Surgical outcomes following strabismus surgery for abducens nerve palsy.

PURPOSE: To assess ocular alignment outcomes and their stability for patients who underwent strabismus surgery for abducens nerve palsy and to identify preoperative patient variables that predict surgical success or repeated surgeries. METHODS: We retrospectively reviewed the medical records of patients diagnosed with abducens nerve palsy and who subsequently underwent strabismus surgery. RESULTS: A total of 209 patients (386 procedures) were included. The mean number of surgeries for patients was 1.9 ± 1.4. Success was achieved after a single surgery for 112 patients (53.6%), and success was achieved for an additional 42 patients, for a total of 154 patients (73.7%), following all surgeries. Preoperative abduction deficit severity was the only variable predictive of surgical success, with mild deficits having the highest odds of both initial success (OR = 5.555; CI, 2.722-11.336) and final success (OR = 5.294; 95% CI, 1.931-14.512). When analyzing survival time until additional surgery, the median survival was 406 days; abduction deficit severity, older age, other coincidental motility abnormalities, greater magnitude esotropia, and surgical technique were predictive of repeat surgical incidence. CONCLUSIONS: In our patient cohort, preoperative abduction deficit was an important predictor of both surgical success and repeat surgical incidence for abducens nerve palsy. Older patient age, additional motility abnormalities, and greater amounts of baseline strabismus were also associated with greater likelihood of multiple surgeries.

Posterior reconstruction before vesicourethral anastomosis in patients undergoing robot-assisted laparoscopic prostatectomy leads to earlier return to baseline continence.

INTRODUCTION: Reapproximation of Denonvilliers' fascia adjacent to bladder neck to the rectourethralis, or posterior reconstruction (PR), has been suggested to improve continence in postprostatectomy patients. We examined the impact of the PR on postoperative urinary and other quality-of-life (QoL) outcomes in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). METHODS: We identified 89 patients who underwent RALP for prostate cancer between 2006 and 2009 by a single surgeon (R.G.), consented to participate in our prospective QoL study, which collects RAND-UCLA QoL and AUA symptom scores for all patients undergoing treatment for prostate cancer, and completed a baseline and a 3- or 6-month questionnaire. Of these, 31 patients had PR before vesicourethral anastomosis. We compared return to baseline function percentage at 3 and 6 months by PR group. Differences found in univariate analysis were further investigated using multiple linear regression models adjusting for demographics, clinical variables, and nerve-sparing status. RESULTS: While most patients had both 3- and 6-month follow-up (n = 74, 83%), sample size at 3 months was n = 86 and at 6 months was n = 77. Groups were comparable by preoperative characteristics, pathologic stage, nerve-sparing status, and baseline QoL/AUA symptom scores. At 3-months, there was a statistically significant improvement comparing PR to non-PR groups in return to baseline score for urinary bother (72% vs. 53%; p = 0.008) and urinary function (64% vs. 50%; p = 0.05), as well as change in absolute AUA symptom score (+0.2 vs. +3.8; p = 0.005). Differences in urinary bother (+20%; 95% confidence interval 5%, 34%) and AUA symptom score (-2.8; 95% confidence interval, -5.4, -0.2) persisted after multivariate adjustment. Groups had similar scores for all parameters by 6 months postprostatectomy. CONCLUSIONS: PR in patients undergoing RALP has a significant impact on early return to baseline parameters relating to urinary bother, urinary function, and AUA symptom score.

Urinary cytology has a poor performance for predicting invasive or high-grade upper-tract urothelial carcinoma.

OBJECTIVE: • To evaluate the diagnostic accuracy of urine cytology for detecting aggressive disease in a multi-institutional cohort of patients undergoing extirpative surgery for upper-tract urothelial carcinoma (UTUC). METHODS: • We reviewed the records of 326 patients with urinary cytology data who underwent a radical nephroureterectomy or distal ureterectomy without concurrent or previous bladder cancer. • We assessed the association of cytology (positive, negative and atypical) with final pathology. Sensitivity and positive predictive value (PPV) of a positive (± atypical) cytology for high-grade and muscle-invasive UTUC was calculated. RESULTS: • On final pathology, 53% of patients had non-muscle invasive disease (pTa, pTis, pT1) and 47% had invasive disease (≥ pT2). Low-grade and high-grade cancers were present in 33% and 67% of patients, respectively. • Positive, atypical and negative urine cytology was noted in 40%, 40% and 20% of cases. Positive urinary cytology had sensitivity and PPV of 56% and 54% for high-grade and 62% and 44% for muscle-invasive UTUC. • Inclusion of atypical cytology with positive cytology improved the sensitivity and PPV for high-grade (74% and 63%) and muscle-invasive (77% and 45%) UTUC. Restricting analysis to patients with selective ureteral cytologies further improved the diagnostic accuracy when compared with bladder specimens (PPV > 85% for high-grade and muscle-invasive UTUC). CONCLUSIONS: • In this cohort of patients with UTUC treated with radical surgery, urine cytology in isolation lacked performance characteristics to accurately predict muscle-invasive or high-grade disease. • Improved surrogate markers for pathological grade and stage are necessary, particularly when considering endoscopic modalities for UTUC.

Preoperative hydronephrosis, ureteroscopic biopsy grade and urinary cytology can improve prediction of advanced upper tract urothelial carcinoma.

PURPOSE: We evaluated the value of hydronephrosis, ureteroscopic biopsy grade and urinary cytology to predict advanced upper tract urothelial carcinoma. MATERIALS AND METHODS: We reviewed the charts of 469 patients with upper tract urothelial carcinoma treated with radical nephroureterectomy or distal ureterectomy. Complete data on hydronephrosis (present vs absent), ureteroscopic grade (high vs low) and urinary cytology (positive vs negative) were available in 172 patients. The outcome was muscle invasive (pT2-pT4) or nonorgan confined (pT3 or greater, or lymph node metastasis) upper tract urothelial carcinoma. RESULTS: Of the patients 92 (54%) had hydronephrosis, 74 (43%) had high grade disease on ureteroscopic biopsy and 137 (80%) had positive cytology. On univariate analysis hydronephrosis (p <0.001), high ureteroscopic grade (p <0.001) and positive cytology (p = 0.03) were associated with muscle invasive and nonorgan confined disease. On multivariate analysis adjusting for tumor site, gender and age hydronephrosis and high ureteroscopic grade were associated with muscle invasive carcinoma (HR 12.0 and 4.5, respectively, each p <0.001) but cytology was not (HR 2.3, p = 0.17). However, all 3 variables were independently associated with nonorgan confined disease (HR 5.1, p <0.001; HR 3.9, p <0.001; and HR 3.1, p = 0.035, respectively). Combining these 3 tests incrementally improved the prediction of upper tract urothelial carcinoma stage. Abnormality of all 3 tests had 89% and 73% positive predictive value for muscle invasive and nonorgan confined upper tract urothelial carcinoma, respectively, but when all tests were normal, the negative predictive value was 100%. CONCLUSIONS: Preoperative evaluation for hydronephrosis, ureteroscopic grade and cytology can identify patients at risk for advanced upper tract urothelial carcinoma. Such knowledge may impact surgery choice and extent as well as the need for perioperative chemotherapy regimens.

Erectile dysfunction for primary care providers.

INTRODUCTION: Erectile dysfunction (ED) affects more than half of men between the ages of 40 and 70 years and is associated with a significant decline in quality of life. ED in an otherwise healthy man should be considered a sentinel event for endothelial dysfunction and cardiovascular disease. Such a person should be carefully evaluated for undiagnosed risk factors including hypertension, diabetes, lipid disorders, and obesity. OBJECTIVE: To understand that erectile dysfunction is prevalent and may be the first sign of undiagnosed cardiovascular risk factors. MATERIALS AND METHODS: Literature review. RESULTS: Current literature suggests that physicians should screen all men for ED, and if present, rule out concomitant cardiovascular risk factors. CONCLUSION: ED is prevalent and may be the first sign of undiagnosed cardiovascular risk factors. With the advent of safe and effective phosphodiesterase type-5 inhibitors (PDE-5i), most patients reporting dissatisfaction with erectile function can start treatment right away. Preventative care algorithms should include screening men 40 years of age or older for ED.

Straightening out Peyronie's: a medical and surgical approach to the patient.

PURPOSE: Peyronie's disease is characterized by plaque formation within the tunica albuginea of the penile corpora cavernosa. The exact etiology of Peyronie's is uncertain at this time, and multiple treatment options exist. Following a literature review, a treatment algorithm has been developed to streamline decisions for both medical and surgical intervention. METHODS: A review of the Medline literature published between 1940 and 2008 was performed looking at the history, pathophysiology, medical and surgical treatments for Peyronie's disease. RESULTS: The current standard is to treat Peyronie's with expectant medical management or by adding oral, topical, or injected medicines to the plaque until the process is stabile for 12 to 18 months. Besides pain relief, few patients experience significant disease regression with these nonsurgical therapies. Although initially discouraging, recent studies of plaque being injected with verapamil, interferon, or collagenase show promising objective improvements. Patients with disabling curvature in the chronic disease phase respond best to surgical intervention. A review of the mechanisms, adverse effects, and supporting literature are provided. CONCLUSION: The approach to concerns about Peyronie's disease should begin with understanding the patient's expectations and making the patient aware of associated successes and risks with each treatment option. Medical treatments provide a reasonable starting point, they: lessen pain in most, improve deformity in some, but completely resolve symptoms in only a few. Those who fail to experience adequate improvement with medical therapy, and those with stable yet significant deformity, should proceed to surgical intervention. The algorithm developed in this review provides an organized approach for making decisions about patient treatment.