Kelvin A. Moses

Minimally Invasive Inguinal Lymphadenectomy via Endoscopic Groin Dissection: Comprehensive Assessment of Immediate and Long-Term Complications

PURPOSEnOpen inguinal lymphadenectomy has been associated with significant postoperative morbidity. Recently, small series have demonstrated the feasibility and efficacy of endoscopic groin lymphadenectomy as an alternative to open surgery. Previously we reported the favorable results of our initial experience. Few reports of novel surgical methods include long-term complications. In this report we present a detailed analysis of immediate and long-term complications associated with the procedure using standardized complications reporting methodology including the Clavien classification.nnnMATERIALS AND METHODSnFrom September 2008 to December 2009, 29 patients underwent endoscopic groin dissection for inguinal lymphadenectomy. The indications for dissection were cutaneous malignancies of the genitourinary area and lower extremities. Endoscopic dissection was performed as previously published. Data were prospectively collected regarding patient demographics and minor/major complications during the perioperative period as well as long-term complications during 1 year. Complications were described using the Clavien classification as well as other complication profiles for open inguinal lymphadenectomy. Minor complications were defined as mild to moderate leg edema, seroma formation not requiring aspiration, minimal skin edge necrosis requiring no therapy and cellulitis managed with antibiotics. Major complications included death, sepsis, venous thromboembolism, re-exploration or other invasive procedures, severe leg edema interfering with ambulation, skin flap necrosis and rehospitalization.nnnRESULTSnA total of 41 endoscopic groin dissections (12 single session bilateral) were performed in 29 patients. Patient characteristics were median body mass index 30 kg/m(2) (range 19 to 53, mean 31.1), median age 61 years (range 16 to 86), median Charlson comorbidity score 4 (range 1 to 11) and median length of stay 1 day (range 1 to 14). Median followup was 604 days (range 177 to 1,172, mean 634). There were no perioperative mortalities. A total of 11 (27%) minor and 6 (14.6%) major complications occurred.nnnCONCLUSIONSnComplications from endoscopic minimally invasive lymphadenectomy have low clinical morbidity. Analysis of the immediate and long-term complication profile using standardized Clavien complications reporting reveals that this procedure is safe, even in patients with a high Charlson comorbidity score and body mass index. Major complications were most often infection requiring intravenous antibiotics.

Exercise is Associated with Better Erectile Function in Men Under 40 as Evaluated by the International Index of Erectile Function

INTRODUCTIONnStudies have shown an association between erectile dysfunction and sedentary lifestyle in middle-aged men, with a direct correlation between increased physical activity and improved erectile function. Whether or not this relationship is present in young, healthy men has yet to be demonstrated.nnnAIMnThe aim of this study was to assess the association between physical activity and erectile function in young, healthy men.nnnMAIN OUTCOME MEASURESnThe primary end points for our study were: (i) differences in baseline scores of greater than one point per question for the International Index of Erectile Function (IIEF); (ii) differences in baseline scores of greater than one point per question for each domain of the IIEF; (iii) exercise energy expenditure; and (iv) predictors of dysfunction as seen on the IIEF.nnnMETHODSnThe participants were men between the ages of 18 and 40 years old at an academic urology practice. Patients self-administered the Paffenbarger Physical Activity Questionnaire and the IIEF. Patients were stratified by physical activity into two groups: a sedentary group (≤1,400 calories/week) and an active group (>1,400 calories/week). Men presenting for the primary reason of erectile dysfunction or Peyronies disease were excluded.nnnRESULTSnSeventy-eight patients had complete information in this study: 27 patients (34.6%) in the sedentary group (≤1,400 kcal/week) and 51 patients (65.4%) in the active group (>1,400 kcal/week). Sedentary lifestyle was associated with increased dysfunction in the following domains of the IIEF: erectile function (44.4% vs. 21.6%, P = 0.04), orgasm function (44.4% vs. 17.7%, P = 0.01), intercourse satisfaction (59.3% vs. 35.3%, P = 0.04), and overall satisfaction (63.0% vs. 35.3%, P = 0.02). There was a trend toward more dysfunction in the sedentary group for total score on the IIEF (44.4% vs. 23.5%, P = 0.057), while sexual desire domain scores were similar in both groups (51.9% vs. 41.2%, P = 0.37).nnnCONCLUSIONSnWe have demonstrated that increased physical activity is associated with better sexual function measured by a validated questionnaire in a young, healthy population. Further studies are needed on the long-term effects of exercise, or lack thereof, on erectile function as these men age.

Stage IV Prostate Cancer: Survival Differences in Clinical T4, Nodal and Metastatic Disease

PURPOSEnIn the prostate specific antigen era most prostate cancer presents at an early stage. However, a significant number of patients have advanced disease, including those with stage IV disease. Assignment to stage IV prostate cancer may occur by different modes, namely as T4N0M0 vs N1 vs M1 disease. We hypothesize that patients with clinical T4 disease have better outcomes than those with N1 or M1 disease.nnnMATERIALS AND METHODSnA total of 17 SEER registries were queried from 1995 through 2003. Multivariate and univariate analyses examined overall survival and prostate cancer specific survival across subcategories of stage IV disease while controlling for various patient and disease related characteristics.nnnRESULTSnThere were 615 patients with cT4N0M0 disease, 3,189 with TxN1M0 and 10,893 with TxNxM1 who met the study inclusion criteria. Survival differences were observed between cT4N0M0 and M1 cancer, between N1 and M1 disease, and were most pronounced in younger patients (age 50 years or younger), gradually narrowing with increasing patient age. Factors that demonstrated significant association with poor survival included higher tumor grade, unknown tumor grade and absence of a spouse.nnnCONCLUSIONSnStaging systems based on American Joint Committee on Cancer/TNM staging enables the grouping of patients into homogenous categories for treatment selection and prognostication. However, our data suggest that not all stage IV prostate cancers behave similarly. The difference in survival among locally advanced (T4), node positive and distantly metastatic stage IV prostate cancer appears to be dependent on patient age.

Increased Low Density Lipoprotein and Increased Likelihood of Positive Prostate Biopsy in Black Americans

PURPOSEnDifferences in prostate cancer incidence, grade and stage at diagnosis, and survival in black vs nonblack men are well documented. Recent studies indicate that lipids may have a role in oncogenesis, including that of prostate cancer. We investigated the relationship between circulating lipids in black and nonblack patients, and newly diagnosed prostate cancer.nnnMATERIALS AND METHODSnThe study population included consecutive patients who underwent prostate biopsy for increased prostate specific antigen and/or abnormal digital rectal examination at Atlanta Veterans Affairs Medical Center. Age, race, prostate specific antigen, prostate volume, body mass index, family history, high and low density lipoprotein, triglyceride and cholesterol lowering medications were included in data analysis.nnnRESULTSnA total of 1,775 men with complete information were included in data analysis. A total of 521 black and 451 white men had positive biopsies. Using 100 mg/dl or less as the referent the adjusted OR reflecting the association of low density lipoprotein and prostate cancer diagnosis in black men was 1.49 (95% CI 1.04-2.13, p = 0.031), 1.51 (95% CI 0.96-2.39, p = 0.076) and 3.24 (95% CI 1.59-6.92, p = 0.002) for low density lipoprotein greater than 100 to 130, greater than 130 to 160 and greater than 160 mg/dl, respectively. Corresponding results in nonblack men showed no significant association.nnnCONCLUSIONSnIncreased serum low density lipoprotein is associated with an increased likelihood of prostate cancer diagnosis in black men but not in nonblack men. This association is strongest in the highest low density lipoprotein risk category. The reasons for the racial differences are unknown but may include genetic, dietary or other environmental factors.

Tubulocystic Carcinoma of the Kidney: A Case Report of Natural History and Long-Term Follow-Up

Tubulocystic carcinoma (TC) is a rare primary renal tumor that has been recently described in the pathology literature. Formerly termed low-grade collecting duct carcinoma, further molecular analysis has shown TC to be a distinct entity that is separate from the more aggressive collecting duct carcinoma. Previous series have described the microscopic and immunohistochemical features of this tumor. We describe the natural history of this tumor in a patient who was followed with active surveillance for several years and then underwent partial nephrectomy. Long-term follow-up has shown no evidence of disease. A review of the pertinent literature is performed.

Longer Time to Peak Flow Predicts Better Arterial Flow Parameters on Penile Doppler Ultrasound

OBJECTIVESnTo review the associations between measured variables in Penile Doppler ultrasound procedures. Penile Doppler ultrasound is useful in the evaluation of erectile dysfunction, but there is no uniform standard of performing the procedure. It is generally believed that a peak systolic velocity > 30 cm/s, minimal venous leak, and resistive index > 0.8 are essential for adequate erection. While the arterial parameters are well studied, data on the predictive value of time to peak flow are lacking.nnnMETHODSnPenile duplex Doppler ultrasounds performed for either erectile dysfunction or Peyronies disease evaluation were reviewed. Clinical records, International Index of Erectile Function scores, and ultrasound variables were examined. Fast responders reached maximal peak systolic velocity (PSV) < or = 10 minutes, whereas slow responders reached maximal PSV between 15 and 25 minutes.nnnRESULTSnOf 146 total patients, 36 (25%) were fast responders and 110 (75%), slow responders. No preprocedural characteristics, including the Erectile Function domain score of the International Index of Erectile Function, predicted time to peak flow. Compared with the fast responders, slow responders had higher mean PSV (left: 33.9 +/- 19.5 vs 25.0 +/- 11.7 cm/s, P = .01; and right: 36.4 +/- 21.3 vs 25.0 +/- 13.3 cm/s, P = .002). There was also a higher percentage of patients with average PSV > 30 cm/s in slow responders (58% vs 36%, P = .02).nnnCONCLUSIONSnThere were no significant differences in baseline characteristics between slow and fast responders. However, slow responders did seem to have significantly better arterial flow parameters, although penile dimensions, cavernosal artery diameter, Erectile Function domain scores, and subjective rigidity were similar.

Partial ureteral quadruplication with contralateral multicystic dysplastic kidney.

Ureteral quadruplication is a rare congenital anomaly of the urinary tract that is associated with other genitourinary malformations. Few cases have been reported worldwide, the majority being described in children. We report the first known case associated with contralateral multicystic dysplastic kidney.

An Unusual Presentation of a Mixed Epithelial and Stromal Tumor in an Elderly Male

Mixed epithelial and stromal tumors (MESTs) of the kidney are rare renal neoplasms characterized by mixed cystic and solid components. These tumors are typically present in middle-aged women as a flank mass, or as a cause of flank pain or hematuria. We outline the case of an older male who presented with an enlarging abdominal mass causing symptoms that suggested a partial small bowel obstruction. Management of the patient and a brief review are discussed.