William I. Jaffe

Pelvic Anatomy on Preoperative Magnetic Resonance Imaging Can Predict Early Continence After Robot-Assisted Radical Prostatectomy

BACKGROUND AND PURPOSE Postoperative incontinence is multifactorial after radical prostatectomy. Using endorectal coil MRI, we examined features of the male urethra and accompanying muscular sphincter to predict continence after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS 80 patients underwent preoperative 1.5 Tesla endorectal coil MRI. Urethral length was measured in the coronal plane. All patients underwent RARP. Questionnaires were completed by patients at monthly intervals. The primary end point was time to continence defined as necessitating 0 to 1 pad per day (PPD). Statistical analysis was performed using Cox regression models to create both univariate and multivariate survival models. RESULTS Mean age was 59.7 (standard deviation [SD] 7.1); 98% had bilateral nerve sparing. Mean urethral length was 17.1 mm (SD 4.5 mm). Mean prostate size was 34.7 g (SD 17.8). By 3 months, 60 patients achieved 1 PPD (mean 8.1 weeks, SD 9.4) and 34 patients achieved 0 PPD (mean 10.5 weeks, SD 8.0). Time to social continence was significantly related to prostate size both as a continuous variable (P=0.01), and as a dichotomized variable of ≥ 50 vs<50 g (P=0.02). Increased urethral length was related to decreased time to continence both as a continuous variable (P=0.06), and when dichotomized to ≥ 20 vs<20 mm (P=0.08). In addition to larger prostate size (hazard ratio [HR] 0.97, P<0.04), older age (0.95 P<0.025) was also associated with a longer time to achieve 0 PPD. Multivariate analysis revealed that longer urethral length was associated with a faster recovery of continence (HR 1.11, P<0.01). After controlling for age and urethral length, patients with a prostate size ≥ 50 g had 75% lower likelihood of achieving continence at all time points when compared with patients with prostate size <50 g (HR 0.25; 95% confidence interval: 0.06, 1.06; P=0.06). CONCLUSIONS Longer urethral length increased the likelihood of achieving continence at all time points postoperatively. Advanced age and larger prostate size were negatively associated with continence outcomes.

Decreasing Electrosurgical Transurethral Resection of the Prostate Surgical Volume During Graduate Medical Education Training is Associated With Increased Surgical Adverse Events

PURPOSE In the United States the numbers of electrosurgical transurethral prostate resection procedures have been decreasing. Since electrosurgical transurethral resection of the prostate is a difficult procedure to master, we hypothesized that recent residents are lacking in training for this procedure. We used summary case log information provided by the Accreditation Council for Graduate Medical Education to determine if the number of electrosurgical transurethral prostate resection procedures performed by graduating chief residents has decreased and if there has been an increase in surgical adverse events. In addition, we investigated whether the increased number of laser procedures impacted the rate of adverse events. MATERIALS AND METHODS Summary operative data from graduating chief resident case logs were provided by the Accreditation Council for Graduate Medical Education for academic years 2001 to 2007. The numbers of electrosurgical transurethral prostate resection procedures, laser procedures and procedures for adverse events were recorded for each year. RESULTS The number of electrosurgical transurethral prostate resection procedures performed by graduating chief residents has steadily decreased from 58 in 2001 to 43 in 2007. Conversely the number of laser procedures started increasing in 2004. The rate of procedures for adverse events as a percentage of electrosurgical transurethral resection of the prostate procedures increased during the study period (from 3% in 2001 to 6% in 2007), and as a percentage of electrosurgical transurethral resection of the prostate and laser procedures the rate increased until 2005 and subsequently started decreasing. CONCLUSIONS The rate of surgical adverse events, as measured by the need for subsequent procedures, has increased during the last 7 years. However, when laser procedures are accounted for, it appears that adverse events have recently started trending down as an increasing number of laser procedures started being performed.

Gunshot wounds to the scrotum: a large single-institutional 20-year experience.

Study Type – Therapy (case series)

OVARIAN TORSION MIMICKING UROLOGICAL DISEASE

Case 1. A 9-year old girl presented with intermittent right lower quadrant pain radiating to the right flank, low grade fever, emesis and dysuria 4 days in duration. Her father had a history of recurrent nephrolithiasis. Physical examination revealed right lower quadrant tenderness to deep palpation without peritoneal signs. Rectal examination was normal. Urinalysis demonstrated calcium oxalate crystals and 5 to 7 red blood cells per high power field. Ultrasonography showed normal kidneys and a 7 x 4 cm. right ovary with cystic components, and blood flow was decreased on a Doppler study. Exploration through a Pfannenstiel incision revealed a necrotic right ovary. The patient underwent oophorectomy and contralateral oophoropexy. Hematuria had resolved by 3 weeks postoperatively. Case 2. A 19-year-old woman presented with acute onset of right lower quadrant and mild right flank pain associated with nausea and vomiting. Episodes of pain lasted up to 30 minutes. Physical examination demonstrated mild right flank and right lower quadrant tenderness without peritoneal signs. Pelvic examination was normal. Urinalysis revealed 5 to 7 red blood cells per high power field. Excretory urography was normal. Pain resolved and the patient left the hospital but she returned within 12 hours with excruciating right lower quadrant pain. Pelvic ultrasound was consistent with ovarian torsion. Laparoscopic right oophorectomy was performed without contralateral oophoropexy. The patient was subsequently lost to followup.

Detrusor overactivity leak point pressure in women with urgency incontinence

Introduction and hypothesisWhen incontinence accompanies detrusor overactivity (DO), the pressure at which it occurs may have important predictive value and should be termed DO leak point pressure (DOLPP).MethodsA retrospective review of our video urodynamics database (n = 222) including validated questionnaires was performed. DOLPP was defined as detrusor pressure the moment DO incontinence occurred. Statistical analysis was performed using Student’s t-test.ResultsWomen with DO leakage (47) and with DO without leakage (15) were analyzed. Urgency and urgency incontinence (UUI) were greater among patients with DO leakage. A link between sphincter deficiency and greater severity of UUI was noted. Among patients with DO leakage, those with subjective mixed incontinence had a lower mean DOLPP than those with pure UUI (p = 0.004). The detrusor pressure at peak flow was lower in the DO leakage group (versus DO alone, p = 0.05) likely reflecting a measure of outlet resistance.ConclusionDOLPP has predictive meaning in women and should be further studied for possible inclusion in standard urodynamic terminology.

Urodynamics in Male LUTS: When Are They Necessary and How Do We Use Them?

In this article, the value of urodynamic studies in the evaluation of treatment of male lower urinary tract symptoms is appraised based on current evidence. The information gained by urodynamics can be a valuable tool for counseling patients considering invasive outlet reduction procedures.

Overactive bladder in the male patient: Epidemiology, etiology, evaluation, and treatment

The urologist’s approach to the diagnosis and treatment of lower urinary tract symptoms (LUTS) in male patients has changed significantly over the past decade. Advances in the basic science arena combined with a wealth of clinical data have pointed to the importance of bladder pathophysiology in the development of urinary symptoms. Historically, men with LUTS were diagnosed with “prostatism,” an allencompassing term that includes both voiding and storage symptoms that may or may not be related to prostatic obstruction. Parallel to the scientific advances in the field, the urologic lexicon began to evolve and has allowed us to more specifically describe, and therefore investigate and treat, different aspects of male LUTS. It is now well recognized that many men suffer from storage symptoms that may be more related to bladder dysfunction than to prostatic obstruction. It will be critical to integrate our knowledge of prostatic growth and obstruction, the bladder response to outlet obstruction, environmental and lifestyle factors, and age-related changes to fully understand the complex pathophysiology of male LUTS, specifically overactive bladder syndrome.

Primary Seminal Vesicle Adenocarcinoma Presenting With Bilateral Orbital Metastasis: A Case Report

Seminal vesicle (SV) adenocarcinoma is a rare and poorly understood malignancy. Symptoms are non-specific and prognosis is extremely poor. Herein we present a case report of a primary SV clear cell adenocarcinoma with bilateral orbital metastases at the time of initial presentation treated with multimodal therapy including radiotherapy and multi-drug chemotherapy.