Joel Vetter

Urine Aquaporin 1 and Perilipin 2 Differentiate Renal Carcinomas From Other Imaged Renal Masses and Bladder and Prostate Cancer

OBJECTIVE To evaluate the sensitivity and specificity of urine aquaporin 1 (AQP1) and perilipin 2 (PLIN2) concentrations to diagnose clear cell or papillary renal cell carcinoma (RCC) by comparing urine concentrations of these unique biomarkers in patients with RCC, noncancer renal masses, bladder cancer, and prostate cancer. METHODS From February 1, 2012, through October 31, 2012, preoperative urine samples were obtained from patients with a presumptive diagnosis of RCC based on an imaged renal mass, prostate cancer, or transitional cell bladder cancer. Imaged renal masses were diagnosed postnephrectomy—as malignant or benign—by histology. Urine AQP1 and PLIN2 concentrations were measured by using a sensitive and specific Western blot and normalized to urine creatinine concentration. RESULTS Median concentrations of urine AQP1 and PLIN2 in patients with clear cell and papillary RCC (n=47) were 29 and 36 relative absorbance units/mg urine creatinine, respectively. In contrast, median concentrations in patients with bladder cancer (n=22) and prostate cancer (n=27), patients with chromophobe tumors (n=7), and patients with benign renal oncocytomas (n=9) and angiomyolipomas (n=7) were all less than 10 relative absorbance units/mg urine creatinine (Kruskal-Wallis test, P<.001 vs RCC for both biomarkers) and comparable with those in healthy controls. The area under the receiver operating characteristic curve ranged from 0.99 to 1.00 for both biomarkers. CONCLUSION These results support the specificity and sensitivity of urine AQP1 and PLIN2 concentrations for RCC. These novel tumor-specific proteins have high clinical validity and high potential as specific screening biomarkers for clear cell and papillary RCC as well as in the differential diagnosis of imaged renal masses. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00851994.

Correlation between psychological stress levels and the severity of overactive bladder symptoms

BackgroundThe relationship between psychological stress and interstitial cystitis/bladder pain syndrome (IC/BPS) has been well described. Even though there is some overlapping of symptoms between overactive bladder (OAB) and IC/BPS, there have been very few studies that specifically investigated the relationship between psychological stress and urinary symptoms in OAB patients who do not have pelvic pain. Here we examined the relationship between psychological stress levels and the severity of overactive bladder (OAB) symptoms.MethodsPatients diagnosed with OAB (n=51), IC/BPS (n=27), and age-matched healthy controls (n=30) participated in a case control study that inquired about their psychological stress levels using the perceived stress scale (PSS). PSS reported by the three patient groups were compared. Among OAB patients, their responses on the PSS was correlated to OAB symptoms using the following questionnaires: 1) international consultation on incontinence – urinary incontinence (ICIQ-UI), 2) international consultation on incontinence – overactive bladder (ICIQ-OAB), 3) OAB-q short form, 4) urogenital distress inventory (UDI-6), 5) incontinence impact questionnaire (IIQ-7), 6) urgency severity scale (USS), 7) numeric rating scales of urgency symptom, and 8) frequency symptom. Spearman’s correlation tests were performed to examine the relationship between psychological stress levels and the severity of OAB symptoms.ResultsOAB patients reported psychological stress levels that were as high as IC/BPS patients (median 17.0 versus 18.0, p=0.818, Wilcoxon sum rank test), and significantly higher than healthy controls (17.0, versus 7.5, p=0.001). Among OAB patients, there was a positive correlation between perceived stress levels and urinary incontinence symptoms (ICIQ-UI, Spearman’s correlation coefficient=0.39, p=0.007), and impacts on quality of life (UDI-6, IIQ-7, OAB-q quality of life subscale; Spearman’s correlation coefficient=0.32, 0.31, 0.39, and p=0.028, 0.005, 0.029, respectively). No significant correlation was observed between perceived stress levels and urgency or frequency symptoms (ICIQ-OAB, USS, numeric ratings of urgency and frequency).ConclusionsOAB patients reported psychological stress levels that were as high as IC/BPS patients, and significantly higher than healthy controls. There was a positive correlation between perceived stress levels and urinary incontinence symptoms, and its impacts on quality of life among OAB patients.

Re: A Population-Based Analysis of Contemporary Rates of Reoperation for Penile Prosthesis Procedures

OBJECTIVE To perform a population-based comparison of inflatable vs semirigid penile prostheses and to determine contemporary rates of reoperation and identify factors impacting the type of prosthetic implanted. METHODS Patient-level discharge data and revisit files from the Agency for Healthcare Research and Quality for semirigid and inflatable prosthesis procedures performed for erectile dysfunction from 2006 to 2009 in the state of California were examined. Regression analysis was performed to determine differences between the procedures in terms of infectious and noninfectious failure. Regression analysis was performed to identify factors associated with revision and to identify associations between potential risk factors and the type of implant performed. RESULTS A total of 2263 cases were included in the study (1824 inflatable and 439 semirigid). The overall reoperation rate was 7.42%. There was no difference in the overall revision rate between the 2 groups (7.52% semirigid and 7.40% inflatable; P=.94). The reoperation rate secondary to infectious complications was 3.6% (4.5% semirigid vs 3.23% inflatable; P=.18). The revision rate secondary to noninfectious failure was 2.96% in the semirigid vs 4.17% in the inflatable group (P=.25). Medicaid insurance (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.41-3.61), African American race (OR, 1.7; 95% CI, 1.20-2.49), age>80 (P=.046), and diabetes (OR, 1.67; 95% CI, 1.07-2.59) were associated with receiving a semirigid implant. CONCLUSION Reoperation rates for infectious and noninfectious failure are equivalent between the semirigid and inflatable penile prostheses. Sociodemographic factors appear to significantly influence the type of prosthesis a patient receives.

Revision Techniques After Artificial Urinary Sphincter Failure in Men: Results From a Multicenter Study.

OBJECTIVE To compare the results of various single-component artificial urinary sphincter (AUS) revision techniques for continued/recurrent stress urinary incontinence (SUI). Although AUS placement for male SUI has a high rate of success, revisions may be performed for mechanical failure of an isolated component or continued/recurrent SUI. MATERIALS AND METHODS From 1993 to 2012, 90 AUS revisions including urethral cuff downsizing (19), pressure-regulating balloon replacement (18), cuff repositioning (11), or tandem cuff placement (42) were performed at 2 institutions. End points included reoperation, incontinence failure, and urethral erosion. The Kruskal-Wallis test was used to compare continuous variables, and the log-rank test was used to compare Kaplan-Meier curves. RESULTS Mean age was 70.2 years, and median follow-up was 33.6 months. Median time to revision was 28.9 months. Tandem cuff placement was associated with a lower rate of incontinence failure (P = .02), whereas cuff repositioning was associated with a higher rate of incontinence failure (P = .02). An increased rate of mechanical failure was observed with cuff downsizing (P = .01). Among options for revision (1) cuff downsizing is associated with a higher rate of mechanical failure, and (2) cuff repositioning with the same size is associated with a higher rate of incontinence failure, whereas (3) tandem cuff placement is associated with a lower rate of recurrent SUI compared to other types of AUS revision. CONCLUSION Cuff repositioning is associated with an increased rate of persistent incontinence after AUS revision whereas tandem cuff placement is associated with a lower rate of recurrent or persistent incontinence.

Magnetic resonance imaging-targeted vs. conventional transrectal ultrasound-guided prostate biopsy: Single-institution, matched cohort comparison

OBJECTIVES To compare magnetic resonance imaging-targeted biopsy (MRITB) and conventional transrectal ultrasound-guided biopsy (TRUSGB) in the detection of prostate cancer (PCa) at our institution. METHODS Our prospective registry of patients undergoing prostate MRITB from December 2010 to July 2013 was analyzed. Patients were matched one-to-one to patients who underwent TRUSGB based on the following characteristics: age, prostate-specific antigen level, prostate volume, race, family history of PCa, initial digital rectal examination (DRE), prior use of 5-alpha reductase inhibitor, and prior diagnosis of PCa. MRITB was performed using a TargetScan system with the patient under general anesthesia. Magnetic resonance imaging suspicious regions (MSRs) were targeted with cognitive registration, and a full TargetScan template biopsy (TSTB) was also performed. RESULTS In total, 34 MRITB patients were matched individually to 34 TRUSGB patients. As compared with TRUSGB, patients who underwent MRITB had a greater overall rate of PCa detection (76% vs. 56%, P = 0.12) and a significantly higher number with Gleason score≥7 (41% vs. 15%, P = 0.03), whereas the rates of Gleason score 6 PCa detection were similar between MRITB and TRUSGB (35% vs. 41%, P = 0.80). As compared with the TSTB, magnetic resonance imaging suspicious regions-directed biopsies during MRITB had a significantly higher overall PCa detection (54% vs. 24%, P<0.01) and Gleason score≥7 PCa detection (25% vs. 8%, P<0.01). When compared with TSTB, TRUSGB had similar detection rates for benign prostate tissue (76% vs. 79%, P = 0.64), Gleason score 6 PCa (16% vs. 14%, P = 0.49), and Gleason score ≥7 PCa detection (8% vs. 7%, P = 1.0). CONCLUSIONS Cognitive registration MRITB significantly improves the detection of Gleason score≥7 PCa as compared with conventional TRUSGB.

Determination of the Role of Negative Magnetic Resonance Imaging of the Prostate in Clinical Practice: Is Biopsy Still Necessary?

OBJECTIVE To assess the negative predictive value (NPV) of multiparametric magnetic resonance imaging (mpMRI) for detection of prostate cancer (PCa) in routine clinical practice and to identify characteristics of patients for whom mpMRI fails to detect high-grade (Gleason score ≥7) disease. MATERIALS AND METHODS We reviewed our prospectively maintained database of consecutive men who received prostate mpMRI at our institution, interpreted by a clinical practice of academic radiologists. Between January 2012 and December 2015, 84 men without any magnetic resonance imaging suspicious regions according to prior institutional classification, or with Prostate Imaging Reporting and Data System (PI-RADS) 1-2 lesions according to the PI-RADS system, underwent standard template transrectal ultrasound (TRUS)-guided prostate biopsy. Using these biopsy results, we calculated the NPV of mpMRI for the detection of PCa and identified patient risk factors for having a Gleason score ≥7 PCa on biopsy. RESULTS High-grade PCa (Gleason score ≥7) was found on TRUS biopsy in 10.3% of biopsy-naive patients (NPV=89.7%), 16.7% of patients with previous negative biopsy (NPV=83.3%), and 13.3% of patients on active surveillance (NPV=86.6%). On multivariate analysis, the Prostate Cancer Prevention Trial Risk Calculator (PCPTRC) estimated risk for high-grade PCa (as a continuous variable) was a significant predictor for high-grade PCa on biopsy (odds ratio 1.01, P < .01). CONCLUSION Men with negative mpMRIs interpreted in a routine clinical setting have a significant risk of harboring Gleason score ≥7 PCa on a standard 12-region template biopsy, independent of indication. Standard template TRUS prostate biopsy should still be recommended for patients with negative mpMRI, particularly those with elevated PCPTRC estimated risk of high-grade PCa.

The Relationship Between Anxiety and Overactive Bladder or Urinary Incontinence Symptoms in the Clinical Population

OBJECTIVE To investigate the relationship between anxiety and overactive bladder (OAB) or urinary incontinence symptoms among clinical population. MATERIALS AND METHODS Patients who were diagnosed with OAB and age-matched control subjects without OAB were enrolled. Anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS-A). OAB or incontinence symptoms were assessed using the International Consultation on Incontinence-Urinary Incontinence Short Form (ICIQ-UI), ICIQ-OAB, Urogenital Distress Inventory Short Form (UDI-6), Incontinence Impact Questionnaire Short Form (IIQ-7), and OAB-q. Other psychosocial factors were also assessed. RESULTS About half of the OAB subjects (48%) had anxiety symptoms, and one quarter of OAB subjects (24%) had moderate to severe anxiety. OAB subjects reported significantly higher anxiety symptoms compared to age-matched controls (HADS-A: 7.5 ± 4.5 vs 3.3 ± 3.6, P < .001). OAB subjects with anxiety reported more severe OAB or incontinence symptoms, and greater bother and impact on quality of life compared to OAB subjects without anxiety (ICIQ-UI, ICIQ-OAB, UDI-6, IIQ-7, OAB-q, P values all <.05). OAB subjects with anxiety also have more psychosocial difficulties (eg, more depression, higher stress levels). Among OAB subjects, there were positive correlations between the severity of anxiety symptoms and the severity of OAB/incontinence symptoms (Spearmans correlation coefficients 0.29 to 0.47, P < .05). OAB subjects with both anxiety and depression reported higher ICIQ-UI and IIQ-7 scores than those who had anxiety but no depression (P = .014, .025 respectively). CONCLUSION OAB patients reported higher anxiety symptoms compared to controls. OAB patients with anxiety reported more severe OAB or incontinence symptoms, worse quality of life, and more psychosocial difficulties compared to OAB patients without anxiety. There are positive correlations between the severity of anxiety symptoms and OAB or incontinence symptoms.

Presence of Magnetic Resonance Imaging Suspicious Lesion Predicts Gleason 7 or Greater Prostate Cancer in Biopsy-Naive Patients.

OBJECTIVE To compare the relative value of magnetic resonance imaging (MRI) in biopsy-naive patients to those with previous negative biopsy. Although MRI-targeted biopsy has been studied in several major prostate cancer (PCa) cohorts (biopsy naive, previous negative biopsy, and active surveillance), the relative benefit in these cohorts has not been established. METHODS We retrospectively reviewed biopsy-naive (n = 45) and previous negative biopsy (n = 55) patients who underwent prostate MRI prior to biopsy at our institution. Patients with an MRI suspicious region (MSR) underwent MRI-targeted biopsy as well as a systematic template biopsy, whereas those without MSR underwent only the template biopsy. All biopsies were performed with the TargetScan (Envisioneering, Pittsburgh, PA) biopsy system. MRI targeting was performed with cognitive guidance. RESULTS On multivariate logistic regression, the presence of an MSR was the only statistically significant and independent predictor of Gleason ≥ 7 PCa on biopsy for biopsy-naive men (odds ratio [OR] 40.2, P = .01). For men with previous negative biopsy, the presence of MSR was not a predictor of Gleason ≥ 7 PCa on biopsy (OR 4.35, P = .16), whereas PSA density > 0.15 ng/mL(2) was a significant and independent predictor (OR 66.2, P < .01). CONCLUSION Prostate MRI should be considered prior to biopsy in all patients presenting with clinical suspicion for PCa, as presence of a MSR will help guide prebiopsy counseling and provide an opportunity for MRI targeting during biopsy.

Impact of childhood and recent traumatic events on the clinical presentation of overactive bladder

(1) To describe the Prevalence of childhood and recent trauma in patients with overactive bladder (OAB), and (2) assess the impact of traumatic events on the clinical presentation and the severity of OAB symptoms, quality of life, and psychosocial health.

Cerebrovascular Disease and Chronic Obstructive Pulmonary Disease Increase Risk of Complications with Robotic Partial Nephrectomy

OBJECTIVE To identify specific comorbidities within the Charlson Comorbidity Index (CCI) that are associated with increased complication rates after robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS After institutional review board approval, a consecutive series of 641 patients undergoing RAPN were retrospectively identified. Perioperative complications were defined and classified using the Clavien grading system. Fishers exact test or chi-square test was performed to evaluate the association of individual comorbidities with perioperative complications. Logistic regression was used for multivariable analysis to adjust for other non-CCI comorbidities and tumor-specific and patient-specific characteristics. RESULTS Of the 641 patients undergoing RAPN, complications occurred in 67 patients (10.5%), including 10 (14.9%), 28 (41.8%), 20 (29.9%), 5 (7.5%), and 4 (6.0%) patients with Clavien grade 1, 2, 3a, 3b, and 4 complications, respectively. Cerebrovascular disease [odds ratio 3.01 (95% confidence interval [CI] 1.10, 8.26) p = 0.03] and chronic obstructive pulmonary disease [COPD; 3.12 (1.24, 7.89) p = 0.02] predicted complications in multivariable analysis of clinicopathologic characteristics, including all CCI and non-CCI comorbidities. In additional modeling with only CCI comorbidities, similar results were observed, with cerebrovascular disease [2.93 (1.04, 7.56) p = 0.04] and COPD [2.69 (1.04, 6.28) p = 0.04] as the only two significant variables. No other variables reached statistical significance in either model, including nephrometry score or estimated blood loss (p >  .50 for both). COPD predicted major complications (Clavien grade 3 or 4) in multivariable analysis [3.19 (1.07, 9.48) p = 0.04]. CONCLUSIONS Cerebrovascular disease and COPD predict perioperative RAPN complications after RAPN. Identification of patients with these comorbidities preoperatively may afford improved counseling and risk stratification.