Janet Colli

Efficacy of adding behavioural treatment or antimuscarinic drug therapy to α-blocker therapy in men with nocturia.

Nocturia is a common and bothersome lower urinary tract symptom, particularly in men. Many single drug therapies have limited benefit. For men who have persistent nocturia despite alpha‐blocker therapy, the addition of behavioural and exercise therapy is statistically superior to anticholinergic therapy.

Underutilization of Partial Nephrectomy for Stage T1 Renal Cell Carcinoma in the United States, Trends From 2000 to 2008. A Long Way to Go

INTRODUCTIONnRecent American Urologic Association Guidelines for small renal masses recommend partial nephrectomy for surgical treatment of T1 renal masses to preserve renal function and minimize cardiovascular comorbidities. This procedure is performed more often than in the past, after the technical issues of hemorrhage, fistula, and technique evolved. We reviewed the trends, practice patterns, and application of partial nephrectomy for T1 renal cell carcinoma in the United States from 2000 to 2008, before the American Urologic Association Guidelines. The objective is to investigate whether economic or societal factors favor the use of partial over radical nephrectomy surgery.nnnMETHODSnData on 142,194 cases from 1267 hospitals diagnosed with kidney and renal pelvis cancer in the National Cancer DataBase from 2000 to 2008 were the basis of the study.nnnRESULTSnPartial nephrectomy rates for stage T1 kidney and renal pelvis cancer have increased from 17% in 2000 to 31% in 2008. Differences in partial nephrectomy rates that arise from sex or race were not large. However, there was a disproportionate increase based on income and education. Also, there were differences based on insurance status; patients with managed care, in the military and veterans had higher partial nephrectomy rates. Partial nephrectomy rates were higher in teaching and research hospitals and in veterans hospitals. Geographically, the procedure was performed at higher rates in the eastern and midwestern parts of the country.nnnCONCLUSIONSnPartial nephrectomy rates for stage T1 renal cell carcinoma increased from 17% in 2000 to 31% in 2008. The procedure has been used preferentially with patients who are more educated and have high incomes.

Urothelial cancers after renal transplantation

ObjectiveAfter solid organ transplantation, risk of cancer varies significantly based on cancer type. In this study, we determine the incidence of urothelial cancers (bladder and kidney) after renal transplantation from a single high-volume transplantation institution. In addition, we analyze the risk factors and review outcomes from the patients.Materials and methodsWe performed a retrospective review of all patients in the University of Alabama at Birmingham (UAB) transplant database to identify all patients who received renal transplants at UAB between January 1, 1990, and January 1, 2010. We further identified transplant patients diagnosed with bladder, urothelial of other cancers in the same time period. We also examined tumor-specific variables such as presentation, clinical and pathologic staging, treatment type, recurrence, progression, interval to recurrence and progression, cancer-specific mortality, and interval from time to diagnosis to death.ResultsReview of the transplant database confirmed 5,920 renal transplants. Thirteen patients underwent the diagnosis of urothelial cancer, providing an incidence of 0.2%. Eight patients had bladder cancer for an incidence of 0.13%, compared to an incidence of 0.02% among the general population. Patients diagnosed with bladder cancer after renal transplantation were younger than those in the general population and frequently present with more advanced and aggressive disease.ConclusionsPatients are at an elevated risk of urothelial cancers after renal transplantation probably from immune suppression.

Protective Effects of Reducing Renal Ischemia-reperfusion Injury During Renal Hilar Clamping: Use of Allopurinol as a Nephroprotective Agent

OBJECTIVEnTo investigate the relationship between renal ischemia injury and concentrations of 8-isoprostane in a rat kidney model during renal hilar clamping and their correlation with the administration of allopurinol before clamping.nnnMATERIALS AND METHODSnReperfusion injury occurs after the reintroduction of blood flow after a prolonged period of ischemia. Thought to be due to oxygen free radicals released by the endothelial, mitochondrial, and parenchymal cells, this process leads to a cascade of events whereby infiltrative leukocytes generate cytokines and reactive oxygen species. The present study was performed in 2 parts. Our primary objective was to first develop a method of quantitating the renal damage using a prostaglandin compound formed inxa0vivo, specifically isoprostane. After the development of this animal model of quantitating renal injury, our second objective was to apply this model and investigate allopurinols nephroprotective abilities. A microdialysis probe was inserted into the renal parenchyma of rats to allow continuous dialysis and collection of the effluent for isoprostane levels. After clamping of the renal vessels to induce ischemia, the interstitial effluent from the probe was collected and subsequently analyzed for 8-isoprostane levels with and without allopurinol pretreatment.nnnRESULTSnClamping of the renal hilum in this rat model significantly increased 8-isoprostane levels. After 60 minutes of clamp time, the largest absolute increase in 8-isoprostane levels resulted, representing a 3.2-fold increase from baseline. However, the rats that had been pretreated with allopurinol demonstrated significantly less isoprostane levels, to baseline levels.nnnCONCLUSIONnAllopurinol has demonstrated significant benefits by reducing reperfusion injury in rat kidneys, as demonstrated by the use of 8-isoprostane as a tool for the real-time measurement of ischemic injury.

Bladder neck closure and suprapubic catheter placement as definitive management of neurogenic bladder

Abstract Objective Surgical management for neurogenic bladder may require abandonment of the native urethra due to intractable urinary incontinence, irreparable urethral erosion, severe scarring from previous transurethral procedures, or urethrocutaneous fistula. In these patients, bladder neck closure (BNC) excludes the native urethra and provides continence while preserving the antireflux mechanism of the native ureters. This procedure is commonly combined with ileovesicostomy or continent catheterizable stoma, with or without augmentation enterocystoplasty. Alternatively, BNC can be paired with suprapubic catheter diversion. This strategy does not require a bowel segment, resulting in shorter operative times and less opportunity for bowel-related morbidity. The study purpose is to examine preoperative characteristics, indications, complications, and long-term maintenance of renal function of BNC patients. Methods A retrospective review of medical records of 35 patients who underwent BNC with suprapubic catheter placement from 1998 to 2007 by a single surgeon (LKL) was completed. Results Neurogenic bladder was attributable to spinal cord injury in 71%, 23% had multiple sclerosis, and 9% had cerebrovascular accident. Indications for BNC included severe urethral erosion in 80%, decubitus ulcer exacerbated by urinary incontinence in 34%, urethrocutaneous fistula in 11%, and other indications in 9%. The overall complication rate was 17%. All but two patients were continent at follow-up. Forty-nine per cent of patients had imaging available for review, none of which showed deterioration of the upper tracts. Conclusions Our results suggest that BNC in conjunction with suprapubic catheter diversion provides an excellent chance at urethral continence with a reasonable complication rate.

Population densities in relation to bladder cancer mortality rates in America from 1950 to 1994

ObjectivePrevious studies have reported that bladder cancer risks are elevated in industrial and urban areas. The cause is believed to be the result of occupational exposure from industries located in urban areas. Recent studies suggest that traffic air pollution may also increase bladder cancer risks. The study purpose is to investigate the relationship between bladder cancer mortality and population density of counties in America. Another objective is to explore traffic air pollution and industrial exposures as risk factors.Materials and methodsBladder cancer mortality rates for white men and women from 1950 to 1994 and population densities (population per 10 square miles) of 2,248 counties were the basis of the study. A linear regression analysis was performed to evaluate the relationship between bladder cancer mortality rates and population densities after log transforming the population density data set. In addition, the counties were divided into quartiles based on bladder cancer mortality rates. Mean population density values with 95% confidence intervals for the quartiles were computed.ResultsCorrelation coefficients (R) between bladder cancer mortality rates and the population densities were Rxa0=xa0.37, Pxa0<xa0.001 for men and Rxa0=xa0.28, Pxa0<xa0.001 for women. In addition, population densities increased with increasing bladder cancer mortality rates across all quartiles. The mean population density of the highest quartile was more than ten times higher than the lowest.ConclusionsIn this study, we found a strong association between bladder cancer mortality and population density. Traffic air pollution is a potential cause.

Does Urological Cancer Mortality Increase With Low Population Density of Physicians

PURPOSEnWe examined the association between urological cancer mortality rates and the presence of physicians. We hypothesized that cancer mortality rates increase with a low physician population density since this would decrease the detection of cancers at an early stage.nnnMATERIALS AND METHODSnMortality rates for prostate cancer, bladder cancer, kidney and renal pelvis cancer, and cancer at all sites for white patients in United States counties from 2003 to 2007 were obtained from the National Vital Statistics System. High and low rate groups of counties were reviewed for each type of cancer. The high rate groups consisted of 15 or 25 counties with the highest cancer mortality rates. The low rate groups consisted of counties, selected from the same states as high rate groups, with the lowest mortality rates. Levels of physicians per 10,000 general population, income, poverty and no health insurance were compared between the high and low cancer rate groups.nnnRESULTSnThere was a statistically significant inverse association between physician population density levels and kidney and renal pelvis cancer mortality rates. The association was suggestive for bladder cancer and prostate cancer mortality but not for cancer at all sites. There was also a tendency for an inverse association between family income and cancer mortality rates.nnnCONCLUSIONSnKidney and renal pelvis cancer mortality rates increased significantly with a low physician population density. We found a suggestive but not significant negative association between physician population density and mortality rates for prostate cancer and bladder cancer but not for cancer at all sites. Low family income was associated with higher cancer rates.

Clamping renal artery alone produces less ischemic damage compared to clamping renal artery and vein together in two animal models: near-infrared tissue oximetry and quantitation of 8-isoprostane levels

PurposeTo investigate renal ischemia injury during renal hilar clamping (artery alone versus clamping artery/vein together) by evaluating ischemic damage via two different modalities in animal models—near-infrared tissue oximetry and 8-isoprostane levels.MethodsNear-infrared renal oximetry measurements of Yorkshire swines (nxa0=xa04; 8 renal units) subject to hilar clamping were obtained at baseline, during warm ischemia (15- and 30-min trials) and after unclamping. Quantitation of 8-isoprostane levels is the second technique of quantitating interstitial fluid collected from a dialysis catheter placed through renal parenchyma of male Sprague–Dawley rats (nxa0=xa050) subject to hilar clamping during preclamp, clamp (either 15 or 30xa0min of hilum clamping), and post-clamp.ResultsNear-infrared tissue oximetry. In the 15-min trial, oxygen saturation decreased 6× faster with artery alone compared to artery/vein clamped together. In the 30-min trial, the decrease was 5× faster. Recovery of oxygen saturation with only artery clamped occurred more than 2× faster in the 15- and 30-min periods. Isoprostane. For 15-min clamp times, 8-isoprostane levels in the artery alone group demonstrated a 1.54 decrease in the artery clamped alone group (pxa0=xa00.006) versus artery/vein together: preclamp (11.47 and 11.63xa0pg/mL/g), clamp (14.61 and 17.70xa0pg/mL/g), and post-clamp (14.26 and 22.04xa0pg/mL/g).ConclusionsRenal ischemia injury from clamping the renal artery alone was significantly less than clamping artery/vein together demonstrated in two different techniques. Recovery of oxygen saturation was twofold faster, and mean post-clamp 8-isoprostane levels demonstrated a 1.54-fold decrease with clamping renal artery alone compared to clamping artery/vein together.

Intrarenal pressures remain low with placement of a dual lumen catheter for retrograde irrigation to induce renal hypothermia

ObjectiveTo determine whether placement of a 10 French dual lumen catheter produces a low-pressure collecting system during retrograde irrigation to induce renal hypothermia. Indication for the study is as a potential adjunct for partial nephrectomy.MethodsEx vivo porcine kidneys underwent harvest, and a ureteral catheter (either single lumen or dual lumen) was placed in the ureter within the renal pelvis. Pressure measurements (nxa0=xa01,080) were recorded at 1-s intervals. Irrigant flow rates were initiated at gravity and subsequently increased at 10xa0cc/min increments to a maximum of 100xa0cc/min.ResultsDuring retrograde infusion without a dual lumen catheter, every 10xa0cc/min rate increase resulted in an 8xa0cm H2O rise in intrarenal pressure. The maximum flow rate obtained was 20xa0cc/min before urinary extravasation or intrarenal drainage occurred. Maximum pressure obtained before urinary extravasation or collecting system perforation was 16xa0cmxa0H2O. Placement of a dual lumen catheter within the renal pelvis allowed intrarenal pressures to remain less than 5xa0cmxa0H2O (when infusion rates <80xa0cc/min). The maximum flow rate while maintaining pressures <20xa0cm H2O was 90xa0cc/min. Flow rates above 100xa0cc/min resulted in urinary extravasation. The maximal flow rate that is safe for collecting systems with a dual lumen catheter is 80xa0cc/min, and without a dual lumen catheter rates greater than 20xa0cc/min resulted in collecting system perforations.ConclusionUsing an ex vivo porcine model, application of a 10 French ureteral dual lumen catheter produced adequate retrograde drainage that resulted in low intrarenal pressures at high infusion rates (up to 80xa0cc/min).

Bladder Preservation Approaches

As more and more patients are living longer, they bring with them a host of chronic conditions. Often times, these comorbidities may prevent patients from being optimal candidates for the standard treatment for invasive or high-grade bladder cancer. This chapter briefly looks at some therapeutic surgical options for patients who are not ideal candidates for a prolonged radical cystectomy with concomitant reconstruction of the urinary tract.