Kerrin Palazzi-Churas

Serum sex hormones and the 20‐year risk of lower urinary tract symptoms in community‐dwelling older men

Study Type – Prognosis (inception cohort)
Level of Evidence 2b

The Relationship of Obesity and Gender Prevalence Changes in United States Inpatient Nephrolithiasis

OBJECTIVE To review the Nationwide Inpatient Sample database to examine the relationships between obesity, gender, and nephrolithiasis. Recent reports indicate that the prevalence of nephrolithiasis has been increasing, especially among women. METHODS The Nationwide Inpatient Sample contains data on approximately 20% of hospital stays in the United States. Included in this analysis were discharges with primary diagnosis ICD-9 codes 592.0 (renal calculus) or 592.1 (ureteral calculus), from 1998 through 2003. All raw data were weighted to produce national estimates. Descriptive and inferential statistics were performed to determine changes in nephrolithiasis prevalence and associations of obesity and other comorbidities with nephrolithiasis. RESULTS We reviewed 181,092,957 hospital stays (weighted data). The prevalence of nephrolithiasis was relatively stable: 0.52% (149,302) in 1998 and 0.47% (147,541) in 2003. The prevalence of obesity increased from 3.06% (878,155) to 4.99% (1,575,247). The male:female ratio of patients with stones decreased from 1.6:1 to 1.2:1. Multivariate analysis revealed a statistically significant relationship (OR = 1.22, 95% CI 1.20-1.23, P <.001) between obesity and urinary stones. Obese females were more likely to develop stones than nonobese females (OR = 1.35, 95% CI 1.33-1.37, P <.001). The association between obesity and stones was weaker in males (OR = 1.04, 95% CI 1.02-1.06, P <.001). CONCLUSION In this sample of inpatients, obesity was associated with a significantly increased prevalence of urinary stones. This relationship was stronger in females than in males. Further studies are needed to determine whether weight reduction in obese patients affects urinary stone disease.

Trends in adverse events of benign prostatic hyperplasia (BPH) in the USA, 1998 to 2008

Study Type – Harm (Cohort)

Second Prize: Recurrence Rates After Percutaneous and Laparoscopic Renal Cryoablation of Small Renal Masses: Does the Approach Make a Difference?

BACKGROUND AND PURPOSE As radiologic detection of small renal masses increases, patients are increasingly offered percutaneous renal cryoablation (PRC) or transperitoneal laparoscopic renal cryoablation (TLRC). This multicenter experience compares these approaches. PATIENTS AND METHODS Between September 1998 and May 2010, review of our PRC and TLRC experience was performed. Patients with ≥ 12-month follow-up were included for analysis. Post-treatment surveillance consisted of laboratory studies and imaging at regular intervals. Treatment failure was considered if persistent mass enhancement or interval tumor growth was radiographically evident. Repeated biopsy and re-treatment were recommended in the event of recurrence. RESULTS Sixty-one patients underwent PRC and 84 patients underwent TLRC. No significant differences were noted with respect to demographic factors. Mean tumor size was 2.7 ± 1.1 cm (PRC) and 2.5 ± 0.8 (TLRC) cm (P = 0.090). Mean follow-up was 31.0 ± 15.9 months (PRC) and 42.3 ± 21.2 (TLRC) months (P = 0.008), with local tumor recurrence noted in 10/61 (16.4%) PRC and 5/84 (5.9%) TLRC (P = 0.042). For PRC, disease-free survival (DFS) and overall survival (OS) were 93.7% and 88.9%, respectively, with four patients having evidence of disease at last follow-up. DFS and OS were 91.7% and 89.3% for TLRC, with seven patients having evidence of disease at last follow-up. DFS (P = 0.654) and OS (P = 0.939) were similar. CONCLUSIONS In this multicenter study of well-matched cohorts, PRC had higher primary treatment failure rates than TLRC. While no differences were noted between DFS and OS, analysis is limited by intermediate follow-up. Further study is necessary to discern reasons for the higher recurrence rates in PRC and to determine what long-term consequences exist.

Prospective Study of Serum Dihydrotestosterone and Subsequent Risk of Benign Prostatic Hyperplasia in Community Dwelling Men: The Rancho Bernardo Study

PURPOSE Little is known about midlife serum levels of dihydrotestosterone and other androgens before the onset of clinical benign prostatic hyperplasia in community dwelling older men. MATERIALS AND METHODS We measured sex steroid hormones between 1984 and 1987 in the Rancho Bernardo Study. Between 1992 and 1996 surviving participants were evaluated for benign prostatic hyperplasia at followup clinic visits. Benign prostatic hyperplasia was defined as a history of noncancer prostate surgery or a medical diagnosis of benign prostatic hyperplasia. Regression modeling was used to examine associations of serum hormone measures with benign prostatic hyperplasia. RESULTS In 340 surviving participants with complete data available and no history of prostate cancer or benign prostatic hyperplasia at baseline mean +/- SD age was 64 +/- 9 years and mean followup was 8.4 +/- 0.8 years. Men who reported benign prostatic hyperplasia during followup were older at baseline than those who did not (p <0.001). Higher baseline serum dihydrotestosterone was associated with an increased risk of benign prostatic hyperplasia. The OR for the second, third and fourth quartiles of dihydrotestosterone was 1.83 (95% CI 0.96-3.47), 1.50 (0.79-2.85) and 2.75 (1.46-5.19), respectively (p trend = 0.02). A higher testosterone-to-dihydrotestosterone ratio was associated with a 42% decreased risk of benign prostatic hyperplasia when comparing the top 3 quartiles to the first quartile (OR 0.58, 95% CI 0.35-0.97, p = 0.04). Higher dehydroepiandrosterone was associated with an increased benign prostatic hyperplasia risk (p = 0.05). CONCLUSIONS Community dwelling men show a stepwise increase in benign prostatic hyperplasia risk with higher midlife serum dihydrotestosterone. These data justify investigations of 5alpha-reductase inhibitors for primary prevention of benign prostatic hyperplasia.

Comparison of Laparoendoscopic Single-Site, Conventional Laparoscopic, and Open Nephrectomy in a Pediatric Population

INTRODUCTION We provide a single-institution comparison of open, conventional laparoscopic (CL) and laparoendoscopic single-site (LESS) nephrectomy in children. METHODS We identified all nephrectomy cases occurring at Rady Childrens Hospital from July 2007 to March 2010. Exclusion criteria included redo/bilateral operations, malignancy, transplant nephrectomy, or complex urogenital anomalies. We compared patient demographics, total operative times, estimated blood loss (EBL), length of stay (LOS), complication rates, postoperative pain score, narcotic usage, and total hospital costs. RESULTS We identified 7 LESS, 11 CL, and 8 open nephrectomy patients who met our criteria. The mean age of patients was 8.5, 7.3, and 4.2 years for LESS, CL, and open nephrectomy, respectively (P=.217). Operative times were 192.2, 219.3, and 127.4 minutes for LESS, CL, and open nephrectomy, respectively (P=.076). EBL was 15, 13.2, and 12.5 mL, respectively, for these groups (P=.871). There were no complications in any of the groups, although 1 LESS patient required conversion to open nephrectomy for bleeding. Mean LOS was 46.8, 36.9, and 33.8 hours in the LESS, CL, and open nephrectomy groups (P=.308). Mean pain scores on postoperative day 1 were 2.3, 1.8, and 1.6 in each group, respectively (P=.518). Hospital costs were comparable between the LESS and CL groups. The mean cost for open nephrectomy was 54.4% the mean cost for CL, however (P=.001). CONCLUSIONS LESS nephrectomy in children is safe and overall comparable with CL. In our experience, no modality confers a distinct advantage except for the decreased cost associated with open surgery.

Prostate atypia: Clinical and pathological variables associated with cancer diagnosis on repeat biopsy

The clinical significance of atypical glands suspicious for malignancy (atypia) on prostate biopsy is unclear. We studied a cohort of 139 patients with atypia who underwent repeat prostate biopsy. We analyzed clinical and pathological variables that may be associated with cancer on repeat biopsy. Cancer was diagnosed in 41 (29%) of patients with atypia: 26 of 41 (66%) were Gleason 6, 20% were Gleason 7 and 7% were Gleason 8 (Gleason <6 not reported). There were no significant associations of age, race, family history, PSA, PSA density (PSAd), number of previous biopsies or time to repeat biopsy with cancer diagnosis. In multivariate regression, histological inflammation was associated with an 85% decreased probability of cancer on repeat biopsy (odds ratio; OR 0.15; 95% confidence interval; CI 0.04–0.57; P=0.04). Radical prostatectomy was performed in 14 of 41 (34%) patients with cancer; 6 (43%) were Gleason sum ⩾7, 3 (21%) were pT3a and 1 (7%) had lymph node metastases. In conclusion, inflammation was independently associated with a significantly decreased risk of cancer on repeat biopsy. However, some patients with initial atypia have higher-risk prostate cancer. Additional studies are needed to elucidate these associations.

Robot-assisted laparoscopic radical prostatectomy in men with human immunodeficiency virus

The aim of this study is to evaluate the outcomes of robot-assisted laparoscopic prostatectomy (RALP) in prostate cancer (PCa) patients with human immunodeficiency virus (HIV). This is a prospective cohort study of HIV patients undergoing RALP, comparing the demographics, tumor characteristics, complications, and short-term oncological outcomes of HIV-positive men to HIV-negative men using univariate (χ2, Mann–Whitney test) and multivariable (logistic regression) analyses. From 2007 to 2010, 298 men underwent RALP, 8 of whom were known to be HIV positive. Preoperatively, all eight were taking highly active antiretroviral therapy (HAART) and had undetectable viral loads (<50); mean CD4 count was 634 cells per mm3. HIV-positive men were younger (54 versus 62 years, P=0.010) and less likely to be white (P=0.007). There were no significant differences between groups with respect to clinical staging, pathological and oncological outcomes or most complication rates. However, the prevalence of perioperative transfusions (P=0.031) and ileus (P=0.021) were higher in HIV-positive patients. HIV remained significantly associated with risk of transfusion after adjustment for age, race, Gleason sum and clinical T stage (P=0.002). After a median of 2.6 (range 0.03–19.2) months of follow-up, PSA remained undetectable in all eight HIV patients. These data suggest that RALP is safe for, and demonstrates short-term oncological efficacy in, HIV-positive patients with PCa.

Prostate laser vaporization in men with urinary retention.

Study Type – Therapy (cohort)

1546 PRACTICE PATTERNS FOR INPATIENT URINARY STONE SURGERY IN U.S.

INTRODUCTION AND OBJECTIVES: The increasing prevalence of urinary stone disease has been demonstrated in numerous studies. Understanding differences in urinary stone surgery practice patterns may optimize healthcare, since different surgical techniques have different outcomes. We sought to describe the U.S. inpatient surgical practice patterns for urinary stones and determine what factors predict particular urinary stone surgery. METHODS: We used the NIS (Nationwide Inpatient Sample) database from 1998–2007 to identify 380,531 patients who underwent one of three urinary stone surgeries: percutaneous nephrolithotomy (PNL) ICD-9 55.04, 55.03, 55.21; shock wave lithotripsy (SWL) ICD-9 98.51; ureteroscopy (URS) ICD-9 56.31. Descriptive statistics were used to illustrate surgical frequencies and their potential covariates: demographics, co-morbidities, academic/community hospital, rural/urban location, U.S. geographic region (Northeast, Midwest, South, West), patient income, payer mix, and year. Linear regression illustrated surgical trends over time. Using above covariates, we compared on multi-variate analysis the odds of undergoing SWL to PNL as well as SWL to URS, as these are commonly comparable modalities. RESULTS: URS was the most common procedure (58.9%) with SWL slightly less common (22.4%) and PNL least common (16.9%) among inpatients undergoing urinary stone surgery. Over time, there was a significant increase in the utilization of PNL (p 0.001), SWL remained stable (p 0.213) and ureteroscopy declined (p 0.001). On multivariate analysis SWL was statistically more likely performed than PNL in younger subjects, male subjects, community hospitals, or rural hospitals. On multivariate analysis SWL was statistically more likely performed than URS in older subjects, male subjects, rural hospitals, or if location was South or West. CONCLUSIONS: Trends in inpatient renal stone surgery continue to evolve during the time period of our study with increasing adoption of PNL and decreasing use of ureteroscopy. Age and gender as well as type of hospital and its rural location predict SWL use over PNL, despite the lower efficacy associated with SWL technology. Assuming equal stone size (data not available), further explanation is necessary to reconcile these differences. Similar findings were found in the SWL versus URS analysis, though SWL appeared to have regionalization. Further investigation is necessary to understand causes for the differences inpatient practice patterns and whether outpatient practice patterns share common findings.