Urology
19 Nov Standardized Model Empowers Nurses To Decrease Urinary Catheter Use
[caption id="attachment_19485" align="alignleft" width="200"]
Dr. Jerome Leis[/caption]
MedicalResearch.com Interview with:
Jerome A. Leis, MD MSc FRCPC
Staff physician, General Internal Medicine and Infectious Diseases
Physician Lead, Antimicrobial Stewardship Team
Staff member, Centre for Quality Improvement and Patient Safety
Sunnybrook Health Sciences Centre
Assistant Professor, Department of Medicine, University of Toronto
Medical Research: What is the background for this study? What are the main findings?
Dr. Leis: Overuse of urinary catheters leads to significant morbidity among hospitalized patients. In most hospitals, discontinuation of urinary catheters relies on individual providers remembering to re-assess whether patients have an ongoing reason for a urinary catheter. We engaged all of the attending physicians to agree on the appropriate reasons for leaving a urinary catheter in place and developed a medical directive for nurses to remove all urinary catheters lacking these indications. This nurse-led intervention resulted in a significant reduction in urinary catheter use and catheter-associated urinary tract infections, compared with wards that continued to rely on usual practice.
28 Oct Men Have Small Risk of Falls and Fractures When Starting Prostate Alpha Blockers
Posted at 11:51h
in Author Interviews, Blood Pressure - Hypertension, BMJ, Geriatrics, Orthopedics, Prostate, Urology
[caption id="attachment_17326" align="alignleft" width="231"] Dr. Welk[/caption] MedicalResearch.com Interview with: Blayne Welk MD Assistant Professor in the Division of Urology Department of Surgery, Western University Institute for Clinical Evaluative Sciences Department of Epidemiology and Biostatistics Western University, London, Ontario Medical Research: What is the background for this study? What are the main findings? Dr. Welk: Alpha blocker medications are...
10 Sep Transvaginal Mesh Complications Lower In High Volume Surgical Practices
MedicalResearch.com Interview with:
Blayne Welk MD
Assistant Professor in the Division of Urology
The University of Western Ontario
Medical Research: What is the background for this study? What are the main findings?
Dr. Welk: Stress incontinence is a common problem among women. The most frequently used surgical treatment is a mesh-based midurethral sling. This procedure is commonly called a transvaginal sling, and is usually an outpatient procedure that takes about an hour in the operating room. However, there has been significant concern about some of the complications of this procedure, which include chronic pain, and mesh erosions into the urinary tract. This prompted the FDA and Health Canada to issue warnings regarding the use of transvaginal mesh, and numerous lawsuits have been launched against manufactures of transvaginal mesh products.
This study by Dr Welk and colleagues identifies the long term rate of surgical treated complications among a group of almost 60,000 women who had mesh based incontinence procedures between 2002-2012. The rate of surgically treated complications at 1 year is 1.2%, however this increased to 3.3% after 10 years of followup. The FDA and Health Canada recommend that surgeons obtain training and experience in their chosen type of midurethral sling, and we demonstrated that patients of high volume surgeons (who frequently performed mesh based incontinence procedures) were 27% less likely to have one of these complications.
12 Jun Some Prostate Cancer Patient Decision Aids Need Updating
MedicalResearch.com Interview with: Prajakta Adsul, MBBS, MPH, PhD; Ricardo Wray, PhD, and Sameer Siddiqui, MD Center for Cancer Prevention, Research and Outreach Saint Louis University MedicalResearch: What is the background for this study? What are the main findings? Response: Patient decision aids are interventions designed to help patients engage in shared decision making with their providers when multiple choices with more or less equivalent efficacy are available for a particular medical decision. Several patient decision aids exists for numerous medical conditions and previous research has demonstrated them to be effective in improving the patient's knowledge and understanding of treatment options and their relative efficacy and side-effects and resulting in a higher proportion of decision that are consistent with patient's values and personal preferences. In the context of prostate cancer treatment, the practice of shared decision making is vital as highlighted by recent calls from the American Urological Association and the American Cancer Society. To aid with this process, several patient decision aids exist. However, the content presented, the format and presentation styles of decision aids can be variable and can have an influence on the choice made by the patients. The purpose of this study was to assess the characteristics of the patient decision aids designed for men facing prostate cancer treatment. We used the widely accepted International Patient Decision Aids Standards (IPDAS) for the assessment, supplemented with implementation criteria to strategize successful future improvement and promotion of decision aids in routine urological practice. The main findings of the review were that none of the decision aids reviewed met all standards. The aids had variable content, format and presentation of prostate cancer treatment information. Several decision aids were outdated and critical issues such as the risk of overtreatment and active surveillance as a treatment option for prostate cancer were not always covered in decision aids.09 Jun Use of Mesh Surgery For Prolapse Continues To Rise
MedicalResearch.com Interview with: Bilal Chughtai, MD & Art Sedrakyan, MD, PhD Department of Urology Weill Cornell Medical College Medical Research: What is the background for this study? What are the main findings? Response: Since 2008, the U.S. Food and Drug Administration has released number of public health notifications cautioning the use of mesh in pelvic organ prolapse (POP) surgery. Despite these notifications and subsequent public scrutiny, studies have reported a large increase of mesh use in female patients with pelvic organ prolapse during the last decade. In light of the reported rise in mesh utilization, we sought to determine the use of mesh in prolapse surgery and compare short-term outcomes of prolapse surgery with or without mesh. After identifying 7,338 and 20,653 patients who underwent prolapse repair procedures with and without mesh in a 4-year period, we found that mesh use increased 44.7%. Most patients were under 65 (62.3%), and there were more patients older than 65 years in the mesh group (44.3% versus 35.4%). Overall, complications were not common. However, patients who received mesh were more likely to experience urinary retention within 90-days and had a higher chance of having re-intervention at 1 year. Mesh use was also associated with higher risk of urinary retention in older patients (≥ 65 year olds) and re-intervention within 1 year in younger patients (<65 year olds).21 May Analysis Of Large Medical Datasets Can Be Both Informative and Misleading
MedicalResearch.com Interview with:
David F. Penson, MD, MPH
Hamilton and Howd Chair in Urologic Oncology
Professor and Chair, Department of Urologic Surgery
Director, Center for Surgical Quality and Outcomes Research
Vanderbilt University Medical Center
Nashville, TN 37232-2765
Medical Research: What is the background for this editorial? What are the main findings?
Response: This editorial discusses the implication of the recent removal of the PSA data from the seer-medicare dataset. It reviews the significance of the action: specifically what it means for prior publications that used this information to address clinical research questions in prostate cancer. It makes the point that, while these datasets are powerful, researchers have stretched the limits of what they can do too far. Simply put, we cant always guarantee that the clinical data collected in administrative datasets will necessarily be accurate so we need to be more selective in how we use these data and not simply run analyses on the data just because it is easy.
21 May Grandfather’s Age At Paternity May Affect Man’s Fertility
Medicalresearch.com Interview with: Ross Anderson M.D.,M.C.R. Allina Health clinics and Jim Hotaling M.D.,M.S.,F.E.C.S.M. Utah Center for Reproductive Medicine Salt Lake City, UT 84108 MedicalResearch: What is the background for this study? What are the main findings? Dr. Anderson: There is a growing trend of delayed marriage and childbearing, particularly into the third and fourth decade of life. Advanced maternal age is well recognized as a risk factor for chromosomal abnormalities and perinatal complications, but there is also growing interest in the impact of advanced paternal age. Multiple studies have demonstrated that as men age their sperm quality and ability to have children decreases. We were interested in how the age of the parents and the age of the grandparents at the time of conception can affect a man’s sperm quality. We hypothesized that men with older parents and grandparents at the time of conception would have a linear decrease in the quality of their sperm. We used Utah’s two largest andrology lab’s semen analyses and these men were linked to the Utah Population Database. The Utah Population Database allows us access to birth certificate data and pedigree data going back to the late 1800s. With this we can determine the age of the parents and grandparents at the time they had each subsequent generation. We found that the age of the parents did not influence a man’s semen concentration, motility, or total sperm count. Interestingly, the age of the paternal grandfather was associated with an increased risk of poor semen concentration. For instance, if a grandfather was older than 45 year of age at the time of conception of the father, there is a 39% chance a man’s semen concentration would be considered low according to the World Health Organization (less than 15 million per milliliter).18 May Testosterone Therapy Lowered Mortality In Hypogonadal Men
MedicalResearch.com Interview with:
Ranjith Ramasamy MD
Assistant Professor of Urology
University of Miami
Medical Research: What is the background for this study?
Dr. Ramasamy: The association between testosterone supplementation therapy (TST) and thrombotic risk in elderly men remains controversial. We evaluated the prevalence of thrombotic events and all-cause mortality in men older than 65 years with hypogonadism treated with testosterone therapy. We compared men treated with testosterone to an age and comorbidity matched cohort of hypogonadal men not treated with testosterone supplementation therapy.
Medical Research: What are the main findings?
Dr. Ramasamy: No man who received testosterone supplementation therapy died, whereas 6 hypogonadal men who did not receive TST died (p=0.007). There were 4 thrombotic events (1 MI - myocardial infarction, 2 CVA/TIA - stroke, 1 PE - pulmonary embolism) in men who received testosterone supplementation therapy compared to 1 event (CVA/TIA) among men who did not receive TST (p = 0.8). All the events (except one death which took place at 6 months of follow–up) occurred 2 years or more after follow–up. Strengths of the study include long follow–up (>3 years), availability of serum testosterone levels before and after therapy and of a control group (hypogonadal men not treated with TST) for comparison. Limitations included retrospective study design, and a small sample size.
18 May Poor Sleep May Contribute To Lower Urinary Tract Symptoms in Men
MedicalResearch.com Interview with: Alexander W. Pastuszak, MD, PhD Male Reproductive Medicine and Surgery Scott Department of Urology Jason Malcolm Scovell Medical Student, Ofc SA-BCM Students Baylor College of Medicine Houston, TX Medical Research: What is the background for this study? What are the main findings? Response: Sleep quality is an important component of overall health, and can both exacerbate health issues and be impaired by health problems. Shift workers, primarily those who do not work standard daylight shifts, are prone to sleep problems, a significant concern in light of the fact that up to 25% of the U.S. workforce is comprised of shift workers. As men age, the prevalence of Lower Urinary Tract Symptoms (LUTS), which include urgency, frequency, waking up at night to urinate, and difficulties with urination, increases. Unsurprisingly, men with LUTS report poor sleep in part due to awakening repeatedly during the night. We studied a group of male shift workers, who we believe to be an ‘at-risk’ population, and found that not only do the men who report worse sleep quality have worse Lower Urinary Tract Symptoms, but also men who report difficulty falling asleep have more severe LUTS than those who do not. This latter point is significant, given that most men with LUTS can fall asleep without difficulty, but then awaken repeatedly throughout the night, and suggests that sleep difficulties in this population may be resulting in Lower Urinary Tract Symptoms rather than LUTS exclusively resulting in sleep difficulties.01 Apr Bladder Urine Is Not Sterile
MedicalResearch.com Interview with:
Alan J. Wolfe PhD, Professor
Department of Microbiology and Immunology
Stritch School of Medicine, Loyola University Chicago
Maywood, IL
Medical Research: What is the background for this study?
Dr. Wolfe: Several years ago, Dr. Brubaker and I began a conversation. As a urogynecologist, she was concerned about the general lack of improvement in diagnosis and treatment in her urogynecological practice and thus in clinical outcome. As a microbiologist, I was extremely skeptical of the dogma that urine in the bladder was sterile in the absence of a clinical infection. This skepticism was based upon my former work in bacterial motility and biofilm formation and on the knowledge that most bacteria are not cultured by the standard clinical microbiology urine culture method. With the goal of ultimately improving urogynecological practice, and with the help of our colleagues in the Loyola Urinary Education and Research Collaborative (LUEREC), we decided to test the sterile bladder hypothesis by seeking evidence of bacteria in urine taken directly from the bladder to avoid vulva-vaginal contamination. To detect bacterial DNA, we used high-throughput DNA sequencing technology. To detect live bacteria, we developed an Expanded Quantitative Urine Culture (EQUC) protocol. We applied these complementary approaches to women with and without urgency urinary incontinence (UUI) whose standard clinical urine culture was negative.
Medical Research: What are the main findings?
Dr. Wolfe: First and foremost, the bladder is not sterile. We can detect bacteria and/or bacterial DNA in most women whether they have urgency urinary incontinence (UUI) or not. Thus, the female bladder contains a resident bacterial community, which we call the female urinary microbiome (FUM). We found that bacterial members of the FUM are distinct from the bacteria that typically cause urinary tract infections (UTI). Thus, the bacteria that make up the FUM are not the bacteria that cause typical UTIs. Indeed, detection of the female urinary microbiome was associated with reduced risk of UTIs that often occur after instrumentation or surgery. We therefore hypothesize that the FUM or some members of the FUM could protect against UTI. We also saw that the FUM in women with UUI differs from the FUM in women without UUI and that certain bacterial species were considerably more common in women with urgency urinary incontinence than in women without urgency urinary incontinence . We hypothesize that some of these bacteria could be causative or contributory to UUI or they could be a consequence of urgency urinary incontinence.
16 Jan Risk of Prostate Cancer Reclassification Varies With Time
MedicalResearch.com Interview with: Mufaddal Mamawala, MBBS, MPH, CPH Biostatistician Johns Hopkins School of Medicine Brady Urological Institute Medical Research: What is the background for this study? What are the main findings? Dr. Mamawala: Twenty years after prostate-specific antigen (PSA) was FDA approved for the diagnosis of prostate cancer, its use remains highly controversial. There has been an ‘over- diagnosis’ and ‘over-treatment’ of low-risk prostate cancers that would have never progressed to a more lethal form of the disease during one’s life. Active surveillance (AS) is an alternative to immediate treatment, which allows for monitoring of favorable risk patients with selective delayed intervention among those with disease progression. However ‘misclassification’ is a cause of concern for patients in the initial years of been in AS. The initial biopsy may have missed an area of prostate with an aggressive cancer, due to under-sampling of cores or due to randomness, such that this patient could get misclassified as having a low-risk disease and by the time the follow-up biopsy shows an aggressive cancer the window of curability is lost. However with more sampling of the prostate there is more likelihood to find an aggressive cancer. As such if the patient is compliant with their biopsies, and more prostate is sampled under the microscope, better are the chances of finding a higher risk cancer. Conversely if the patient has more biopsies that show no high-risk cancer then they are less likely to have a high-risk cancer on future biopsies. Thus we wanted to evaluate the risk of reclassification, from a low-risk disease to a high-risk disease (higher Gleason score, or increase in extent of the disease), over a period of time in compliant active surveillance patients. The length of time under Active surveillance without reclassification has not been evaluated as a predictor of future reclassification. Biopsies are invasive procedures, and the fact that patient has to undergo this invasive procedure regularly is a deterrent from been in Active surveillance. This study would help to make informed decisions about the need for doing frequent biopsies in light with other clinical factors especially in older patients who had many non-reclassifying biopsies before. We found that the risk of reclassification was not equally distributed across time. As a result of ‘under sampling’ of prostate at diagnostic biopsy we had highest rates of reclassification in the first two years of been in Active surveillance with more than 50% of total reclassifications happening during those two years. The ‘low-risk’ and the ‘very-low-risk’ groups, determined by the Epstein criteria, had similar rates of reclassification in the first two years. After first two years the ‘low-risk’ group were 2.4 times as likely to have a higher risk of reclassification than the ‘very-low-risk’ group. In both the groups the risk of reclassification declined over time significantly by at least 30% with each biopsy that did not show reclassification.29 Nov Testosterone Therapy May Not Increase Risk of Prostate Cancer
MedicalResearch.com Interview with: Prof. h.c.* Dr. Farid Saad on behalf of Dr. Haider and co-authors Global Medical Affairs, Andrology c/o Bayer Pharma AG, D-13342 Berlin *Gulf Medical University, Ajman, UAE Medical Research: What is the background for this study? Response: In early 1940s Dr. Charles Huggins demonstrated that in few men with metastatic prostate cancer, castration reduced tumor growth and androgen administration promoted tumor growth. This observation became the corner stone of androgen deprivation therapy (ADT) in men with prostate cancer for the past 7 decades without any clinical evidence to the contrary. Indeed, normal prostate growth depends on androgens and therefore testosterone and its metabolite DHT are responsible for the biochemical signaling in the prostate cells through interaction with the androgen receptor. Since tumor cells have been transformed from normal epithelial cells, it is no surprise that they retained the expression of the androgen receptor and continue to depend on their growth on the androgen signal. For the past 7 decades, physicians thought that testosterone is a carcinogen for the prostate, despite lack of any biochemical or clinical data. This long period of training physicians on this unproven concept, has precipitated in the minds of many clinicians that testosterone (T) causes prostate cancer. Based on a plethora of clinical data, there is no evidence to support such myth. In fact, many recent studies have debunked this hypothesis based on longitudinal and prospective studies. A newly advanced hypothesis was formulated suggesting that “T therapy does not pose a greater risk for development of PCa.” However this hypothesis is met with considerable skepticism. Interestingly, however, no new compelling evidence is available to discredit or dismiss this newly advanced hypothesis.23 Aug Skin Irritants Increase Risk of Urinary Tract Infections
MedicalResearch.com Interview with:
Steve J. Hodges MD
Associate Professor, Department of Urology
Wake Forest University School of Medicine
Medical Center Blvd, Winston-Salem, NC
Medical Research: What are the main findings of this study?
Dr. Hodges: The main findings of this study were that skin irritants (typically urine) may cause vulvitis in prepubertal girls, which leads to an alteration of their perineal microbiome, with increased colonization by uropathogenic bacteria, increasing the risk of UTI.
29 Jul Surveillance vs. Surgery For Small Kidney Masses?
Medic
alResearch.com Interview with:
David C. Johnson, MD, MPH
Department of Urology
University of North Carolina School of Medicine
Medical Research: What are the main findings of the study?
Dr. Johnson: The first main finding from this study is that the likelihood of benign pathology after surgical removal of a renal mass suspected to be malignant based on pre-operative is inversely proportionate to size. This concept is well-established, however we systematically reviewed the literature for surgical series that published rates of benign pathology stratified by size and combined these rates to determine a single pooled estimate of benign pathology of pre-operatively suspicious renal masses for each size strata. Using benign pathology rates from US studies only, we found that 40.4% of masses < 1 cm, 20.9% of masses 1-2 cm, 19.6% of masses 2-3 cm, 17.2% of masses 3-4 cm, 9.2% of masses 4-7 cm, and 6.4% of masses >7 cm are benign.
The more novel finding from this study was the quantification of a previously unmeasured burden of over treatment in kidney cancer. By combining the above mentioned rates of benign pathology with epidemiological data, we estimated that the overall burden of benign renal masses surgically removed in the US to approach 6,000 per year in 2009. This represented an 82% increase over the course of a decade. Most importantly, we found an overwhelmingly disproportionate rise in the surgical treatment of renal masses in the smallest size categories – those which were most likely to be benign. We found a 233%, 189% and 128% increase in surgically removed benign renal lesions < 1 cm, 1-2 cm, and 2-3 cm, respectively from 2000 – 2009 in the US.
12 Jul Kidney Stone Risk Rises With the Temperature
MedicalResearch.com Interview with:
Gregory Tasian, MD, MSc, MSCE
Attending Urologist
The Children’s Hospital of Philadelphia
Medical Research: What are the main findings of the study?
Dr. Tasian: The risk of developing kidney stones increased during the study period in all the cities except Los Angeles when mean daily temperatures rose above 50°F (10°C). Mean daily temperatures reaching 86°F (30°C) were associated with risk increases of 38% in Atlanta, 37% in Chicago, 36% in Dallas, and 47% in Philadelphia compared with 50°F (10°C). Kidney stone risk peaked within 3-5 days of exposure to high temperatures but then decreased within 7 to 10 days afterward.
21 May Kidney Stones: Non-Invasive Treatment Not Always Better
MedicalResearch Interview with:
Charles D. Scales, Jr MD MSHS
Assistant Professor of Surgery
Division of Urologic Surgery
Duke University Medical Center
MedicalResearch: What are the main findings of the study?
Dr. Scales: When it comes to treating kidney stones, less invasive is not always better.
We used the best method short of a randomized trial to balance out patients in terms of factors that might influence the success of treatment. In other words, we achieved a “statistical toss-up” for factors that could influence the outcome of the procedure.
When we balanced out all of the factors that might influence the chance of a repeat procedure, we found that about 11% of patients treated with non-invasive SWL had a repeat procedure, as compared to <1% with minimally invasive URS.
20 May New Anti-Incontinence Surgery Uses No Synthetic Mesh
MedicalResearch.com Interview with:
Daniel S. Elliott, M.D
MAYO Clinic, Associate Professor
Department of Urology
Section of Pelvic and Reconstructive Surgery
Rochester, Minnesota
MedicalResearch: What are the main findings of the study?
Dr. Elliott: The biggest issue is that we were able to devise a new procedure that is a simple outpatient anti-incontinence surgery for women that does NOT use any synthetic meshes. The importance of this is that all traditional (meaning NON-mesh) surgeries for female incontinence have been large surgeries with fairly significant risks such as pain, bleeding and prolonged recovery. When the meshes came out in the late ‘90’s, their big benefit was that they were outpatient and quick procedures. But now that we are discovering all the long term complications from meshes such as chronic pain, scarring, painful intercourse, vaginal extrusion of the meshes, and organ injury, patients have become VERY reluctant and fearful to undergo any mesh type surgery. Therefore, we devised a new procedure that used a very small piece of the patient’s own tissue (from the rectus fascia) and placed this via the “transobturator route.” In the process, we melded together the “best” of both worlds---a NON-mesh, outpatient anti-incontinence procedure that is safe (no long term problems as seen with meshes) .
20 May Radical Cystectomy: Simple Test of Functional Status Identifies Higher Risk Patients
MedicalResearch.com Interview with: Sarah P. Psutka, MD Fellow in Urologic Oncology Department of Urology, Mayo Clinic MedicalResearch: What are the main findings of each study? Dr. Psutka: In this study, we analyzed 1335 patients who underwent radical cystectomy at the Mayo clinic between 1996 and 2006. We categorized patients who stayed in the hospital longer than 10 days, putting them in the top 25th percentile of the length of stay, as having a prolonged hospital stay. We noted that prolonged hospital stay was associated with adverse postoperative outcomes, including serious complications and early postoperative death. Patients who had a prolonged length of stay had a higher burden of comorbidities, American Society of Anesthesiologist score, and their Eastern Cooperative Oncology Group Score. A multivariable analysis, holding these factors and other clinically relevant potential confounders constant, revealed that only the ECOG performance score independently predicted whether or not a patient had a prolonged hospital course following radical cystectomy.01 Apr Does Cialis Work For Erectile Dysfunction in Men afer Prostate Cancer Radiation?
Posted at 20:29h
in Author Interviews, Erectile Dysfunction, JAMA, Prostate, Prostate Cancer, Radiation Therapy
MedicalResearch.com Interview with:
Dr. Thomas M. Pisansky MD
Mayo Clinic, Rochester, Minnesota
MedicalResearch.com: What are the main findings of the study?
Dr. Pisansky: This patient-reported outcomes research did not identify a beneficial effect of once-daily tadalafil to prevent radiotherapy-related erectile dysfunction in men with prostate cancer.
25 Nov Prostate Biopsy: Psychological Impact
MedicalResearch.com Interview with:
Dr Julia Wade PhD
Research Associate
University of Bristol, Clifton, Bristol
MedicalResearch.com: What are the main findings of the study?
Dr. Wade: We hope that our study provides men with more information about diagnosing prostate cancer. A diagnosis of prostate cancer can only be confirmed through prostate biopsies after the finding of a raised PSA. This biopsy process requires 10 or so samples to be taken rectally, with a local anaesthetic, and this has some side effects. Most men describe prostate biopsies as uncomfortable, but around 40% report pain and many experience bleeding; a small number, 1%, are admitted to hospital and 10% need to see a doctor because of post-biopsy symptoms. We found that the men who experienced post-biopsy symptoms as ‘problematic’ at 7 days post biopsy also experienced raised anxiety compared to men who experienced symptoms as non-problematic