Harpreet Wadhwa

Long-term oncological outcomes of apical positive surgical margins at radical prostatectomy in the Shared Equal Access Regional Cancer Hospital cohort

Background:Approximately 29–38% of all positive surgical margins (PSMs) at radical prostatectomy (RP) involve the apex. The prognostic significance of apical PSM remains unclear. We therefore compared the long-term oncologic outcomes of men with apical PSMs to those with negative PSMs, apical and other PSMs, and other PSMs at RP.Methods:The SEARCH (Shared Equal Access Regional Cancer Hospital) database was used to identify 4031 men with prostate cancer (PCa) managed with RP with complete pathologic grade and stage data. Margin status was categorized as negative, apex only, or other positive. Multivariable Cox regression models adjusted for pathologic stage and grade were developed to test the relationship between margin status and biochemical recurrence (BCR), metastases and PCa death.Results:In the final cohort, 34.3% had PSMs, whereas 65.7% had negative margins. Univariable analysis showed that compared with negative margins, apex-only PSM was associated with BCR (hazard ratio (HR): 1.4 [1.1–1.8]), but not metastases or PCa death, whereas apex and other PSMs were associated with BCR (HR: 3.3 [2.8–4]) and metastases (HR: 1.8 [1.02–3.1]) but not PCa death. Nonapical PSMs were associated with BCR (HR: 2.7 [2.4–3.1]), metastases (1.7 [1.2–2.5)] and PCa death (1.8 [1.05–3]). On multivariable analysis, apex-only, apex and other, and nonapical PSMs were associated with BCR but margin status was not associated with metastases or PCa death.Conclusions:In a large cohort of men undergoing RP, those with PSMs at the prostatic apex had lower BCR, metastases, or PCa death compared with those with PSMs at other locations. When adjusted for pathologic stage and grade, however, PSMs were associated with BCR but not long-term oncologic outcomes. These data confirm that men with apex-only PSMs may not be ideal candidates for adjuvant therapy after RP.

Is prostate cancer stage migration continuing for black men in the PSA era

Background:In the United States, disease-specific mortality from prostate cancer (PC) is highest among black men. While the introduction of widespread PSA testing has been associated with a downward stage migration, whether this trend continues in the late PSA era and for black men is unknown. The objective of our study was to evaluate current PC stage migration patterns in the United States by race.Methods:The Surveillance, Epidemiology and End Results (SEER) registry was queried to obtain all cases of PC reported between 2000 and 2013. Year of diagnosis was categorized into 2000–2003, 2004–2007, 2008–2010 and 2011–2013. Predictors of distant stage PC at diagnosis were determined using logistic regression adjusted for year of diagnosis, age at diagnosis, SEER region and race.Results:A total of 791 184 PC cases were identified. The cohort comprised 78.9% (n=594 920) white and 14.1% (n=106 133) black men. The stage at diagnosis was 83.3% localized, 12.0% regional and 4.7% distant. Age-adjusted incidence demonstrated a steady decline for black men in all time groups while white men had a stable incidence of distant disease between 2000 and 2013. In univariate analysis, black men in the 2004–2007 (OR 0.86 (0.81–0.93)) and 2008–2010 cohorts (OR 0.85 (0.79–0.91)) were less likely to be diagnosed with metastatic PC as compared with the 2000–2003 baseline cohort. In multivariate analysis, the 2004–2007 black cohort was less likely to be diagnosed with distant PC (OR 0.90 (0.84–0.97)). This trend was not observed in white men who in multivariate analysis had an increased risk of distant PC in the 2004–2007 (OR 1.08 (1.04–1.11)), 2008–2010 (OR 1.22 (1.18–1.27)) and 2011–2013 (OR 1.65 (1.59–1.71)) groups.Conclusions:PC downward stage migration continues in black men but not in white men. Discontinuation of PSA-based screening for PC could disproportionately affect black men.

A Review of Adjustable Continence Devices for the Treatment of Stress Urinary Incontinence with Neurogenic Etiology

Midurethral slings may lose their effectiveness due to changes in urethral compression over time in patients with urinary incontinence due to intrinsic sphincter deficiency and neurogenic bladder. Adjustable continence devices offer potential solutions. We reviewed the current literature regarding six adjustable continence devices for male and female patients suffering from incontinence. We reviewed the following devices: Adjustable Continence Therapy® (Uromedica, Irvine, CA), Pro-Adjustable Continence Therapy® for men (Uromedica, Irvine, CA), TRT Remeex (Neomedic, Barcelona, Spain) for females, MRS II Remeex (Neomedic, Barelona, Spain) for men, Argus ®, and Phorbas® adjustable continence therapy for men (Promedon SA, Cordoba, Argentina). Based on the reviewed studies, adjustable continence devices offer similar, if not less, risk than traditional stress urinary incontinence (SUI) procedures with greater outcomes as reported by patients. Adjustable continence devices allow clinicians to adjust urethral tension post-operatively if necessary without secondary procedures and general anesthesia. Adjustable devices are particularly well-suited to SUI with a neurogenic etiology as these devices allow for post-operative adjustments to sphincter pressure from a clinical setting.

Case Report of a Ureterocutenous Fistula Post Aortobifemoral Bypass Graft Removal in a Patient With Obstructive UPJ Calculus

Ureterocutaneous fistulas are rare, often iatrogenic complications. We present a case of a 60 year old woman suffering a ureterocutaneous fistula in association with an infected vascular graft. Percutaneous diversion of urinary fluid with a nephrostomy tube is an acceptable form of management.

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications