Long-term durability of pubovaginal fascial slings in women who then become pregnant and deliver.

INTRODUCTION AND HYPOTHESIS: Pubovaginal fascial slings are commonly performed after childbearing is completed. Limited data is available regarding women who become pregnant following a sling procedure. METHODS: Three hundred forty-one women of childbearing age underwent pubovaginal sling surgery at our institution from July 1993 to December 2005. All patients were sent a questionnaire regarding their incontinence and health status. RESULTS: Nine women who delivered following surgery were identified (seven vaginal and two cesarean sections). Overall, five remained dry, three had no change in continence, and one noted worsening incontinence. Four women completed questionnaires (two vaginal and two caesarean sections). One patient who delivered vaginally reported high symptom scores and dissatisfaction while the remaining three reported low symptom scores and satisfaction. CONCLUSIONS: The pubovaginal fascial sling is a durable option for women with reproductive potential. Given our results, both vaginal delivery and cesarean section appear to be acceptable modes of delivery in this patient population.

Understanding differences between high and low volume hospitals for radical prostatectomy.

OBJECTIVES: We evaluated the impact of the specialized medical and ancillary services available at low vs. high volume prostatectomy centers on prolonged length of stay (LOS) outcomes after radical prostatectomy. METHODS: Using the Nationwide Inpatient Sample, we identified patients who underwent prostatectomy (n = 9,266) for prostate cancer in 2003 using ICD-9 codes. Hospital characteristics were ascertained using the American Hospital Association file. Differences in health services availability according to hospital prostatectomy volume were estimated using logistic regression. Logistic models were fitted to measure the effect of available health services on a prolonged LOS (>90 percentile for sample was 5 days). RESULTS: Among patients undergoing radical prostatectomy in 2003, 19.0% and 5.4% of patients had a prolonged LOS at low and high volume hospitals, respectively (unadjusted OR 4.2, 95% CI 2.5-6.9). After adjusting for differences in patients and availability of select health services, those treated at low volume centers were 3.3 times more likely to have a prolonged hospitalization compared with those treated at high volume hospitals (95% CI 1.9-5.6). Adjusting for hospital differences attenuated the volume effect by 14.8%. CONCLUSIONS: There are substantial differences in the health care environment according to radical prostatectomy volume. Generally, high volume hospitals offer a much wider array of health care services specific to both post-prostatectomy and general medical care.

Long-term follow-up after epididymectomy for chronic epididymal pain.

OBJECTIVES: Epididymectomy is an option for the relief of epididymal pain related to postoperative obstruction, epididymal cysts, or epididymitis. We performed 66 epididymectomies on 52 patients from 1996 to 2006 at our institution for localized epididymal pain. We evaluated the long-term symptomatic relief after epididymectomy. METHODS: All 52 epididymectomy patients were mailed questionnaires regarding their current pain level and satisfaction. Patients who did not return the questionnaires were interviewed by telephone for follow-up. RESULTS: Of the 52 patients, 34 returned 44 completed questionnaires (the patients with bilateral procedures were mailed a questionnaire for each side). The average age at epididymectomy was 44.2 years (range 25.0 to 67.9). The average follow-up was 45.8 months (range 4.2 to 119.3). Of the 34 procedures, 17 were left sided, 7 right sided, and 10 were bilateral; 25 had been performed for postvasectomy pain and 5 for obstruction related to hernia repair. Of the 44 cases, 31 (70%) reported no pain. Of the 13 still with pain, 8 (62%) reported less pain. Also, 90% were very satisfied or satisfied with their choice to undergo epididymectomy. CONCLUSIONS: We found excellent results after epididymectomy, especially for the indication of postvasectomy pain.

Growth rates of renal cell carcinoma and oncocytoma under surveillance are similar.

OBJECTIVE: Through examining our experience with renal mass surveillance, we hoped to determine factors suggestive of renal cell carcinoma. METHODS: We followed for at least 1 year 41 patients with 47 solid renal masses (mean diameter 2.0 cm, range 0.8-5). Mean surveillance duration was 29 months and was more than 2 years for 23 masses (49%). RESULTS: Overall mean increase in diameter was 0.27 cm/year, but 21 (45%) did not grow, and mean growth rate was 0.5 cm/year in the 26 that did grow. Of the masses, 14 have been treated, 33 continue to be followed, and pathology is known in 16 (34%). Growth was seen in all 6 known oncocytomas (mean 0.52 cm/year), 80% of the 10 biopsy proven renal cell carcinomas grew (mean 0.71 cm/year), but only 12 (39%) of the masses with unknown pathology (0.08 cm/year). There was no factor that distinguished oncocytomas from renal cell carcinomas. In 1 patient, a 3-cm mass that had not changed in size for 6 years doubled in size over 6 months, and metastatic disease developed. CONCLUSIONS: Although growth of most renal masses is slow, some grow quickly, and delayed growth with metastases can occur. No factor distinguished renal cell carcinomas from oncocytomas. Surveillance for renal masses remains an option but must be rigorous and continuous, and is not without risk of progression.

Association between marijuana use and transitional cell carcinoma.

OBJECTIVES: Marijuana smoking has been implicated as a causative factor in traditionally tobacco-related tumors of the head and neck and of the lung. When associated with marijuana use, such tumors occur in a much younger patient population than do similar tumors in tobacco smokers. Owing to the large number of young men with a history of marijuana presenting with transitional cell carcinoma to VA facilities, this study was designed to compare the marijuana use among young (aged less than 60 years) transitional cell carcinoma patients with that among age-matched controls. METHODS: Fifty-two men aged less than 60 years presenting consecutively with transitional cell carcinoma and 104 age-matched controls (defined by having no history of transitional cell carcinoma, hematuria, or irritative voiding symptoms, as well as unremarkable results on urinalysis and urine cytology) completed questionnaires about exposure to various potential carcinogens, including radiation, Agent Orange, smoked or processed meats, dyes, tobacco, and marijuana. RESULTS: Of the 52 transitional cell carcinoma patients, 46 (88.5%) reported a history of habitual marijuana usage, and 72 (69.2%) of the age-matched controls gave a history of habitual marijuana use. This difference was statistically significant (P = 0.008). In those with transitional cell carcinoma, marijuana use significantly correlated with tumor stage, grade, and number of recurrences. CONCLUSIONS: Marijuana smoking might increase the risk of transitional cell carcinoma.

Use of extended pattern technique for initial prostate biopsy.

PURPOSE: An extended prostate biopsy schema has been advocated at initial prostate biopsy to decrease the rate of false-negative cancer cases. However, critics have raised concerns that this may lead to the greater detection of clinically insignificant cancers. We examined the impact of using an extended pattern schema on cancer detection and also on the finding of smaller and clinically insignificant cancer. MATERIALS AND METHODS: Clinical data, including patient age, race, prebiopsy prostate specific antigen (PSA), digital rectal examination, prostate volume, number of needle cores and biopsy findings were abstracted from the medical records of all patients who underwent prostate biopsy in a 5-year period. Extended pattern prostate biopsy was defined as more than 10 cores. Clinically insignificant cancer was defined as a maximal tumor dimension of 1.0 cm or less, Gleason sum 6 or less and organ confined disease at radical prostatectomy. Adjusted regression models were developed to assess the independent effects of using an extended biopsy pattern on the detection of cancer overall and on the detection of clinically insignificant cancer. RESULTS: A total of 740 men with a mean age of 62.6 years were referred for prostate biopsy. Median PSA was 5.7 ng/ml and prostate volume was 39.7 cc. The OR for detecting prostate cancer was 1.55 (95% CI 1.09 to 2.19) for the extended pattern compared with standard biopsy. Of the subset of 136 patients who underwent radical prostatectomy 12.6% had clinically insignificant cancer. However, in contrast to overall cancer detection, extended pattern prostate biopsy was not found to be associated with an increased risk of detecting smaller or clinically insignificant cancer. PSA density was the single parameter found to be independently associated with the detection of clinically insignificant cancer (95% CI 0.20 to 0.98). CONCLUSIONS: Using an extended prostate biopsy pattern involving more than 10 cores increases the likelihood of detecting prostate cancer. A significant association between more needle cores at initial prostate biopsy and finding smaller and clinically insignificant cancer was not apparent.