Nitya Abraham

The Population Level Prevalence and Correlates of Appropriate and Inappropriate Imaging to Stage Incident Prostate Cancer in the Medicare Population

PURPOSE According to guidelines most men with incident prostate cancer do not require staging imaging. We determined the population level prevalence and correlates of appropriate and inappropriate imaging in this cohort. MATERIALS AND METHODS We performed a cross-sectional study of men 66 to 85 years old who were diagnosed with prostate cancer in 2004 and 2005 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. Low risk (no prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or clinical stage greater than T2) and high risk (1 or more of those features) groups were formed. Inappropriate imaging was defined as any imaging for men at low risk and appropriate imaging was defined as bone scan for men at high risk as well as pelvic imaging as appropriate. Logistic regression modeled imaging in each group. RESULTS Of 18,491 men at low risk 45% received inappropriate imaging while only 66% of 10,562 at high risk received appropriate imaging. For patients at low risk inappropriate imaging was associated with increasing clinical stage (T2 vs T1 OR 1.35, 95% CI 1.27-1.44), higher Gleason score (7 vs less than 7 OR 1.80, 95% CI 1.69-1.92), increasing age and comorbidity as well as decreasing education. Appropriate imaging for men at high risk was associated with lower stage (T4, T3 and T2 vs T1 OR 0.63, 95% CI 0.48-0.82, OR 0.67, 95% CI 0.60-0.80 and OR 0.87, 95% CI 0.80-0.86) and with higher Gleason score (greater than 8 and 7 vs less than 7 OR 2.18, 95% CI 1.92-2.48 and 1.51, 95% CI 1.35-1.70, respectively) as well as with younger age, white race, higher income, lower stage and more comorbidity. CONCLUSIONS We found poor adherence to imaging guidelines for men with incident prostate cancer. Understanding the patterns by which clinicians use imaging for prostate cancer should guide educational efforts as well as research to suggest evidence-based guideline improvements.

Patient Centered Outcomes in Prostate Cancer Treatment: Predictors of Satisfaction Up to 2 Years After Open Radical Retropubic Prostatectomy

PURPOSE Few groups have examined satisfaction after prostate cancer treatment. We determined 1) predictors of satisfaction between 3 months and 2 years after open radical retropubic prostatectomy, and 2) whether these factors are time dependent. MATERIALS AND METHODS This prospective cohort study included 1,542 men who underwent radical retropubic prostatectomy from October 2000 to July 2008. The primary outcome was satisfaction self-assessed at 3, 6, 12 and 24 months. We used multivariate logistic regression and repeated measures analysis to determine predictors of satisfaction, adjusting for demographic and clinical characteristics. RESULTS Median followup was 24 months. About 93% of the men were satisfied. On multivariate analysis men were significantly less satisfied at 3 months when the urinary catheter was indwelling for 3 weeks or greater (OR 0.23, 95% CI 0.10-0.54), or they required intervention for anastomotic stricture (OR 0.23, 95% CI 0.11-0.49) or experienced 4-point or greater worsening in American Urological Association symptom score (OR 0.26, 95% CI 0.13-0.49). At 6 months worsening urinary function (OR 0.34, 95% CI 0.13-0.88) and biochemical failure (OR 0.15, 95% CI 0.05-0.43) were significantly associated with satisfaction. Worsening sexual function became significant at 12 and 24 months. These associations were confirmed on repeated measures analysis. CONCLUSIONS Most men were satisfied after radical retropubic prostatectomy. Satisfaction determinants showed a nonsignificant trend toward time dependence. Postoperative factors, such as the duration of indwelling Foley catheterization, were associated with short-term satisfaction while sexual and urinary function, and biochemical failure were associated with long-term satisfaction. Based on high satisfaction rates open radical retropubic prostatectomy is an excellent treatment for prostate cancer.

Patterns of repeat prostate biopsy in contemporary clinical practice.

PURPOSE The objectives of this study were to 1) describe the patterns of repeat prostate biopsy in men with a previous negative biopsy and 2) identify predictors of prostate cancer diagnosis on repeat biopsy in these men. MATERIALS AND METHODS From a university faculty group practice we identified 1,837 men who underwent prostate biopsy between January 1, 1995 and January 1, 2010. Characteristics of repeat biopsy were examined, including the indication for biopsy, the number of repeat biopsies performed, the number of cores obtained and total prostate specific antigen before biopsy. Features of prostate cancer diagnosed on repeat biopsy were examined, including Gleason score, number of positive cores, percent of tumor and treatment choice. Multivariable logistic regression was done to identify prostate cancer predictors. RESULTS Initial biopsy was negative in 1,213 men. In 255 men a total of 798 repeat biopsies were performed. Of the 63 men diagnosed with prostate cancer Gleason score was 6 or less in 33 (52%), 7 in 22 (35%) and 8-9 in 8 (13%). When categorized by Epstein criteria, the rate of clinically insignificant cancer diagnosis decreased substantially by the third and fourth repeat biopsies. Repeat biopsy in men older than 70 years, biopsies including more than 20 cores and the fourth repeat biopsy were associated with an increased likelihood of prostate cancer diagnosis. CONCLUSIONS In men selected for multiple repeat biopsies clinically significant cancer is found at each sampling round. Given the continued likelihood of cancer detection even by the fifth biopsy, early consideration of saturation or image guided biopsy may be warranted in the repeat biopsy population.

An update on the pharmacotherapy for lower urinary tract dysfunction

Introduction: The lower urinary tract (LUT) stores and evacuates urine. It is controlled by autonomic, somatic and sensory innervation. Pharmacotherapy has been developed to optimize neural control of the LUT in pathologic states. Areas covered: The bladder can be overactive or underactive. For overactive bladder, medications targeting various receptors include i) antimuscarinics, ii) mixed-action drugs, iii) β-adrenergic receptor agonists and iv) other medications. There is no effective pharmacotherapy for underactive bladder, although medications have been used with limited success, including i) muscarinic receptor agonists, ii) anticholinesterase inhibitors and iii) α-adrenergic receptor antagonists. At the level of the outlet, there can be decreased resistance resulting in stress urinary incontinence (SUI) or increased resistance resulting in bladder outflow obstruction (BOO). The classes of medications for SUI include i) α-adrenergic receptor agonists, ii) β-adrenergic receptor agonists and iii) antidepressants. Medications used to treat BOO include i) α-adrenergic receptor antagonists, ii) 5-α reductase inhibitors, iii) benzodiazepines, iv) baclofen and v) PDE inhibitors. Expert opinion: Pharmacotherapy for the LUT must be individualized based on degree of bother, medication side-effect profile, concomitant comorbidities, current medication regimen, and insurance coverage. This review describes current medical therapies for the LUT.

Addressing challenges in underactive bladder: recommendations and insights from the Congress on Underactive Bladder (CURE-UAB)

Underactive bladder (UAB) is an expanding troublesome health issue, exerting a major influence on the health and independence of older people with a disproportionally low level of attention received. The 2nd International Congress on Underactive Bladder (CURE-UAB 2) convened in Denver, CO on December 3 and 4, 2015, and comprised of top clinicians, scientists, and other stakeholders to address the challenges in UAB. A series of workshops aimed to define UAB and its phenotype, define detrusor underactivity (DU) and create a subtyping of DU, evaluate existing animal models for DU, and lastly to establish research priorities for UAB.

Incidence of adverse events after high doses of onabotulinumtoxina for multiple indications

OBJECTIVE To determine the occurrence of all treatment-related adverse events (AEs), especially life-threatening AEs, after the injection of a cumulative dose of >360 units of onabotulinumtoxinA for multiple indications (neurogenic detrusor overactivity, lower limb spasticity, and so forth) within a 3-month interval. METHODS This is a retrospective cohort study of patients who received >360 units of onabotulinumtoxinA within a 3-month interval, with at least 1 urologic indication for injection, between January 1, 2002 and January 1, 2013. The rate of treatment-related AE up to 8 days after injection and life-threatening AE up to 90 days after injection was compared between the injection sessions below and exceeding the maximum dosage recommendations. RESULTS Thirteen patients met the study criteria. Eleven were female patients and had a diagnosis of multiple sclerosis. Sixty-five injection sessions involved >360 units of onabotulinumtoxinA administered within a 90-day interval. Median interval between injections was 54 days (interquartile range [IQR], 30-71 days) and median dose administered was 800 units (IQR, 600-1000 units). Seventy injection sessions involved <360 units of onabotulinumtoxinA administered >90 days after prior injection. Median interval between these injections was 113 days (IQR, 97-158 days) and median dose administered was 200 units (IQR, 100-300 units). The maximum cumulative dosage injected was 1900 units (1500 units for lower extremities and 400 units for bladder). This patient did not experience any AE. There was a total of 6 AEs (general and/or extremity weakness or leg pain) that occurred in 4 patients, of a total of 183 injection sessions. These AEs all eventually resolved. There were no life-threatening AEs in either group. CONCLUSION This is the first report of patients receiving >360 cumulative units of onabotulinumtoxinA within a 3-month interval for multiple indications. There were no life-threatening AEs. This study provides preliminary data on administration of high doses of onabotulinumtoxinA for multiple indications.

Laparoscopic Radical Nephrectomy during Pregnancy : Case Report and Review of the Literature

Routine ultrasonography revealed a large, complex renal mass in a 39-year-old pregnant woman. An MRI confirmed a 14.5 x 12 x 17 cm complex renal mass, and laparoscopic nephrectomy was chosen as the management option. During the mid-second trimester, a right laparoscopic nephrectomy was performed. The pathology report noted clear-cell carcinoma with negative margins. The child, delivered without incident, is now more than 2 years old and is developmentally normal. A review of laparoscopy in pregnancy is also presented.

The effect of time to release of an obstructing synthetic mid-urethral sling on repeat surgery for stress urinary incontinence.

The primary objectives were to describe the rate of repeat surgery for stress urinary incontinence (SUI) after release of an obstructing synthetic mid‐urethral sling (MUS) and to evaluate the effect of time from sling placement to sling release on repeat surgery rates. The secondary objective was to assess rates of recurrent and persistent SUI.

Repair of complete urethral disruption due to synthetic sling complication

Introduction and hypothesisUrethral complications due to synthetic midurethral slings are rare. Possible causes may include unrecognized trocar injury, mesh implantation despite recognized injury, mesh contamination leading to inflammation and delayed perforation, and excessive sling tension. There is no consensus as to the surgical management of urethral complications with regard to how much mesh should be excised, whether an interposition flap should be used, and whether a pubovaginal sling should be placed at the time of surgery. The purpose of this video is to present a technique of repairing complete urethral disruption due to a synthetic midurethral sling complication.MethodsIn this video, we demonstrate the steps to perform primary end-to-end urethral reconstruction for repairing complete urethral disruption. Any residual synthetic mesh must first be excised, after which the anastomosis may be completed.ResultsComplete urethral disruption is a rare complication of synthetic midurethral sling surgery that can be repaired primarily with good results. ConclusionsThere is no consensus regarding surgical management of urethral complications caused by synthetic midurethral slings, and thus an individualized approach should be used based on patient presentation and surgeon expertise.

Transvaginal Prolapse Repair

Transvaginal pelvic floor reconstruction can be divided by compartment: anterior repair, posterior repair, and apical repair. Approaches can be restorative, utilizing native tissue to fix defects, compensatory, utilizing biologic or synthetic graft material to fix defects, and obliterative. The presence of prolapse alone is not an indication for treatment. Only symptomatic patients should be treated. The transvaginal approach to pelvic floor reconstruction offers the potential benefits of decreased morbidity, convalescence, and cost compared to the transabdominal approach. However, long-term outcomes can vary and an informed discussion with the patient and consideration of surgeon expertise should guide the approach used for pelvic floor reconstruction.