Mary E. Westerman

Heavy Testosterone Use Among Bodybuilders: An Uncommon Cohort of Illicit Substance Users.

OBJECTIVE To identify and characterize patterns of use among a contemporary cohort of current anabolic-androgenic steroid (AAS) users. PATIENTS AND METHODS An anonymous, self-administered, 49-item questionnaire was posted on message boards of Internet websites popular among AAS users and administered via SurveyMonkey from February 1, 2015, to June 1, 2015. Thirty-seven questions were analyzed for this study. RESULTS A total of 231 male respondents met the inclusion criteria. Most were white, were older than 25 years, were employed with above average income, and had received a formal education beyond high school. Ninety-three percent began using AAS after the age of 18 years, and 81% reported using 400 mg or more of testosterone per week. Factors associated with longer duration of use (>5 years) included higher incomes (≥

Are We Using the Best Tumor Size Cut-Points for Renal Cell Carcinoma Staging?

75,000, P=.003), increased testosterone dosages (>600 mg per week, P=.007), older age (≥35 years, P<.001), being married (P<.001), and being self-employed (P<.001). The Internet was the most common source of testosterone (53%). Ninety-three percent used at least one additional performance-enhancing drug. Seventy-seven percent had routine laboratory tests performed, and 38% reported laboratory abnormalities at some point. Nearly all experienced subjective adverse effects while using and not using testosterone. Fifty-three percent reported use of other illegal substances, most commonly (90%) beginning before AAS initiation. Ten percent had a criminal conviction, 91% of which preceded AAS use. Fifty percent were felonies. CONCLUSION The population of AAS users is disparate from that of other drugs of abuse. Laboratory test abnormalities and adverse effects are common and should be taken into account when counseling patients who may be using AASs.

Three-dimensional Printing for Renal Cancer and Surgical Planning

OBJECTIVE To compare the predictive ability for oncologic outcomes among current tumor size cut-points and clinically relevant alternatives to determine which are optimal. METHODS Patients who underwent radical or partial nephrectomy between 1970 and 2010 for T1-2Nx/N0M0 renal cell carcinoma (RCC) were identified. Associations between tumor size and progression-free survival (PFS) and cancer-specific survival (CSS) were evaluated using Kaplan-Meier analyses and Cox models. Predictive ability was assessed using c-indexes. RESULTS The cohort included 3304 patients with a median age of 63 years (interquartile range 53, 70). Median follow-up among survivors was 9.9 years (interquartile range 6.9, 14.3). There were 536 patients who progressed and 354 who died from RCC. For RCC tumors ≤3.0 cm, 10-year PFS and CSS rates were 93%-95% and 97%-99%, respectively. For tumors >3.0-4.0 cm, PFS and CSS began to decline (91% and 95%, respectively), with further gradual declines in PFS and CSS with increasing tumor size. Plots of hazard ratios for progression and RCC death as a function of tumor size did not reveal major inflection points. Differences in discrimination based on various combinations of tumor-size cut-points for progression or RCC death were small, with c-indexes ranging between 0.691-0.704 and 0.734-0.750, respectively. CONCLUSION RCC tumors ≤3.0 cm in size are associated with favorable outcomes. Thereafter, risks of progression and RCC death increase gradually with tumor size, with no compelling biological reason to endorse a given cut-point over another.

Malignant ureteroenteric anastomotic stricture following radical cystectomy with urinary diversion: Patterns, risk factors, and outcomes

Three-dimensional (3D) stereolithographic models provide tactile and anatomic information that offers advantages over digital 3D reconstructions alone. This technology has the potential to alter preoperative surgical planning and significantly enhance successful performance of complex nephron-sparing surgery.

Media reporting of ProtecT: A disconnect in information dissemination?

OBJECTIVE The development of a ureteroenteric anastomotic (UEA) stricture has been reported in up to 15% of patients undergoing radical cystectomy (RC) with urinary diversion. Although benign strictures are thought to be the result of ischemia, the incidence, risk factors, and outcomes of patients with malignant UEA strictures have not been well described. MATERIAL AND METHODS We reviewed 2,523 patients treated with RC for bladder cancer from 1980 to 2012 at Mayo Clinic. Patients diagnosed with a UEA stricture following the surgery were identified, and a subset with malignant UEA was then analyzed. Cox proportional hazard regression models were performed to evaluate factors associated with the diagnosis of malignant UEA. Survival was assessed using the Kaplan-Meier method. RESULTS At a median of 10.5 years of follow-up, 232 (9.2%) patients were diagnosed with UEA stricture, of which 38 (16.4%) had malignant strictures (MS). Median time from RC to the diagnosis of a malignant vs. benign UEA stricture was 32.4 months and 7.2 months, respectively (P = 0.004). Pathologic non-muscle-invasive disease stage at RC was more common among patients diagnosed with a MS compared with patients who did not develop a MS (71.1% vs. 45.9%; P = 0.002). The presence of carcinoma in situ on initial ureteral margin at RC was associated with a significantly increased risk of subsequent diagnosis (hazard ratio = 4.1; P<0.001). Following malignant stricture diagnosis, 2- and 5-year cancer-specific survival was 50% and 30%, respectively, whereas overall survival was 44% and 23%, respectively. CONCLUSIONS MS are uncommon after RC, and present later than benign strictures. Ureteral margin involvement with carcinoma in situ was associated with a significantly increased risk of MS diagnosis.

The Effect of Anticoagulation on Bleeding-related Complications Following Ureteroscopy

Background:Given the central role of the media in disseminating information to the public, we analyzed news coverage of the recent publication from ProtecT to assess views on treatment, the level of detail presented and degree of bias.Methods:We applied a predefined search strategy to identify all news articles reporting on ProtecT within 30 days of its publication. Articles were independently assessed by two urologists and two lay persons using five-point Likert scales. Descriptive statistics and analysis of variance were used.Results:Of 33 unique articles identified, 20 (61%) conveyed negative views on definitive treatment for localized prostate cancer (PCa), while 29 (88%) expressed favorable views of active surveillance/monitoring (AM). Nevertheless, fewer than half of the articles described what AM entails (n=15; 46%) or the rate of treatment in the AM arm (n=12; 36%). Moreover, while 32 (97%) articles highlighted the absence of a difference in cancer-specific mortality at 10 years, only 17 (52%) mentioned the need for longer follow-up. A total of 17 (52%) articles had a notable degree of perceived bias (⩾4/5 on Likert scale), with shorter articles (P=0.02), articles covering few content areas (P=0.03) and articles that did not detail what AM entails (P=0.003) containing significantly increased bias.Conclusions:The majority of news articles regarding ProtecT presented an adverse view of definitive treatment for localized PCa relative to AM, but failed to highlight key nuances of the trial. Healthcare professionals and the lay public should be cautious in acquiring medical news through the general media. Additionally, the urologic community must continue to improve the quality of disseminated information, for example, through proactively engaging with the media, through social media and/or through participation in continuing education lecture series, so as to guide the knowledge translation process, especially upon publication of such potentially influential studies.

Ectopic Penile Prosthesis Reservoir Placement: An Anatomic Cadaver Model of the High Submuscular Technique.

OBJECTIVE To analyze bleeding-related complications among patients on long-term anticoagulation (AC) undergoing ureteroscopy (URS). Current American Urological Association/International Consultation on Urological Diseases guidelines state that it is safe to continue AC in routine URS; however, these recommendations are based on small case series. PATIENTS AND METHODS There were 4799 identified URS procedures performed at our institution between June 2009 and February 2016. Records were then retrospectively reviewed to confirm AC use and identify periprocedural complications. Anticoagulant agents evaluated included warfarin, enoxaparin, and non-vitamin K antagonists (ie, rivaroxaban, dabigatran, apibaxan). Patients were excluded if they were taking a concurrent antiplatelet (AP) agent or if additional non-URS procedures were performed. RESULTS Of the 4799 URS procedures, 272 (5.6%) were done on patients taking chronic AC. Of these, 193 (71%) held AC, 53 (19%) were bridged with enoxaparin, and 26 (10%) continued AC. The median age was 70.2 years and the majority of patients (64.2%) underwent a stone procedure with a stone-free rate of 73%. The overall bleeding-related complication rate was 8.1% whereas the significant bleeding-related event rate was 5.9%. Patients continuing AC had the highest significant bleeding-related event rate at 15.4% compared to 9% and 3% for those bridged with enoxaparin and those who held, respectively (P = .01). CONCLUSION Continuation or bridging of AC may increase the risk of perioperative bleeding. The risks and benefits of proceeding with URS on AC must be weighed carefully. Pending external validation, this information may be used for patient counseling and risk stratification.