The sad and bleak future for urology funding at the National Institutes of Health.

The bulk of federal funding for medical research is delivered through the National Institutes of Health (NIH). Because federal funding is coordinated through the annual discretionary budget review process, the budget for NIH varies from year to year. Small changes in the rate of funding growth lead to significant problems for individual researchers and their supporting institutions. There is no single metric that serves as a surrogate to predict the appropriations process. This article begins with a history and physical examination of NIH. Next, the authors review the internal NIH priorities that continue to drive the funding process. Finally, the authors give a brief review of the impact congressionally mandated medical research programs have had on disease-specific funding.

Current laparoscopy training in urology: a comparison of fellowships governed by the Society of Urologic Oncology and the Endourological Society.

BACKGROUND AND PURPOSE: Laparoscopic surgery is now an integral technique in the practice of urology, particularly in the management of certain urologic malignancies. Advanced laparoscopy training in urology is primarily reserved for those pursuing fellowship training and is offered both by traditional endourology fellowships and increasingly in urologic oncology fellowships. The purpose of our study was to evaluate and compare current laparoscopy training at the fellowship level. MATERIALS AND METHODS: A 17-item questionnaire was developed with support from both the Endourological Society (EUS) and Society of Urologic Oncology (SUO). Surveys were sent to program directors of fellowships recognized by the EUS and SUO. Directors were surveyed on the laparoscopic case volume, degree of oncology training, and career choice of their graduates. Data were analyzed with Wilcoxon rank-sum and Student t tests. RESULTS: Our survey had an overall response rate of 60%. Fellows performed more than 100 laparoscopies during their training period in 57% of EUS and 25% of SUO fellowship programs. Similar trends are demonstrated when analyzing robotic procedures, with 73% of EUS fellows performing more than 50 procedures compared with 43% of SUO fellows. The majority (59%) of EUS programs provide oncologic training. Between 44% and 100% of graduates from EUS and SUO fellowships obtain academic positions. The majority of SUO directors (63%) believe that fellowship training in laparoscopy should be provided in fellowships governed solely by the SUO, while 41% of EUS directors believe this training should be governed solely by the EUS. CONCLUSIONS: Endourology fellowships currently provide a greater exposure to laparoscopy and robotics than SUO fellowships. The percentage of fellows seeking academic positions is similar for EUS and SUO fellowship programs and has remained stable for several years. Directors of fellowship programs that offer advanced laparoscopic training have divergent views as to which administrative body should govern its future.

Agent Orange exposure, Vietnam War veterans, and the risk of prostate cancer.

BACKGROUND: It has been demonstrated that Agent Orange exposure increases the risk of developing several soft tissue malignancies. Federally funded studies, now nearly a decade old, indicated that there was only a weak association between exposure and the subsequent development of prostate cancer. Because Vietnam War veterans are now entering their 60s, the authors reexamined this association by measuring the relative risk of prostate cancer among a cohort of men who were stratified as either exposed or unexposed to Agent Orange between the years 1962 and 1971 and who were followed during the interval between 1998 and 2006. METHODS: All Vietnam War era veterans who receive their care in the Northern California Veteran Affairs Health System were stratified as either exposed (n=6214) or unexposed (n=6930) to Agent Orange. Strata-specific incidence rates of prostate cancer (International Classification of Diseases, 9th Revision code 185.0) were calculated. Differences in patient and disease characteristics (age, race, smoking history, family history, body mass index, finasteride exposure, prebiopsy prostate-specific antigen (PSA) level, clinical and pathologic stage, and Gleason score) were assessed with chi-square tests, t tests, a Cox proportional hazards model, and multivariate logistic regression. RESULTS: Twice as many exposed men were identified with prostate cancer (239 vs 124 unexposed men, respectively; odds ratio [OR], 2.19; 95% confidence interval [95% CI], 1.75-2.75). This increased risk also was observed in a Cox proportional hazards model from the time of exposure to diagnosis (hazards ratio [HR], 2.87; 95% CI, 2.31-3.57). The mean time from exposure to diagnosis was 407 months. Agent Orange-exposed men were diagnosed at a younger age (59.7 years; 95% CI, 58.9-60.5 years) compared with unexposed men (62.2 years; 95% CI, 60.8-63.6 years), had a 2-fold increase in the proportion of Gleason scores 8 through 10 (21.8%; 95% CI, 16.5%-27%) compared with unexposed men (10.5%; 95% CI, 5%-15.9%), and were more likely to have metastatic disease at presentation than men who were not exposed (13.4%; 95% CI, 9%-17.7%) than unexposed men (4%; 95% CI, 0.5%-7.5%). In univariate analysis, distribution by race, smoking history, body mass index, finasteride exposure, clinical stage, and mean prebiopsy PSA were not statistically different. In a multivariate logistic regression model, Agent Orange was the most important predictor not only of developing prostate cancer but also of high-grade and metastatic disease on presentation. CONCLUSIONS: Individuals who were exposed to Agent Orange had an increased incidence of prostate cancer; developed the disease at a younger age, and had a more aggressive variant than their unexposed counterparts. Consideration should be made to classify this group of individuals as 'high risk,' just like men of African-American heritage and men with a family history of prostate cancer.

Cystectomy in the elderly: does the survival benefit in younger patients translate to the octogenarians?

OBJECTIVE: To determine whether the survival benefit achieved with radical cystectomy (RC, the reference standard for treating muscle-invasive bladder cancer) in younger patients justifies its use in octogenarians. PATIENTS AND METHODS: We used the Surveillance Epidemiology and End Results data of the National Cancer Institute and identified 10 807 patients from 1992-2004 who were diagnosed with muscle-invasive bladder cancer, and were treated with either RC or radiotherapy. The data were analysed for age, gender, race, extent of lymphadenectomy and cause of death. We stratified the patients by age groups (<60, 60-69, 70-79 and >79 years), and used Kaplan-Meier survival analysis to compare treatment strategies by age group. RESULTS: In all, 8034 patients had RC and 2773 radiotherapy; RC was the primary method of treatment in all age groups except for octogenarians. Those who had RC had a sizeable overall survival advantage in all age groups, except for the octogenarians (18 vs 15 months). This small survival advantage improved only slightly (23 vs 15 months) when excluding patients having nodal or distant metastasis. The octogenarians who have RC with a limited pelvic lymph node dissection or RC alone receive little (16 vs 15 months) or no survival benefit. However, cancer-specific survival was significantly higher in those who had RC, including octogenarians. CONCLUSIONS: Octogenarians have some benefit to cancer-specific survival from RC if it includes a standard lymphadenectomy. The issue is how to better select the patients, as the overall survival advantage in these patients over radiotherapy is negligible.

Postoperative robotic telerounding: a multicenter randomized assessment of patient outcomes and satisfaction.

HYPOTHESIS: Patient safety and satisfaction are adversely affected when robotic videoconferencing (telerounding) is used in the postoperative setting. DESIGN: Randomized controlled trial. SETTING: Three academic institutions. PATIENTS: A total of 270 adults undergoing a urologic procedure requiring a hospital stay of 24 to 72 hours were randomized to receive either traditional bedside rounds or robotic telerounds. MAIN OUTCOME MEASURES: The primary outcome measure was postoperative patient morbidity. Secondary outcomes were patient-reported satisfaction and hospital length of stay. Other variables assessed included demographics, procedure, operative time, estimated blood loss, and mortality. Patients also completed a validated satisfaction instrument 2 weeks after hospital discharge. RESULTS: Patients were equally distributed based on the baseline demographic and operative measures. Morbidity rates were similar between the study arms (standard rounds vs telerounds: 16% vs 13%; P = .64). Length of stay was similar in both arms (standard rounds vs telerounds: 2.8 vs 2.8 days; P = .94). In addition, patient satisfaction was equivalently high in both arms of the study. CONCLUSIONS: Robotic telerounds matched the performance of standard bedside rounds after urologic surgical procedures. Virtual visits did not result in missed or increased postoperative complications. Hospital length of stay and ratings of hospital satisfaction were on par with those for traditional rounding.

Cost-benefit and outcome analysis: effect of prostate biopsy undergrading.

OBJECTIVES: Brachytherapy is a widely used treatment for localized prostate cancer (CaP) and is only appropriate as monotherapy for low-risk cancer. The predicted response to therapy is defined by the pretreatment parameters, of which the biopsy Gleason grade is central. However, the biopsy grade often misrepresents the true pathologic grade. We examined the impact of incorrect biopsy grading on brachytherapy outcomes. METHODS: We constructed a decision analytic model to assess the theoretical performance of brachytherapy for a theoretical cohort of men with Gleason score 6 CaP who underwent radical prostatectomy. The variables regarding biopsy Gleason scores and the correlation with the surgical specimen findings were generated from the institutional data. The ranges for these variables, biochemical performance of brachytherapy, costs, and disease state utilities, were obtained from a data review. RESULTS: For the base case, 67% of biopsy grades correlated with the pathologic grade. With this concordance, 8% of failures could be attributed, in part, to undergrading. On the basis of the model assumptions, as concordance worsened to 50%, the rate of undergraded failures increased to 12%. After adjusting for the quality of life associated with higher-grade disease and the risk of biochemical failure, the aggregate cost of treatment of biopsy grade 6 disease was increased by 8% because of undergrading ($75,700 versus $81,500 per case). The bulk of this effect was the cost of failure among patients with undergraded disease. CONCLUSIONS: Brachytherapy for Gleason score 6 disease is reported to have excellent results. Undergrading of prostate biopsies can negatively affect clinical outcomes and increase treatment costs. Although the risk is low, it should be considered when counseling patients with CaP.

The evolving presentation of renal carcinoma in the United States: trends from the Surveillance, Epidemiology, and End Results program.

PURPOSE: The incidence of renal cancer is increasing, while cases series suggest that tumor size is decreasing. This has important implications for treatment planning. We evaluated national trends in renal cancer size and observed survival in patients diagnosed in the 3 periods 1988 to 1992, 1993 to 1997 and 1998 to 2002. MATERIALS AND METHODS: From the Surveillance, Epidemiology, and End Results database we identified 29,053 patients diagnosed with primary renal cancer. Patients were stratified into size categories and 5-year time cohorts. Size distribution was compared across cohorts. Kaplan-Meier survival curves and Cox proportional hazards modeling were used to examine trends in overall and stage specific survival. RESULTS: From 1988 through 2002 renal tumor size decreased from 66.8 to 58.6 mm, while the age adjusted incidence of renal cancer increased from 8.6 to 11.2 cases per 100,000 individuals. Kaplan-Meier analysis showed steadily deteriorating survival with increased cancer size above 4 cm with a median survival of 105 months for 4 to 7 cm vs 46 months for more than 7 cm. Cox modeling demonstrated significantly improved survival in patients diagnosed in the latter cohorts. With adjustment for size the latter cohorts remained significantly improved compared to the earliest cohort, although the 1998 to 2002 cohort was no longer significantly different than the 1993 to 1997 cohort. CONCLUSIONS: Nationally renal tumor size at presentation has steadily and consistently decreased. Patients more recently diagnosed had improved survival, which could be attributable to decreased tumor size in the latter cohorts. Patients more recently diagnosed also demonstrated a relative survival advantage independent of size compared to the earliest patients studied.

Novel technique for testicular salvage after combat-related genitourinary injury.

We report a case of traumatic testicular injury resulting in significant loss of both tunica albuginea and seminiferous tubules. Secondary to the substantial tissue loss, our approach to surgical reconstruction required a certain degree of creativity. The injury was managed by creating a single midline testis with two distinct blood supplies. The use of this novel technique was necessary to achieve closure of the tunica albuginea. This case demonstrates the importance of the use of nontraditional reconstructive maneuvers to avoid orchiectomy, given the potential long-term health issues regarding infertility and androgen production.

Early outcomes of mid-urethral slings for female stress urinary incontinence stratified by valsalva leak point pressure.

AIMS: To assess the early results of mid-urethral slings placed via the transobturator approach (TVT-O) for stress urinary incontinence (SUI) in women with high (>60 cm H(2)O) and low (60 cm H(2)O) or low (60. CONCLUSIONS: With limited follow up, TVT-O appears to be a safe and effective surgical treatment for female SUI producing excellent results in patients with VLPP >60 cm/H(2)0. Patients with low VLPP may consider conventional, retropubic mid-urethral slings or other procedures as treatment for SUI.

Robot-assisted laparoscopic nephroureterectomy.

BACKGROUND: Laparoscopic nephroureterectomy for upper-tract urothelial tumors is a minimally invasive approach that parallels the open technique in oncologic efficacy. Multiple approaches to manage the distal ureter have been described. We developed a new technique using the daVinci robot system to perform a transvesical excision of the distal ureter and bladder cuff. PATIENTS AND METHODS: Ten consecutive patients with upper-tract urothelial cancer underwent a laparoscopic nephroureterectomy. The daVinci robot was docked through the umbilical, ipsilateral lateral rectus, and an additional contralateral lateral rectus port. The bladder was clam-shelled in a coronal orientation at the dome and the distal ureterectomy performed. RESULTS: Our technique was successful in all ten patients. The mean operative time for the entire case was 4.4 hours. The average hospital stay was 3 days. CONCLUSIONS: Robot-assisted laparoscopic nephroureterectomy is a safe, minimally invasive approach to upper- tract urothelial cancer that reduces the technical challenge of excision of the distal ureter.

Efficacy of transhepatic radiofrequency ablation of renal cell carcinoma.

OBJECTIVE: The purpose of this report is to describe an alternative, using a transhepatic route, to CT guidance of radiofrequency ablation of renal masses. CONCLUSION: In four supine patients, radiofrequency ablation of a right renal mass was performed under sonographic guidance. The radiofrequency ablation needle was placed transhepatically into the mass. Color sonography was useful in guiding needle placement and avoiding intervening vessels in the liver and kidney. This technique may be used in selected patients as an alternative to CT guidance of radiofrequency ablation.

Ship in a bottle: rapid extraction of large intravesical foreign bodies.

Objects placed in the bladder often become encrusted with stone. Using a technique combining endoscopic visualization and a small open cystotomy, a large encrusted foreign body was successfully and safely removed. The combination of endoscopy and cystotomy is rapid, safe, and potentially applicable for the removal of large vesical calculi.

Testicular cancer patterns in African-American men.

OBJECTIVES: To compare the testicular cancer incidence, pathologic grade, stage, and survival between African Americans and whites. African Americans had a worse outcome relative to whites with regard to a number of different malignancies. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, we extracted all testicular cancer cases among white and African-American males for 1985 to 2000. Baseline demographic data included age at diagnosis, year of diagnosis, stage at diagnosis, and histologic type. Survival was examined using the Kaplan-Meier method and Cox proportional hazards modeling. RESULTS: The incidence of testicular cancer among African Americans was one fourth that observed among whites. However, African-Americans presented with a higher disease stage at diagnosis. African Americans also presented with significantly lower proportions of embryonal cell carcinoma. Overall survival among African-Americans was significantly worse at both 5 and 10 years. When overall survival was adjusted for stage at presentation and histologic type, the observed survival differences disappeared. CONCLUSIONS: African Americans appear to present with a higher disease stage than do whites. Observed differences in survival for the African-American group relative to whites appear to be primarily due to delayed presentation. Cultural perceptions of malignancy and understanding of cancer screening may be an important determinant of later presentation. Healthcare access and education issues, rather than inherent biologic differences, appear to be the primary underlying factor for the observed survival differences in African-American males.

Testicular cancer patterns in Asian-American males: an opportunity for public health education to impact outcomes.

OBJECTIVES: To examine the racial differences in testicular cancer incidence, pathologic grade, stage, and survival with specific reference to Asian and white Americans and to evaluate the impact of disparities in stage at presentation, if present, on survival. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, we extracted all testicular cancer cases among white and Asian-American males for the years 1973 to 2000. Baseline demographic data included age at diagnosis, year of diagnosis, stage at diagnosis, and histologic features. Survival was examined using the Kaplan-Meier method and Cox proportional hazards modeling. RESULTS: The incidence of testicular cancer is lower among Asian Americans than among whites. However, Asian-American males presented with higher stage disease at diagnosis. Significant differences were noted in the histologic features between the two groups, with Asian Americans presenting with greater rates of seminoma. Asians also demonstrated survival differences, with poorer unadjusted survival compared with whites. However, when the variables of stage at diagnosis and histologic features were included in the analysis, the survival curves became similar. CONCLUSIONS: Asians appeared to present with higher stage disease than do whites. Observed differences in survival for the Asian group relative to whites appeared to be primarily a result of delayed presentation. Cultural perceptions of malignancy and the understanding of cancer screening may be important determinants of later presentation. Healthcare access and education issues, rather than inherent biologic differences, are more likely the primary underlying factors for the observed survival differences in Asian males.

Telerounding and patient satisfaction after surgery.

BACKGROUND: Technologic advances in communications have facilitated the development and diffusion of telemedicine. Most applications have focused on remote outpatient management of medical conditions. We assessed the impact of introducing remote video conferencing during the immediate postoperative period (telerounds) on patient-reported satisfaction with their hospitalization. STUDY DESIGN: Between October 2002 and June 2003,85 patients undergoing elective laparoscopic or percutaneous urologic procedures were enrolled in a trial testing the impact of telerounds on patients' satisfaction with their hospitalization. Participants were entered into one of three postoperative care arms: standard once-daily attending bedside rounds; standard once-daily attending level bedside rounds plus one afternoon telerounding visit; or a substitution of one daily bedside round with a robotic telerounding visit. Participants completed a validated patient satisfaction survey 2 weeks after hospital discharge. RESULTS: Eighty-five individuals (100% response rate) completed the questionnaire. With responses dichotomized to "excellent" or "other," patients in the telerounding arm demonstrated statistically substantial improvements in ratings of examination thoroughness, quality of discussions about medical information, postoperative care coordination, and attending physician availability. Patients in the robotic telerounding arm indicated considerably higher satisfaction with regard to physician availability. After adjusting for age differences, ratings of each of the previously listed aspects of care remained notably improved in the telerounding arm. CONCLUSIONS: Telerounding either as an additional visit or as a substituted bedside visit is associated with increased patient satisfaction in postoperative care. This type of interaction appears to acceptably facilitate physician communication with hospitalized patients.

Analysis of treatment for small cell cancer of the bladder and report of three cases.

OBJECTIVES: To present our experience with 3 patients with small cell cancer (SCC) of the bladder who were treated with different modalities and review the literature for patients undergoing primary chemoradiotherapy. SCC of the bladder is a rare tumor, with patients commonly presenting with metastatic disease. Surgery, radiotherapy, and chemotherapy, either alone or as part of combined therapy, have been used. Because of the rarity of this disease, no prospective studies evaluating the most effective treatment have been done. METHODS: The medical records of 3 patients diagnosed with SCC of the bladder at our institution were reviewed. Additionally, we reviewed published reports to identify all cases of SCC of the bladder treated with primary chemoradiotherapy. RESULTS: Three patients with SCC of the bladder were identified at our institution. A total of 23 patients with SCC of the bladder who were treated with primary chemoradiotherapy were identified: 22 in published reports and 1 at our institution. Patients presented with muscle-invasive disease (17%), extravesical disease only (26%), and metastatic disease (52%). Multiagent chemotherapy was administered to most patients. The reported median radiation dose was 6000 cGy. A total of 16 patients (70%) were alive at a median follow-up of 34 months. The median survival of patients had not yet been reached in this study at the last follow-up. We did not find any reports of SCC recurrence in the bladder, and the bladder was preserved in most patients (87%). CONCLUSIONS: SCC of the bladder should be viewed as a systemic disease, because most patients present with metastatic disease. Primary chemoradiotherapy appears to be an effective treatment modality. Prospective studies are needed to evaluate the optimal treatment further.

Radical endoscopic assisted perineal prostatectomy.

PURPOSE: During radical perineal prostatectomy transection of the bladder neck and dissection of the seminal vesicles under direct vision can be difficult. We describe a technique of radical endoscopic assisted perineal prostatectomy that facilitates dissection of these structures. MATERIALS AND METHODS: Cadaveric dissections were performed in 4 individuals to develop and assess the technique. It was subsequently applied to a 64-year-old male with clinically localized prostate cancer (Gleason grade 3+3). Management of the bladder neck and seminal vesicles was performed with a bipolar transurethral resectoscope. The remainder of the procedure was performed via a traditional subsphincteric perineal approach with the patient in the standard dorsal lithotomy position. RESULTS: The bladder neck and seminal vesicles were successfully dissected in 55 minutes. Total operative time was 3 hours. Estimated blood loss was 500 cc. The patient was discharged home the morning of postoperative day 1 and the catheter was removed in the clinic on postoperative day 7. The final pathology report showed organ confined prostate cancer (Gleason 3+3). CONCLUSIONS: Radical endoscopic assisted perineal prostatectomy allows precise dissection of the bladder neck and seminal vesicles under direct vision. Accomplishing this dissection as the initial step of the procedure mobilizes the prostate, facilitating excision, and obviates the need for the extreme lithotomy position.