Effect of elective inguinal hernia repair on urinary symptom burden in men.

BACKGROUND: Our study sought to examine the prevalence of urinary symptoms in men undergoing hernia repair and whether there is an association between symptoms and short-term outcomes. METHODS: This is a prospective cohort study of male veterans consenting to inguinal hernia repair. The American Urological Association Symptom Score (AUASS) was administered preoperatively at 48 hours and again at 30 days after surgery. RESULTS: Median preoperative AUASS was 6 (interquartile range [IQR]: 3 to 12); at 48 hours, the median score increased significantly to 10 (IQR: 4 to 16, P < .01) and at 30 days, the median score dropped below baseline to 3 (IQR: 1 to 8, P < .0001). Multivariable linear regression modeling revealed that the use of an intraoperative urinary catheter was significantly associated with an increase in AUASS from preop to both 48 hours and 30 days. CONCLUSION: Elective repair of an inguinal hernia is associated with reduction in urinary symptom burden at 30 days, whereas the use of an intraoperative foley catheter is associated with no improvement at 30 days.

National trends in hospitalization from indwelling urinary catheter complications, 2001-2010.

PURPOSE: The purpose of this study is to investigate national trends in hospitalization from indwelling urinary catheters complications from 2001 to 2010. MATERIALS AND METHODS: The Healthcare Utilization Project Nationwide Inpatient Sample database was analyzed for this study. We examine hospitalization rates, patient demographics, hospital stays, insurance provider, hospital type, geographic location, and septicemia rates of patients hospitalized for indwelling urinary catheter complications from 2001 to 2010. RESULTS: Hospitalization from indwelling urinary catheters almost quadrupled from 11,742 in 2001 to 40,429 in 2010. The increases have been due to patients who are older and predominantly male compared to all hospitalization. The "national bill" increased from $213 million to $1.3 billion (a factor of 6) after adjusting for inflation. Most patients had urinary tract infections, 77 % in 2001 and 87 % in 2010. Septicemia in indwelling urinary catheter hospitalization patients has increased from 21 % in 2001 to 40 % in 2010. In 2010, secondary diseases associated with hospitalization due to indwelling urinary catheters included urinary tract infections (86.5 %), adverse effects of medical care (61.9 %), bacterial infection (48.6 %), and septicemia (40.3 %). CONCLUSIONS: Hospitalization due to indwelling urinary catheter complications has almost quadrupled from 11,742 in 2001 to 40,429 in 2010, and the majority of patients had urinary tract infections. Septicemia is of particular concern since rates have almost doubled (from 21 to 40 % over the period) in these patients. The specific medical indication for urinary catheters used postoperatively should be scrutinized, and the duration of placement should be minimized to reduce future complication rates.

Efficacy of adding behavioural treatment or antimuscarinic drug therapy to α-blocker therapy in men with nocturia.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Nocturia is a common and bothersome lower urinary tract symptom, particularly in men. Many single drug therapies have limited benefit. For men who have persistent nocturia despite alpha-blocker therapy, the addition of behavioural and exercise therapy is statistically superior to anticholinergic therapy. OBJECTIVE: To compare reductions in nocturia resulting from adding either behavioural treatment or antimuscarinic drug therapy to α-adrenergic antagonist (α-blocker) therapy in men. PATIENTS AND METHODS: Participants were men who had continuing urinary frequency >8 voids/day) and urgency after 4 weeks of α-blocker therapy run-in and who had ≥1 nightly episode of nocturia. Participants received individually titrated drug therapy (extended-release oxybutynin) or multicomponent behavioural treatment (pelvic floor muscle training, delayed voiding and urge suppression techniques). Seven-day bladder diaries were used to calculate reductions in mean nocturia. RESULTS: A total of 127 men aged 42-88 years with ≥1 nocturia episode per night were included in the study. There were 76 men who had a mean of ≥2 nocturia episodes. Among those with ≥1 nocturia episode, behavioural treatment reduced nightly nocturia by a mean of 0.97 episodes and was significantly more effective than drug therapy (mean reduction = 0.56 episodes; P = 0.01). Participants with ≥2 episodes nocturia at baseline also showed larger changes with behavioural treatment compared with antimuscarinic therapy (mean reduction = 1.26 vs 0.61; P = 0.008). CONCLUSIONS: Both behavioural treatment and drug therapy reduced nocturia in men with ≥1 episode of nocturia/night when added to α-blocker therapy. These results were similar even when only those with ≥2 episodes of nocturia were considered. The addition of behavioural treatment was statistically better than bladder-relaxant therapy for nocturia.

Retrograde renal cooling to minimize ischemia.

OBJECTIVE: During partial nephrectomy, renal hypothermia has been shown to decrease ischemia induced renal damage which occurs from renal hilar clamping. In this study we investigate the infusion rate required to safely cool the entire renal unit in a porcine model using retrograde irrigation of iced saline via dual-lumen ureteral catheter. MATERIALS AND METHODS: Renal cortical, renal medullary, bowel and rectal temperatures during retrograde cooling in a laparoscopic porcine model were monitored in six renal units. Iced normal saline was infused at 300 cc/hour, 600 cc/hour, 1000 cc/hour and gravity (800 cc/hour) for 600 seconds with and without hilar clamping. RESULTS: Retrograde cooling with hilar clamping provided rapid medullary renal cooling and significant hypothermia of the medulla and cortex at infusion rates ≥ 600 cc/hour. With hilar clamping, cortical temperatures decreased at -0.90 C/min. reaching a threshold temperature of 26.90 C, and medullary temperatures decreased at -0.90 C/min. reaching a temperature of 26.10 C over 600 seconds on average for combined data at infusion rates = 600 cc/hour. The lowest renal temperatures were achieved with gravity infusion. Without renal hilum clamping, retrograde cooling was minimal at all infusion rates. CONCLUSIONS: Significant renal cooling by gravity infusion of iced cold saline via a duel lumen catheter with a clamped renal hilum was achieved in a porcine model. Continuous retrograde irrigation with iced saline via a two way ureteral catheter may be an effective method to induce renal hypothermia in patients undergoing robotic assisted and/or laparoscopic partial nephrectomy.

Retrograde Renal Cooling to Minimize Ischemia

Objective: During partial nephrectomy, renal hypothermia has been shown to decrease ischemia induced renal damage which occurs from renal hilar clamping. In this study we investigate the infusion rate required to safely cool the entire renal unit in a porcine model using retrograde irrigation of iced saline via dual-lumen ureteral catheter. Materials and Methods: Renal cortical, renal medullary, bowel and rectal temperatures during retrograde cooling in a laparoscopic porcine model were monitored in six renal units. Iced normal saline was infused at 300 cc/hour, 600 cc/hour, 1000 cc/hour and gravity (800 cc/hour) for 600 seconds with and without hilar clamping. Results: Retrograde cooling with hilar clamping provided rapid medullary renal cooling and significant hypothermia of the medulla and cortex at infusion rates ≥ 600 cc/hour. With hilar clamping, cortical temperatures decreased at -0.9° C/min. reaching a threshold temperature of 26.9° C, and medullary temperatures decreased at -0.90 C/min. reaching a temperature of 26.1° C over 600 seconds on average for combined data at infusion rates ≥ 600 cc/hour. The lowest renal temperatures were achieved with gravity infusion. Without renal hilum clamping, retrograde cooling was minimal at all infusion rates. Conclusions: Significant renal cooling by gravity infusion of iced cold saline via a duel lumen catheter with a clamped renal hilum was achieved in a porcine model. Continuous retrograde irrigation with iced saline via a two way ureteral catheter may be an effective method to induce renal hypothermia in patients undergoing robotic assisted and/or laparoscopic partial nephrectomy. .

Protective effects of reducing renal ischemia-reperfusion injury during renal hilar clamping: use of allopurinol as a nephroprotective agent.

OBJECTIVE: To investigate the relationship between renal ischemia injury and concentrations of 8-isoprostane in a rat kidney model during renal hilar clamping and their correlation with the administration of allopurinol before clamping. MATERIALS AND METHODS: Reperfusion injury occurs after the reintroduction of blood flow after a prolonged period of ischemia. Thought to be due to oxygen free radicals released by the endothelial, mitochondrial, and parenchymal cells, this process leads to a cascade of events whereby infiltrative leukocytes generate cytokines and reactive oxygen species. The present study was performed in 2 parts. Our primary objective was to first develop a method of quantitating the renal damage using a prostaglandin compound formed in vivo, specifically isoprostane. After the development of this animal model of quantitating renal injury, our second objective was to apply this model and investigate allopurinol's nephroprotective abilities. A microdialysis probe was inserted into the renal parenchyma of rats to allow continuous dialysis and collection of the effluent for isoprostane levels. After clamping of the renal vessels to induce ischemia, the interstitial effluent from the probe was collected and subsequently analyzed for 8-isoprostane levels with and without allopurinol pretreatment. RESULTS: Clamping of the renal hilum in this rat model significantly increased 8-isoprostane levels. After 60 minutes of clamp time, the largest absolute increase in 8-isoprostane levels resulted, representing a 3.2-fold increase from baseline. However, the rats that had been pretreated with allopurinol demonstrated significantly less isoprostane levels, to baseline levels. CONCLUSION: Allopurinol has demonstrated significant benefits by reducing reperfusion injury in rat kidneys, as demonstrated by the use of 8-isoprostane as a tool for the real-time measurement of ischemic injury.

Underutilization of partial nephrectomy for stage T1 renal cell carcinoma in the United States, trends from 2000 to 2008. A long way to go.

INTRODUCTION: Recent American Urologic Association Guidelines for small renal masses recommend partial nephrectomy for surgical treatment of T1 renal masses to preserve renal function and minimize cardiovascular comorbidities. This procedure is performed more often than in the past, after the technical issues of hemorrhage, fistula, and technique evolved. We reviewed the trends, practice patterns, and application of partial nephrectomy for T1 renal cell carcinoma in the United States from 2000 to 2008, before the American Urologic Association Guidelines. The objective is to investigate whether economic or societal factors favor the use of partial over radical nephrectomy surgery. METHODS: Data on 142,194 cases from 1267 hospitals diagnosed with kidney and renal pelvis cancer in the National Cancer DataBase from 2000 to 2008 were the basis of the study. RESULTS: Partial nephrectomy rates for stage T1 kidney and renal pelvis cancer have increased from 17% in 2000 to 31% in 2008. Differences in partial nephrectomy rates that arise from sex or race were not large. However, there was a disproportionate increase based on income and education. Also, there were differences based on insurance status; patients with managed care, in the military and veterans had higher partial nephrectomy rates. Partial nephrectomy rates were higher in teaching and research hospitals and in veterans hospitals. Geographically, the procedure was performed at higher rates in the eastern and midwestern parts of the country. CONCLUSIONS: Partial nephrectomy rates for stage T1 renal cell carcinoma increased from 17% in 2000 to 31% in 2008. The procedure has been used preferentially with patients who are more educated and have high incomes.

Robotic urologic reconstructive procedures.

PURPOSE OF REVIEW: This review provides an overview of reconstructive robotic procedures in urology. Recently, robotic surgeons have described techniques in urologic reconstruction. We summarize the literature regarding outcomes and surgical steps for robotic pyeloplasty, robotic ureteral neocystostomy with ureteral reimplantation and robotic ureteroureterostomy/ureterolithotomy. RECENT FINDINGS: Outcomes reveal robotic assistance has greatly decreased the morbidity of urinary tract reconstruction, when compared with open surgical techniques. In addition, the superior visual and manual acuity of the robot allows one to perform surgical steps easier as compared with conventional laparoscopy. SUMMARY: Robotic assistance provides many benefits for urinary tract reconstruction and in this review we outline the salient features, with the goal of adding these techniques to the urology armamentarium. Future outcome studies need to confirm the long-term efficacy of these techniques.

Population densities in relation to bladder cancer mortality rates in America from 1950 to 1994.

OBJECTIVE: Previous studies have reported that bladder cancer risks are elevated in industrial and urban areas. The cause is believed to be the result of occupational exposure from industries located in urban areas. Recent studies suggest that traffic air pollution may also increase bladder cancer risks. The study purpose is to investigate the relationship between bladder cancer mortality and population density of counties in America. Another objective is to explore traffic air pollution and industrial exposures as risk factors. MATERIALS AND METHODS: Bladder cancer mortality rates for white men and women from 1950 to 1994 and population densities (population per 10 square miles) of 2,248 counties were the basis of the study. A linear regression analysis was performed to evaluate the relationship between bladder cancer mortality rates and population densities after log transforming the population density data set. In addition, the counties were divided into quartiles based on bladder cancer mortality rates. Mean population density values with 95% confidence intervals for the quartiles were computed. RESULTS: Correlation coefficients (R) between bladder cancer mortality rates and the population densities were R = .37, P < .001 for men and R = .28, P < .001 for women. In addition, population densities increased with increasing bladder cancer mortality rates across all quartiles. The mean population density of the highest quartile was more than ten times higher than the lowest. CONCLUSIONS: In this study, we found a strong association between bladder cancer mortality and population density. Traffic air pollution is a potential cause.

Isoprostane: quantitation of renal ischemia and reperfusion injury after renal artery clamping in an animal model.

BACKGROUND AND PURPOSE: Laparoscopic and robotic partial nephrectomy involves temporary clamping of the renal artery, making the kidney susceptible to ischemic damage. Isoprostane represents one potential marker of oxidative injury. The objective was to determine if renal interstitial isoprostane levels can quantitate renal damage secondary to warm ischemia. A second goal is to investigate allopurinol for renoprotective abilities using this model. We chose to investigate potential renoprotection of allopurinol because previous studies have demonstrated transplant kidneys pretreated with allopurinol to have less damage from ischemia. MATERIALS AND METHODS: A microdialysis probe was inserted into the renal parenchyma of rats to allow continuous dialysis and collection of the effluent for isoprostane levels. After clamping of the renal vessels for predefined intervals of ischemia, the interstitial effluent from the probe was collected and subsequently analyzed for isoprostane levels with and without allopurinol pretreatment. RESULTS: Clamping of the renal artery and vein produced increases in isoprostane levels during the ischemic period and larger increases during reperfusion. There was a trend for increased postclamp isoprostane levels as clamp times increased. When comparing isoprostane levels in rats that did not receive allopurinol, there were significant differences between the clamp and postclamp levels of isoprostane, with allopurinol offering protection to the kidney from ischemic changes caused by clamping the renal hilum. CONCLUSIONS: Our data have demonstrated that isoprostane levels are a potential real-time marker of renal ischemia and reperfusion injury. We also found allopurinol administration demonstrated a trend toward renoprotective abilities in the hilar occluded kidney.

Behavioral versus drug treatment for overactive bladder in men: the Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial.

OBJECTIVES: To compare the effectiveness of behavioral treatment with that of antimuscarinic therapy in men without bladder outlet obstruction who continue to have overactive bladder (OAB) symptoms with alpha-blocker therapy. DESIGN: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial was a two-site randomized, controlled, equivalence trial with 4-week alpha-blocker run-in. SETTING: Veterans Affairs Medical Center outpatient clinics. PARTICIPANTS: Volunteer sample of 143 men aged 42 to 88 who continued to have urgency and more than eight voids per day, with or without incontinence, after run-in. INTERVENTIONS: Participants were randomized to 8 weeks of behavioral treatment (pelvic floor muscle exercises, urge suppression techniques, delayed voiding) or drug therapy (individually titrated, extended-release oxybutynin, 5-30 mg/d). MEASUREMENTS: Seven-day bladder diaries and a validated urgency scale were used to calculate changes in 24-hour voiding frequency, nocturia, urgency, and incontinence. Secondary outcomes were global patient ratings and American Urological Association Symptom Index. RESULTS: Mean voids per day decreased from 11.3 to 9.1 (-18.8%) with behavioral treatment and 11.5 to 9.5 (-16.9%) with drug therapy. Equivalence analysis indicated that posttreatment means were equivalent (P < .01). After treatment, 85% of participants rated themselves as much better or better; more than 90% were completely or somewhat satisfied, with no between-group differences. The behavioral group showed greater reductions in nocturia (mean = -0.70 vs -0.32 episodes/night; P = .05). The drug group showed greater reductions in maximum urgency scores (mean = -0.44 vs -0.12; P = .02). Other between-group differences were nonsignificant. CONCLUSION: Behavioral and antimuscarinic therapy are effective when added to alpha-blocker therapy for OAB in men without outlet obstruction. Behavioral treatment is at least as effective as antimuscarinic therapy.

Does urological cancer mortality increase with low population density of physicians?

PURPOSE: We examined the association between urological cancer mortality rates and the presence of physicians. We hypothesized that cancer mortality rates increase with a low physician population density since this would decrease the detection of cancers at an early stage. MATERIALS AND METHODS: Mortality rates for prostate cancer, bladder cancer, kidney and renal pelvis cancer, and cancer at all sites for white patients in United States counties from 2003 to 2007 were obtained from the National Vital Statistics System. High and low rate groups of counties were reviewed for each type of cancer. The high rate groups consisted of 15 or 25 counties with the highest cancer mortality rates. The low rate groups consisted of counties, selected from the same states as high rate groups, with the lowest mortality rates. Levels of physicians per 10,000 general population, income, poverty and no health insurance were compared between the high and low cancer rate groups. RESULTS: There was a statistically significant inverse association between physician population density levels and kidney and renal pelvis cancer mortality rates. The association was suggestive for bladder cancer and prostate cancer mortality but not for cancer at all sites. There was also a tendency for an inverse association between family income and cancer mortality rates. CONCLUSIONS: Kidney and renal pelvis cancer mortality rates increased significantly with a low physician population density. We found a suggestive but not significant negative association between physician population density and mortality rates for prostate cancer and bladder cancer but not for cancer at all sites. Low family income was associated with higher cancer rates.

Bladder neck closure and suprapubic catheter placement as definitive management of neurogenic bladder.

OBJECTIVE: Surgical management for neurogenic bladder may require abandonment of the native urethra due to intractable urinary incontinence, irreparable urethral erosion, severe scarring from previous transurethral procedures, or urethrocutaneous fistula. In these patients, bladder neck closure (BNC) excludes the native urethra and provides continence while preserving the antireflux mechanism of the native ureters. This procedure is commonly combined with ileovesicostomy or continent catheterizable stoma, with or without augmentation enterocystoplasty. Alternatively, BNC can be paired with suprapubic catheter diversion. This strategy does not require a bowel segment, resulting in shorter operative times and less opportunity for bowel-related morbidity. The study purpose is to examine preoperative characteristics, indications, complications, and long-term maintenance of renal function of BNC patients. METHODS: A retrospective review of medical records of 35 patients who underwent BNC with suprapubic catheter placement from 1998 to 2007 by a single surgeon (LKL) was completed. RESULTS: Neurogenic bladder was attributable to spinal cord injury in 71%, 23% had multiple sclerosis, and 9% had cerebrovascular accident. Indications for BNC included severe urethral erosion in 80%, decubitus ulcer exacerbated by urinary incontinence in 34%, urethrocutaneous fistula in 11%, and other indications in 9%. The overall complication rate was 17%. All but two patients were continent at follow-up. Forty-nine per cent of patients had imaging available for review, none of which showed deterioration of the upper tracts. CONCLUSIONS: Our results suggest that BNC in conjunction with suprapubic catheter diversion provides an excellent chance at urethral continence with a reasonable complication rate.

Urothelial cancers after renal transplantation.

OBJECTIVE: After solid organ transplantation, risk of cancer varies significantly based on cancer type. In this study, we determine the incidence of urothelial cancers (bladder and kidney) after renal transplantation from a single high-volume transplantation institution. In addition, we analyze the risk factors and review outcomes from the patients. MATERIALS AND METHODS: We performed a retrospective review of all patients in the University of Alabama at Birmingham (UAB) transplant database to identify all patients who received renal transplants at UAB between January 1, 1990, and January 1, 2010. We further identified transplant patients diagnosed with bladder, urothelial of other cancers in the same time period. We also examined tumor-specific variables such as presentation, clinical and pathologic staging, treatment type, recurrence, progression, interval to recurrence and progression, cancer-specific mortality, and interval from time to diagnosis to death. RESULTS: Review of the transplant database confirmed 5,920 renal transplants. Thirteen patients underwent the diagnosis of urothelial cancer, providing an incidence of 0.2%. Eight patients had bladder cancer for an incidence of 0.13%, compared to an incidence of 0.02% among the general population. Patients diagnosed with bladder cancer after renal transplantation were younger than those in the general population and frequently present with more advanced and aggressive disease. CONCLUSIONS: Patients are at an elevated risk of urothelial cancers after renal transplantation probably from immune suppression.

Characterizing changes in kidney and renal pelvis cancer incidence from 1998 to 2006 in the United States.

In this study, we characterize the changes in kidney and renal pelvis cancer (RCC) from 1998 to 2006 in the United States. The goal is to examine variations in stage and treatments. In addition, we explore changes in risk factors that have occurred over the same period. Data on over 20,000 patients diagnosed with RCC in National Cancer Data Base were used for the study. We investigated the changes in stage and treatment rates based on race, gender and age at diagnosis from 1998 to 2006. Changes in smoking, obesity and hypertension rates over the period were examined for comparison. The increase in RCC incidence rates from 1998 to 2006 was almost entirely a result of increases in stage I. Increases for blacks were proportionally higher than whites. Obesity and hypertension increased over the period but smoking declined. In terms of treatment, there was an increase in surgery cases primarily for stage I. There were no significant differences in trends based on gender, although rates in men were 65% greater than in women. The mean age at diagnosis was stable for stages I-IV. There are increased incidences of renal tumors, particularly stage I renal cancer among blacks and whites from 1998 to 2006. Patients were more likely to undergo surgical therapy for these tumors.

The effect of prostate cancer screening on stage IV disease in America.

OBJECTIVE: Some studies have found that prostate cancer (PCa) screening provides little or no change in PCa-related mortality during the 7-10 years following diagnoses. However, most men are diagnosed with PCa at low-stage disease and die of unrelated causes during this period. Men diagnosed at stage IV are at much higher risk of dying of the disease. Therefore, stage IV rates at first diagnoses may be a surrogate marker of PCa-related mortality over a time span less than 10 years. The study objective is to examine the association between PCa screening and stage IV disease rates in new cases to explore potential benefits for PCa screening. MATERIALS AND METHODS: The percent of stages I, II, III, IV and unclassified PCa diagnosed in white males in 2005 was compared to PCa screening rates on a state-by-state basis. To consider access to medical care and socioeconomic status, median family income, degree of urbanization, urologist population density and health insurance status were included in the analysis. RESULTS: PCa stage IV disease correlated inversely with PCa screening rates (r = -0.42, P = 0.006) where r is the correlation coefficient and P is the probability. Stage I PCa correlated with lack of health insurance (r = 0.37, P = 0.02). CONCLUSIONS: The results of this study suggest that with PCa screening may be associated with reduced rates of stage IV disease.

Surgical factors affecting return of renal function after partial nephrectomy.

INTRODUCTION: Nephron-sparing surgery is becoming the standard treatment for small renal tumors. In this study, we investigate the relationship between operative factors and recovery of renal function after partial nephrectomy. METHODS: Records of 141 partial nephrectomy patients at the University of Alabama Medical Center at Birmingham between 1999 and 2008 were reviewed retrospectively. Renal function was assessed preoperatively, at 1 day (early) and 6 months (late) postoperatively by calculated creatinine clearance (CC). Anesthesia time, arterial clamp time, use of ice slush, tumor size, and change in hematocrit following surgery were assessed for their impact on change in early and late renal function after adjusting for patient age, gender, race, co-morbidities, preoperative renal function and operative approach. Descriptive statistics are presented for independent predictors and research outcome by time points. Multivariate regression model was used to identify independent predictors of renal function. RESULTS: Increasing anesthesia time, clamp time, and postoperative hematocrit were associated with decreased renal function (CC) at 1 day postoperative. At 6 months, tumor size and change in early postoperative hematocrit predicted a decline in CC. In multivariate analysis, decreased renal function at 6 months was predicted by change in postoperative hematocrit level. CONCLUSION: Long hilar clamp times and anesthesia times adversely affect early postoperative renal function but not late renal function. Intraoperative bleeding adversely affected renal function at both early and late time points. Limiting intraoperative blood loss may be more important than clamp times or renal cooling in the recovery of renal function after partial nephrectomy.

Bladder cancer incidence and mortality rates compared to ecologic factors among states in America.

PURPOSE: Smoking, inadequate vitamin D and pesticide exposure have been linked to bladder cancer (BCa) in past studies. The objective of this study is to explore associations between BCa rates and these risk factors. MATERIALS AND METHODS: BCa incidence and mortality rates among states were compared to smoking; solar ultraviolet (UV) radiation levels and drinking water from a surface water supply (which has greater residual pesticide contamination than groundwater and both are used as sources for drinking water). Lack of health insurance, median family income and urbanization were included to adjust for access to health care and socioeconomic status. RESULTS: BCa incidence and mortality correlated directly with smoking and inversely with solar UV radiation for males and females. BCa mortality correlated directly with drinking surface water for both sexes. Lack of health insurance correlated inversely with BCa incidence for females and trended toward significance for males. Multivariable analyses identified solar UV radiation as the best predictor of BCa incidence in males and solar UV radiation and smoking in females. Solar UV radiation, smoking and drinking surface water were the best predictors of BCa mortality in males, while smoking and drinking surface water were the best predictors of mortality in females. CONCLUSIONS: BCa incidence and mortality for both sexes correlated directly with smoking and inversely with solar UV radiation levels. BCa mortality for both sexes correlated with drinking water from a surface water source. It is hypothesized that BCa mortality risks may increase from drinking water contaminated with low levels of pesticides.