William S. Kubricht

Serum testosterone levels in african-american and white men undergoing prostate biopsy

OBJECTIVESnBecause androgen levels are known to influence prostate growth, we performed a prospective analysis of serum testosterone levels in all African-American and white men who underwent transrectal ultrasound-guided prostate biopsies to evaluate an abnormal digital rectal examination (DRE) and/or serum prostate-specific antigen (PSA) level greater than 4 ng/mL.nnnMETHODSnFrom June 1996 through July 1998, we evaluated 453 men (189 African-American and 264 white men) who underwent prostate needle biopsy because of an abnormal DRE or serum PSA greater than 4 ng/mL, or both. All men had morning serum testosterone levels determined just before undergoing prostate needle biopsy. Serum testosterone levels were compared on the basis of the prostate biopsy result (positive or negative for prostate cancer) and by race.nnnRESULTSnA total of 453 men underwent prostate biopsy and had morning serum testosterone levels available for comparison. Of the 264 white men who underwent biopsy, 88 (33%) were found to have prostate cancer compared with 67 (35%) of 189 African-American men who underwent biopsy. In the white men without cancer, the mean serum testosterone level was 380. 19 ng/dL; those with prostate cancer had a mean serum testosterone level of 419.52 ng/dL. The mean serum testosterone level in African-American men without cancer was 424.30 ng/dL; it was 386.55 ng/dL in those with prostate cancer. There was no statistical difference in serum testosterone levels based on biopsy result or race.nnnCONCLUSIONSnAlthough several studies have suggested that African-American men have higher serum testosterone levels than white men, these differences were noted only in men 40 years of age or younger. As was noted in our study, after age 40, African-American and white men have comparable serum testosterone levels. In addition, although prostate growth is androgen dependent, we found no difference in serum testosterone levels in men with and without prostate cancer.

Is Obesity a Risk Factor for Failure and Complications After Surgery for Incontinence and Prolapse in Women

PURPOSEnObese women (body mass index 30 kg/m2 or greater) are considered to be at risk for postoperative complications and failure after stress incontinence surgery. We compare the outcomes in this population with nonobese women (body mass index less than 30 kg/m2) undergoing rectus fascia, porcine dermis and polypropylene sling procedures.nnnMATERIALS AND METHODSnWe retrospectively identified 412 women with a body mass index less than 30 kg/m2 (94 autologous rectus fascia, 157 acellular porcine dermis, 161 transobturator polypropylene mid urethral sling) and 297 with a body mass index of 30 kg/m2 or greater (66 autologous rectus fascia, 114 acellular porcine dermis, 117 transobturator polypropylene mid urethral sling) who underwent sling procedures and other pelvic surgery. Evaluation included SEAPI assessment and quality of life questionnaires. Global cure equaled subjective SEAPI composite=0 and subjective satisfaction. Stress urinary incontinence cure equaled SEAPI (S)=0 and negative cough stress test. Chart review for perioperative data was conducted. Groups and outcomes were statistically compared.nnnRESULTSnAll women had a minimum followup of 12 months. After controlling for body mass index preoperative demographics, SEAPI scores and quality of life indices were not statistically different within each sling group. Global cure and stress urinary incontinence cure rates were significantly higher for nonobese women in each sling group. Statistically significant improvement in SEAPI scores and quality of life indices was achieved for all groups, and there were no statistical differences within each sling group. Overall obese women had no increase in complications compared with nonobese women. The incidence of obstructive sequelae was statistically higher in nonobese women undergoing autologous rectus fascia and transobturator polypropylene mid urethral sling procedures.nnnCONCLUSIONSnAlthough cure rates are lower, obese women have significant improvements in quality of life after surgery for stress urinary incontinence. Obesity does not appear to be a risk factor for additional complications during sling and prolapse surgery.

Tensile strength of cadaveric fascia lata compared to small intestinal submucosa using suture pull through analysis.

PURPOSEnThe modified pubovaginal sling has become popular as first line treatment for stress urinary incontinence. With the increasing use of cadaveric fascia as a sling material, widespread shortages are prevalent, hence limiting its availability. The increased morbidity with the use of synthetic sling materials and autologous fascia has stimulated investigation of other sling materials. We evaluated the tensile strength of 4 suture types, and compared tensile strength of cadaveric fascia lata to porcine small intestinal submucosa using suture pull through analysis to assess their efficacy and durability for use in anti-incontinence procedures.nnnMATERIALS AND METHODSnSuture breaking load was determined using 2 and 1-zero polypropylene suture, and 2 and 1-zero polyglactin suture. Freeze dried gamma irradiated human fascia lata and freeze-dried small intestinal submucosa were evaluated. Suture was fixed to sling material using the cross fold technique. Mean suture breakage and suture pull through were determined using a tensionometer by measuring the load applied to the sling/suture system. Statistical analysis was performed.nnnRESULTSnMean suture breakage load was greatest with 1-zero polyglactin (8.10 pounds) and least with 2-zero polypropylene (3.68 pounds). Mean suture breakage strength was similar for 1-zero polypropylene and 2-zero polyglactin at 5.26 and 5.40 pounds, respectively. Mean suture pull through load using 1-zero polypropylene suture and the cross fold technique was 5.64 pounds for cadaveric fascia and 2.74 pounds for small intestinal submucosa (p <0.0001). Maximum load was limited by the suture strength when using cadaveric fascia, whereas, maximum load was limited in small intestinal submucosa by its inherent tensile strength. However, using a new technique for suture fixation to the small intestinal submucosa, we were able to increase significantly mean suture pull through load to 3.36 pounds (p = 0.008). Additionally, with this new technique small intestinal submucosa allowed gross stretching before suture pull through that was not seen with cadaveric fascia.nnnCONCLUSIONSnDespite the current standard use of 1-zero polypropylene suture for pubovaginal sling fixation, our data suggest that 1-zero polyglactin suture is the strongest, and its use with pubovaginal sling fixation warrants further investigation. Using the cross fold technique and 1-zero polypropylene suture, tensile strength was greatest with cadaveric fascia compared to small intestinal submucosa. Although small intestinal submucosa was not as strong as cadaveric fascia, our persuasive preliminary data suggest that further investigation is warranted in the use of small intestinal submucosa and other suture fixation techniques, and its observed stretch capacity. Hence, with further studies small intestinal submucosa may remain a viable option for pubovaginal sling material.

Race is not independently associated with a positive prostate biopsy in men suspected of having prostate cancer.

OBJECTIVESnTo examine whether race is associated with the prostate biopsy result after controlling for other clinical factors in men undergoing ultrasound-guided prostate biopsy to evaluate an elevated serum prostate-specific antigen (PSA) or an abnormal digital rectal examination (DRE), or both.nnnMETHODSnWe reviewed the records of all men undergoing transrectal ultrasound-guided prostate biopsy at our facilities from January 1990 through March 1998. This included 1056 white men and 874 black men. Patient age, serum PSA, indication for prostate biopsy, and race were examined for association with the biopsy result.nnnRESULTSnOf the 1 930 black and white men who underwent prostate biopsy, 639 (33%) had cancer, including 355 (41%) of 874 black men and 284 (27%) of 1056 white men. Serum PSA, abnormal DRE, and age were independent predictors of a prostate biopsy being positive for cancer. Race was not an independent predictor of cancer being identified in the prostate biopsy.nnnCONCLUSIONSnAfter controlling for PSA, DRE, and age, black men were not at an increased risk of a positive prostate biopsy relative to white men. Our data do not support the need to consider race when estimating the probability that a man has prostate cancer.

Incidence and management of vaginal extrusion of acellular porcine dermis after incontinence and prolapse surgery

We report our experience with vaginal extrusion of acellular porcine dermis in women undergoing pelvic reconstructive surgery. Over 5xa0years, 270 patients received a Pelvicol™ pubovaginal sling (PVS) or prolapse repair using interposition graft. Charts were retrospectively evaluated for evidence of graft extrusion, management, and outcomes. Chi-square analysis was conducted to evaluate the association of extrusion with perioperative variables. Nineteen women (7%) had partial or complete vaginal graft extrusion. After a PVS, 11 of 13 women healed by re-epithelialization and remained continent, while 2 required operative debridement. Four of six patients receiving interposition grafts healed after small incisional separations. Two women underwent additional surgery to address extensive extrusion, and both prolapses recurred. After statistical analysis, vaginal extrusion was significantly associated with PVS and concomitant urethral diverticulectomy. Small incisional separations frequently heal and cause no symptom recurrence. Larger areas of extrusion may require debridement and may contribute to recurrence of symptoms.

Undifferentiated sex cord/stromal testis tumor

Completely undifferentiated sex cord/stromal tumors of the testis are rare after puberty. We describe such a tumor in an 18-year-old man presenting with a right testis mass.

Long-term follow-up of porcine dermis pubovaginal slings

Introduction and hypothesisOutcomes of xenografts in incontinence surgery are uncommon. Our objective was to report long-term outcomes of women after porcine dermis (PD) bladder neck sling.MethodsSeventy women completed a mean follow-up of 62.1xa0months. “Global cure” equaled SEAPI subjective composite = 0 and visual analog score ≥8. “Stress urinary incontinence (SUI) cure” equaled SEAPI-subjective (S) subset = 0 and negative cough stress test.ResultsThe SUI cure rate was 42.9xa0% and global cure rate was 11.4xa0%. Perioperative complications were seen in <10xa0% of women. The mean time to SUI recurrence was 10.4xa0months, with 30 of 40 women redeveloping SUI <12xa0months after sling. Twenty women (28.6xa0%) have since undergone additional anti-incontinence procedures. There was a significant postoperative improvement in SEAPI scores, daily pad use, and quality of life (QOL) indices.ConclusionsAt long-term follow-up, PD is not a durable material in sling surgery. Although QOL generally improves after surgery, most SUI recurrences occurred soon after surgery.

DETERMINANTS OF FAILURE AFTER SLING SURGERY FOR FEMALE STRESS URINARY INCONTINENCE

Results: Of 728 women, 177 (24.3%) underwent autologous rectus fascia bladder neck slings, 259 (35.6%) underwent porcine dermis bladder neck slings, and 292 (40.1%) underwent polypropylene midurethral slings. The mean follow-up period for the entire cohort was 42 months. The “SUI cure” rate was 75.4% and “global cure” rate was 54.9% for the entire cohort. Of the 153 women (21%) who achieved SUI cure but not global cure, 143 (93.5%) had a SEAPI subjective composite score > 0. The reasons for failure included: emptying (43.1%), anatomy or bladder neck descent (9.2%), pad use (20.3%), and inhibition / urge incontinence (66%). A VAS < 8 was recorded in 36 (23.5%) women and 10 of these women (6.5%) failed for reasons not included in SEAPI (e.g. posterior and apical prolapse, pelvic and abdominal pain, dyspareunia, and urgency without incontinence). Despite women undergoing 3 different sling procedures differing in some demographic, urodynamic, and perioperative criteria, reasons for failure were not statistically different between sling types. A statistically significant improvement in all QOL indices was seen in “SUI cure” and failure groups, as well as “global cure” and failure groups. Interpretation of results: Although the populations of women undergoing surgery with different sling materials differed from one another, the rate of SUI resolution appears to be similar. Likewise, the incidence of postoperative urinary urge incontinence, voiding dysfunction, pad use, and bladder neck mobility are also similar. If these factors are considered, along with symptoms not accounted for by the SEAPI scale, then the true cure rate after sling surgery is more modest than originally quoted. Despite the different cure rates, women appear to have a significant improvement in their quality of life after sling surgery.

PREDICTORS OF A FAILED VOIDING TRIAL AFTER SLING AND CONCOMITANT SURGERY

Hypothesis / aims of study: While discharge home with an indwelling urethral catheter was a routine practice in the past, many women are able to void soon after pubovaginal sling surgery. An indwelling catheter may be a source of perioperative infection and the prospect of discharge with a catheter may be a source of anxiety for women undergoing sling surgery. The aim of this study was to identify perioperative factors that could predict success or failure of the postoperative voiding trial.