Unwanaobong Nseyo

Clinical and Microbiological Determinants of Infection After Transrectal Prostate Biopsy

BACKGROUND Increasing numbers of infections following transrectal prostate biopsy (TPB) at our hospital led us to investigate clinical and bacterial risk factors to determine if the colonizing rectal Escherichia coli population is the source. METHODS We performed an observational cohort study of men undergoing TPB (1 January 2010-6 February 2014) at the San Diego Veterans Affairs Medical Center. The primary outcome was clinically significant post-TPB infection. Rectal swabs were collected immediately before the biopsy and cultured selectively for fluoroquinolone-resistant gram-negative bacilli. Fluoroquinolone-resistant clinical and rectal E. coli isolates were compared using phylotyping, pulsed-field gel electrophoresis (PFGE) analysis, sequence typing, and virulence gene profiling. RESULTS Rectal colonization with fluoroquinolone-resistant organisms (98% E. coli) was detected in 121 of 764 subjects (15.8%). Post-TPB infection was more common among fluoroquinolone-resistant-colonized subjects than noncolonized subjects (13/121 [10.7%] vs 8/649 [1.2%]; P < .001). Presence of fluoroquinolone-resistant colonizing E. coli was the most significant host characteristic associated with post-TPB infection (odds ratio, 4.5 [95% confidence interval, 1.2-18.2]; P = .03). Escherichia coli infection isolates (n = 18) did not differ from E. coli rectal culture isolates (n = 68) for any of 49 virulence genes or ST131 status (all P > .05). The rectal and clinical isolates of all 9 men with paired isolates had indistinguishable PFGE patterns and identical antimicrobial susceptibility profiles. CONCLUSIONS The rectal colonizing E. coli population is the source for most fluoroquinolone-resistant post-TPB infections, regardless of clonal background or virulence traits. Screening cultures can identify nearly all patients at risk for fluoroquinolone-resistant post-TPB infection.

Resolution rate of isolated low-grade hydronephrosis diagnosed within the first year of life

OBJECTIVE Diagnosis of low-grade hydronephrosis often occurs prenatally, during evaluation after urinary tract infection (UTI), or imaging for non-urologic reasons within the first year of life. Its significance in terms of resolution, need for antibiotic prophylaxis, or progression to surgery remains uncertain. We hypothesized that isolated low-grade hydronephrosis in this population frequently resolves, UTIs are infrequent, and progression to surgical intervention is minimal. PATIENTS AND METHODS Children < 12 months old diagnosed hydronephrosis (Society for Fetal Urology [SFU] grade 1 or 2) between January 2004 and December 2009 were identified by ICD9 code. Patients with other urological abnormalities were excluded. Stability of hydronephrosis, UTI (≥ 100,000 CFU/mL bacterial growth) or need for surgical intervention was noted. RESULTS Of 1496 infants with hydronephrosis, 416 (623 renal units) met inclusion criteria. Of 398 renal units with grade 1 hydronephrosis, 385 (96.7%) resolved or remained stable. Only 13 (3.3%) worsened, of which one underwent ureteroneocystostomy. Of 225 renal units with grade 2 hydronephrosis, 222 (98.7%) resolved, improved or remained stable, three (1.3%) worsened, of which one required pyeloplasty. Only 0.7% of patients in the ambulatory setting had a febrile UTI. CONCLUSIONS Low-grade hydronephrosis diagnosed within the first year of life remains stable or improves in 97.4% of renal units. Given the low rate of recurrent UTI in the ambulatory setting, antibiotic prophylaxis has a limited role in management.

Long-Term Complications of the Neurogenic Bladder

It is widely accepted that neurogenic lower urinary tract dysfunction, when left untreated, has a natural history that has a potential for causing deterioration of renal function over time. However, certain patient profiles are at risk for this and other complications. This can be linked to their underlying neurologic disease process. Identifying risk profiles allows the provider to determine what surveillance strategies might be adopted. Risk factors for upper urinary tract deterioration include loss of bladder compliance, repeated bouts of pyelonephritis, and chronic indwelling catheterization. Other long-term complications include nephrolithiasis, refractory urinary incontinence, and malignancy.

Vasectomy Reversal Surgical Patterns: an Analysis of the American Board of Urology Case Logs

OBJECTIVE To characterize vasectomy reversal practice patterns among American Board of Urology (ABU) certifying urologists. MATERIALS AND METHODS We reviewed the ABU case logs for certifying urologists from 2008 to 2014. Vasectomy reversal procedures were identified by 3 current procedure terminology (CPT) codes: 55400 (vasovasostomy), 54900 (epididymovasostomy, unilateral), and 54901 (epididymovasostomy, bilateral). Demographic data were obtained and reviewed. Multivariate analysis determined the factors influencing the performance of surgical approach. RESULTS There were 5167 urologists who submitted case logs for 2008-2014, and 9.4% (486) had performed at least one vasectomy reversal procedure. General urologists accounted for the highest overall volume of vasectomy reversal procedures. Andrology-trained urologists performed a higher volume of vasovasostomy per surgeon, and bilateral epididymovasostomy constituted a greater portion of their E-V practice. Multivariate analysis demonstrated that being in recertification years, being younger in age, practicing in the South Central, Southeast, and Western regions, and practicing in the largest and smallest practice areas were associated with being more likely to perform a vasectomy reversal procedure. CONCLUSION Microsurgical vasectomy reversals are putatively considered technically challenging and reserved for fellowship-trained urologists, and the majority of vasectomy reversal surgeries were performed by general urologists. Given the known association between microsurgical technique and improved outcomes, greater emphasis should be placed on microsurgical training during urology residency.

Weight Loss Following Radical Cystectomy for Bladder Cancer: Characterization and Effect on Survival

&NA; Weight loss following radical cystectomy for bladder cancer is commonly observed although poorly characterized. The current study investigates the prevalence of postoperative weight loss and its association with mortality in a cohort of patients undergoing radical cystectomy for bladder cancer. Special attention was given to indicators of nutritional status and the potential effect of malnutrition on postoperative outcomes. Introduction: The purpose of this study was to evaluate the prevalence of postoperative weight loss (WL) following radical cystectomy (RC) and its association with mortality. Nutritional status is recognized as a potential modifiable risk factor for postoperative complications following RC for bladder cancer. The American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics recognize WL as a diagnostic measure for malnutrition. Methods: Seventy‐one patients underwent RC for bladder cancer between July 2008 and July 2013, in whom peri‐operative weights were documented regularly. The primary predictor variable was substantial WL defined as ≥ 10% WL by postoperative month 1. Survival was estimated using Kaplan‐Meier analysis; logistic regression was used for multivariate analyses. Results: Mean postoperative WL at 2 weeks was 9.5 lbs (−5.2%), 14.3 lbs (−7.8%) at 1 month, 16.9 lbs (−9.0%) at 2 months, 12.6 lbs (−6.9%) at 3 months, and 8.9 lbs (−4.6%) at 4 months. Forty‐two percent of patients met criteria for substantial WL. At 19 months median follow‐up, the overall mortality rate was 31% (22 of 71), which rose to 64% (14 of 22) in patients who experienced substantial WL (P < .05). Substantial WL trended towards significance on multivariate analysis (P = .07). There was a significant decrease in 5‐year survival in patients with ≥ 10% WL (log rank P < .05). Conclusions: Patients experience WL following RC, which may be indicative of malnutrition. Substantial WL may predict for poor overall survival. Prospective studies are needed to determine whether nutritional optimization can prevent significant WL and improve outcomes.

FRI-17 “WALK LIKE A MAN”: SEX TESTING AND FEMALE GENDER IDENTITY IN INTERNATIONAL ATHLETIC COMPETITION

radiation hazards to astronauts and pilots in nuclear-powered aircrafts, troops in the fields, and workers in nuclear plants. This became the context for two controversial experiments on the effects of x-ray irradiation on male fertility using human prison inmates. The objective of this study is to review the science and ethics of the medical experimentation on prisoners. METHODS: We reviewed primary scientific literature on the two radiation experiments and secondary sources from legal journals and government investigations. RESULTS: Between 1963 to 1973, the Atomic Energy Commission sponsored two studies on the effects of x-ray irradiation on human testicular function using healthy prison inmates at the Washington and the Oregon State Penitentiary. The studies enrolled a total of 165 prisoners who received exposure of 7.5 to 600 rad of radiation to the testes. Inmates in both control and exposure groups underwent period testicular biopsies and weekly seminal fluid examinations to determine the radiation dose that causes azoospermia or complete sterility. Both studies found a transient complete elimination of sperm production at 50 rad. However, at as high as 400 rad exposure, significant return of sperm production was invariably seen. All men were encouraged to undergo vasectomy at the end of the study to prevent possibility of defective offspring; however, eight men refused and some went on to have children with genetic defects. Both studies would have been in violation of federal regulation on permissible medical research in prison population as they exist today. Major ethical issues include coercion and exploitation of prison subjects, informed consent, and financial incentives. Prisoners were not properly counseled on risk of testicular cancer from radiation, in fact, the term cancer was deliberately avoided in the informed consent process. CONCLUSIONS: The Washington and Oregon prison experiments on radiation effects on male spermatogenesis and fertility confirmed profound effect of radiation on testicular function. The result of the studies formed the basis of current limit of radiation exposure and occupation hazard regulation. These two experiments are important case studies not only for their contribution to the urologic knowledge but also for highlighting the interface between science and ethics.

V5-11 ROBOTIC SIMPLE PROSTATECTOMY: THE RETROPUBIC APPROACH

RESULTS: After initial inspection of the bladder demonstrated asymptomatic ureteroceles, an incision was made at the bladder neck and carried to the depth of the surgical capsule distally to the verumontanum. The lateral dissection expresses purulence almost immediately and a large abscess pocket is encountered during the anterior dissection. The remainder of the enucleation is performed without complication. The patient was spontaneously voiding by POD 2 and discharged with IV antibiotics for 6 weeks to treat his osteomyelitis. CONCLUSIONS: Holmium laser enucleation of a prostatic abscess can be performed safely and effectively to both maximally reduce the abscess cavity and risk of excessive thermal injury when treating an apically located abscess.

MP43-07 CLINICAL UTILITY OF MRI/FUSION BIOPSY IN PROSTATE CANCER PATIENTS ON ACTIVE SURVEILLANCE

INTRODUCTION AND OBJECTIVES: The role of magnetic resonance imaging (MRI)/fusion biopsy for prostate cancer patients on active surveillance (AS) remains unclear. METHODS: We compared MRI/fusion guided targeted biopsy (TB) to standard ultrasound-guided systematic biopsy (SB) for detection of clinically significant cancer in AS patients undergoing confirmatory biopsy. The primary outcome was upgrading defined as detection of Gleason sum 3 + 4 1⁄47 disease. RESULTS: Of 356 AS patients at our institution, 195 (58%) underwent prostate MRI after the initial diagnostic biopsy. Of these, 138 (71%) had MRI-detectable lesions. After implementation of TB in May 2014, 42 AS patients underwent confirmatory MRI/fusion TB: n1⁄49 (21.4%), n1⁄419 (45.2%), n1⁄47 (16.7%), and n1⁄47 (16.7%) with PI-RADS 2, 3, 4, and 5 lesions, respectively. Compared to SB patients undergoing confirmatory biopsy (n1⁄4106), TB patients had higher PSA (5.3 ng/ mL versus 3.5 ng/mL, p<0.001) and modestly higher PSA density (0.14 versus 0.09, p1⁄40.01). There were no significant differences in age (0.29), BMI (p1⁄40.21), family history (p1⁄40.1.0), comorbid diseases (p1⁄40.26-1.0), number of prior biopsies (p1⁄40.167), or time since cancer diagnosis (p1⁄40.58). Gleason sum 3 + 4 1⁄4 7 was diagnosed in 30 (29%) SB patients and 16 (38%) TB patients (p1⁄40.33). Stratification by PI-RADS revealed Gleason 3 + 4 1⁄4 7 diagnosis in 0 (0%), 4 (21%), 6 (86%) and 6 (86%) of PI-RADS 2, 3, 4, and 5 lesions, respectively (p<0.001). Compared to SB, TB of PI-RADS 4 lesions detected 58% more Gleason 3 + 4 1⁄4 7 cancers (86% versus 28%, p<0.0001) and was associated with increased odd of upgrading in multivariable regression (p1⁄40.012). The positive predictive value (PPV) of PI-RADS 4 lesions for Gleason 3 + 4 1⁄4 7 disease was 86%. Sensitivity analyses of patients with only 1 biopsy prior to confirmatory biopsy produced similar results. CONCLUSIONS: A majority of patients on AS have MRIdetectable lesions. Compared to SB, selective TB of PI-RADS 4 and 5 lesions improves the detection of clinically significant cancers in those undergoing confirmatory biopsy.

PD73-07 ANALYSIS OF RISK FACTORS ASSOCIATED WITH INFECTIONS COMPLICATIONS FOLLOWING PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: The duration of renal ischemia is the largest modifiable risk factor during partial nephrectomy. The shorter the warm ischemia time during LPN the lower the effect on long-term renal function. Real advantages of offclamping LPN compared with clamping surgery are not yet sufficiently studied. Few studies reported results of off-clamping LPN for high RENAL score cases. We compared Trifecta outcomes of the LPN with and without clamping stratifying cases through nephrometric RENAL score. METHODS: A total of 109 cases classified as low-complexity (54), intermediate-complexity (33) and high-complexity (22) underwent clamping (55) or off-clamping (54) laparoscopic partial nephrectomy and were compared in each group (clamping x off-clamping LPN). Clamping technique was performed with cold scissors intended to obtain 0.5cm of free surgical margins. Off-clamp technique was performed with harmonic scalpel close to the plane of enucleating to achieve minimal surgical margins. Renal function was measured at 1, 6 and 12 months postoperatively. All enrolled patients had normal contralateral kidney. Trifecta (Trifecta criteria: Clavien 2, negative-margins, and warm ischemia time 20 min) outcomes were analyzed and compared between the groups stratified by the nephrometric RENAL score. RESULTS: Trifecta achievement was similar in both groups for low complexity tumors (p < 0.31). The off-clamping group achieved higher trifecta rates for the intermediate (87.5% x 23.5%, p < 0.001) and high (83% x 0%, p < 0.005) complexity tumors. Patients with off-clamp technique had higher mean blood loss (150 X 400 ml) with no difference in blood transfusions. In the clamping group, significant higher proportion did not achieve trifecta (45.5% x 7.4%, p < 0.001). After 1 year, the difference of remnant renal function was 10% more for patients with off clamp surgery with high complexity RENAL score CONCLUSIONS: Off-clamping pure LPN was associated to accomplish higher trifecta rates for intermediate and high complexity RENAL score tumors. Long-term renal function was slightly better for off clamp group. It is unclear if off-clamp technique or differences in the amount resected of renal parenchyma were responsible for observed differences.