Complications following Primary Penile Inversion Vaginoplasty among 330 Male-to-Female Transgender Patients

Purpose Studies of surgical complications of penile inversion vaginoplasty are limited due to small sample sizes. We describe postoperative complications after penile inversion vaginoplasty and evaluated age, body mass index and years on hormone replacement therapy as risk factors for complications. Materials and Methods We retrospectively reviewed the records of male‐to‐female patients who presented for primary penile inversion vaginoplasty to a high volume surgeon (MLB) from 2011 to 2015. Complications included granulation tissue, vaginal pain, wound separation, labial asymmetry, vaginal stenosis, fistula formation, urinary symptoms including spraying stream or dribbling, infection, vaginal fissure or vaginal bleeding. We classified complications by Clavien‐Dindo grade. Multivariable logistic regression was performed to determine the independent effects of age, body mass index and hormone replacement therapy on postoperative surgical complications. Results A total of 330 patients presented for primary penile inversion vaginoplasty. Median age at surgery was 35 years (range 18 to 76). Median followup in all patients was 3 months (range 3 to 73). Of the patients 95 (28.7%) presented with a postoperative complication. Median time to a complication was 4.4 months (IQR 1–11.5). Rectoneovaginal fistulas developed in 3 patients (0.9%). A total of 30 patients (9.0%) required a second operation. There were no complications greater than Clavien‐Dindo grade IIIB. Age, body mass index and hormone replacement therapy were not associated with complications. Conclusions Penile inversion vaginoplasty is a relatively safe procedure. Most complications due to this surgery develop within the first 4 months postoperatively. Age, body mass index and hormone replacement therapy are not associated with complications and, thus, they should not dictate the timing of surgery.

Multicenter Analysis of Patient Reported Outcomes Following Artificial Urinary Sphincter Placement for Male Stress Urinary Incontinence

Purpose Patient centered data are lacking regarding functional and quality of life improvements after artificial urinary sphincter placement. We analyzed the degree of benefit from artificial urinary sphincter placement using ISI (Incontinence Symptom Index), a validated patient reported outcome measure assessing the severity and bother of urinary incontinence, and IIQ‐7 (Incontinence Impact Questionnaire‐7), a validated patient reported outcome measure assessing the impact and emotional distress of urinary incontinence. Materials and Methods We performed a retrospective review at 4 centers participating in TURNS (Trauma and Urologic Reconstruction Network of Surgeons). Data were available on 51 and 45 patients who underwent artificial urinary sphincter placement, and had preoperative and postoperative ISI and IIQ‐7 data, respectively. Results Mean age was 64.8 years. Median time from surgery to followup questionnaires was 8.5 months. On ISI the median preoperative severity and bother scores were 24 (IQR 20–28.5) and 6 (IQR 4–7), and the median postoperative severity and bother scores were 10 (IQR 4.5–17) and 1 (IQR 0–3), respectively. Improvement on each ISI item was statistically significant. On IIQ‐7 the median preoperative impact and distress scores were 9 (IQR 6–13) and 4 (IQR 2–6), and the median postoperative impact and distress scores were 3 (IQR 0–7) and 0 (IQR 0–3), respectively. Improvement on each IIQ‐7 item was statistically significant. Conclusions Artificial urinary sphincter implantation significantly reduces the severity and bother of stress urinary incontinence symptoms. Longer followup and development are needed of a patient reported outcome measure targeting male stress urinary incontinence.

Web-Based Physician Ratings for California Physicians on Probation

Background Web-based physician ratings systems are a popular tool to help patients evaluate physicians. Websites help patients find information regarding physician licensure, office hours, and disciplinary records along with ratings and reviews. Whether higher patient ratings are associated with higher quality of care is unclear. Objective The aim of this study was to characterize the impact of physician probation on consumer ratings by comparing website ratings between doctors on probation against matched controls. Methods A retrospective review of data from the Medical Board of California for physicians placed on probation from December 1989 to September 2015 was performed. Violations were categorized into nine types. Nonprobation controls were matched by zip code and specialty with probation cases in a 2:1 ratio using the California Department of Consumer Affairs website. Web-based reviews were recorded from vitals.com, healthgrades.com, and ratemds.com (ratings range from 1-5). Results A total of 410 physicians were placed on probation for 866 violations. The mean (standard deviation [SD]) number of ratings per doctor was 5.2 (7.8) for cases and 4 (6.3) for controls (P=.003). The mean rating for physicians on probation was 3.7 (1.6) compared with 4.0 (1.0) for controls when all three rating websites were pooled (P<.001). Violations for medical documentation, incompetence, prescription negligence, and fraud were found to have statistically significant lower rating scores. Conversely, scores for professionalism, drugs or alcohol, crime, sexual misconduct, and personal illness were similar between cases and controls. In a univariate analysis, probation was found to be associated with lower rating, odds ratio=1.5 (95% CI 1.0-2.2). This association was not significant in a multivariate model when we included age and gender. Conclusions Web-based physician ratings were lower for doctors on probation indicating that patients may perceive a difference. Despite these statistical findings, the absolute difference was quite small. Physician rating websites have utility but are imperfect proxies for competence. Further research on physician Web-based ratings is warranted to understand what they measure and how they are associated with quality.

Missed Opportunities to Decrease Radiation Exposure in Children with Renal Trauma

Purpose: Efforts have been made to reduce use of computerized tomography in children with blunt abdominal injury. Computerized tomography may be overused in pediatric patients with renal trauma. Materials and Methods: We performed a retrospective chart review of all renal trauma patients younger than 18 years old treated at 2 urban trauma centers from 2002 to 2016. We collected demographic and clinical characteristics, renal trauma grades, urological interventions, and timing and use of computerized tomography and renal ultrasound. Results: During the study period 145 patients presented with blunt renal trauma. During hospitalization 46 patients (32%) underwent repeat computerized tomography. About 20% of repeat computerized tomograms were performed less than 48 hours after the first scan. After controlling for center, isolated injury (yes/no), stent placement, age and surgical interventions (yes/no) patients who underwent delayed imaging on their first scan had decreased odds of undergoing a second computerized tomogram (adjusted OR 0.2, 95% CI 0.05–0.9, p = 0.04). Number needed to treat to prevent 1 repeat scan in high grade renal trauma patients was 3 (95% CI 2–4). Estimated sensitivity and specificity for ultrasound monitoring to detect an abnormality requiring urological intervention are 50% and 94%, respectively. Conclusions: Repeat computerized tomography in pediatric patients with renal trauma is common. Obtaining delayed imaging on the initial scan in patients with high grade renal trauma may prevent repeat scans. Renal ultrasound provides diagnostic usefulness in monitoring kidney injuries and should be considered before repeating computerized tomography.

Cost-effective Strategies for the Management and Treatment of Urethral Stricture Disease

Following failed endoscopic intervention, the most cost-effective strategy for recurrent urethral stricture disease (USD) is urethroplasty. Inpatient hospital costs associated with urethroplasty are driven by patient comorbidities and postoperative complications. Symptom-based surveillance for USD recurrence will reduce unnecessary diagnostic procedures and cost.

Management of Pediatric Grade IV Renal Trauma

Purpose of ReviewReview the current literature regarding the management of grade IV renal injuries in children.Recent FindingsChildren are at increased risk for renal trauma compared to adults due to differences in anatomy. Newer grading systems have been proposed and are reviewed. Observation of most grade IV renal injuries is safe. Operative intervention is necessary for the unstable patient to control life-threatening bleeding with either angioembolization or open exploration. Symptomatic urinomas may require percutaneous drainage and/or endoscopic stent placement. Ureteropelvic junction (UPJ) disruption, seen more often in children, requires immediate surgical repair.SummaryGrade IV renal injuries in children are increasingly managed in a conservative manner.

Prostate cancer radiation and urethral strictures: a systematic review and meta-analysis

BackgroundWe performed a systematic review and meta-analysis to determine the prevalence and predictors of urethral stricture development post radiation therapy (RT) for prostate cancer (PCa).MethodsPublished articles in PubMed/Medline, Cochrane, and Embase databases from January 2000 to April 2016 were queried. Inclusion criteria were any study that reported the prevalence of urethral strictures following external beam radiation therapy (EBRT), brachytherapy (BT), or both as a primary treatment for PCa. Forty-six articles met our inclusion criteria. A summary estimate of the proportion of patients who developed a urethral stricture was derived via a random effects meta-analysis.ResultsIn total, 16,129 PCa patients underwent either EBRT (5681, 35.2%), BT (5849, 36.3%), or both (4599, 28.5%). Overall, 630 strictures were diagnosed at follow-up with a pooled estimate period prevalence of 2.2% (95% confidence interval, CI 1.9–2.6%) in a median follow-up time of 4 years (interquartile range, IQR 2.7–5). Of which, the pooled estimate prevalence was 1.5% (95% CI 0.9–2%) post EBRT, 1.9% (95% CI 1.3–2.4%) post BT, and 4.9% (95% CI 3.8–6%) post both EBRT and BT. Of 20 studies reporting a median time to stricture formation, the overall median time was 2.2 years (IQR 1.8–2.5, range 1.4–9). In a meta-regression analysis, receiving both EBRT and BT increased the estimated difference in proportion of stricture diagnoses by 3% (95% CI 1–6%), p = 0.018 compared to EBRT alone. An increase in median follow-up time was found to significantly increase the risk of developing urethral strictures (p = 0.04).ConclusionsWith a short-term follow-up, urethral strictures occur in 2.2% of men with PCa receiving radiotherapy. Receiving both EBRT and BT increased the risk of stricture formation. Longer follow-up is needed to determine the long-term natural history of stricture formation after RT.