First 100 cases at a low volume prostate brachytherapy institution: learning curve and the importance of continuous quality improvement.

INTRODUCTION: We report the first 100 patients who underwent prostate brachytherapy as monotherapy with 125I at an institution with moderate volume radical prostatectomy but low volume brachytherapy (<2 cases per month). Learning curve and quality improvement was assessed by way of achieving prescription dose targets. MATERIALS AND METHODS: From May 2002 to August 2006, 100 patients underwent prostate 125I brachytherapy monotherapy via preplanned approach. Preoperative planned dose to 100% of prostate gland (D100) was 145 Gy and postoperative confirmed dose was assessed by computed tomography. The cohort was divided into quartiles and recurrence was assessed using Kaplan-Meier analysis. RESULTS: Patient quartiles were of similar age and Gleason grade, while PSA was slightly higher in the first group. Postoperative D90 increased after the first quartile (p = < 0.0001) reaching targeted values. Kaplan-Meier survival analysis revealed that 5 year recurrence-free survivals by Phoenix definition was 96%-100% in all groups while by ASTRO definition there was a decrease in recurrence for later cases. CONCLUSIONS: At our low volume institution during the first 100 brachytherapy cases, a learning curve for radiation dosimetry was evident, which improved after 25 patients. Preplanned dose-volume parameters were adjusted, enabling the achievement of post-implant goals emphasizing the importance of continuous quality improvement. Although recurrence data is limited by sample size and moderate follow up, there was a discrepancy between the Phoenix and ASTRO definition when evaluating recurrence.

Personality, treatment choice and satisfaction in patients with localized prostate cancer.

OBJECTIVES: Radical prostatectomy (RP), external beam radiation (XRT) and brachytherapy (BTX) are the most commonly used treatments for localized prostate cancer. We studied whether patient personality influences treatment choice and overall treatment satisfaction. METHODS: From 1998 to 2002, 219 consecutive patients treated with RP (n = 74), XRT (n = 73), or BTX (n = 72) at our institution who remained free of biochemical recurrence were sent the Big Five Inventory (BFI) and a satisfaction/treatment participation questionnaire. We compared personality, satisfaction and participation scores between the three groups. Correlation between personality and satisfaction was determined. Multivariate regression was used to determine association between personality and satisfaction/participation after controlling for patient- and disease-related factors. RESULTS: Higher mean satisfaction and participation scores were observed within the RP and XRT groups, respectively (P = NS). No significant differences in personality were observed between groups. XRT patients tended to have higher extroversion, openness and agreeability scores, while RP patients tended to be more neurotic and conscientious (all P = NS). After controlling for other factors, a negative correlation was found between openness scores and satisfaction and a positive correlation between conscientiousness scores and satisfaction. Specific personality traits were associated with interest in participation in care for both RP and BTX patients but not for XRT patients. CONCLUSIONS: There are mild variations in personality as measured by the BFI between patients undergoing treatment for localized prostate cancer. Certain BFI-measured personality traits may be associated with levels of satisfaction following therapy. Disease concerns and provider recommendations may override the influence of personality in the decision-making process.

Indiana pouch stone formation caused by a long-forgotten metallic ball bearing.

The presence of a foreign body in the urinary tract may serve as a nidus for stone formation. A 40-year-old male was found on CT scan to have a 2.4 cm stone in his Indiana pouch urinary diversion. As the stone was fragmented during endoscopic lithotripsy, a metallic round object was visualized, which was subsequently established to be a metallic ball bearing. Upon questioning after the procedure, the patient reported that 4 years earlier he had been accidentally shot with a blow dart gun and the "miraculous hit" went directly into his Indiana pouch stoma.

Management of obstructing pulmonary broncholithiasis with three-dimensional imaging and holmium laser lithotripsy.

Major airway obstruction due to broncholithiasis produces significant morbidity, and management is difficult. Many of the patients are elderly and are not good candidates for surgical removal. Bronchoscopic removal may be limited due to anatomic considerations, skill of the bronchoscopist, and exposure of the patient to additional procedural risks. Preprocedural planning with three-dimensional (3D) multidetector CT (MDCT) imaging enhances the bronchoscopist's knowledge of the relationships of the target lesions with critical structures, and improves the efficiency of the application of specific endobronchial therapies. Here we report our experience treating obstructing broncholithiasis in two patients utilizing pretreatment planning with 3D MDCT imaging, followed by bronchoscopically delivered holmium laser fragmentation of the stones.

Urodynamic assessment of sphincteric function in the incontinent female: which test, and does it matter anyway?

The overall prevalence of urinary incontinence among women surveyed in the United States is approximately 37%. The lifetime risk of undergoing urinary incontinence surgery for women in the United States is estimated to be 11.1%. Conservative therapy can be instituted without performing extensive evaluation such as urodynamics, voiding cystourethrograms, ultrasonography, or video studies. Further evaluation is recommended when conservative measures have failed or if invasive, potentially morbid surgical therapies are being considered. This paper reviews the available methods for evaluating the urinary sphincter in the incontinent female.

Spontaneous dissolution of a guaifenesin stone.

Guaifenesin is a commonly used expectorant whose use may lead to the occasional formation of guaifenesin urinary stones. We herein describe a patient who was taking 2400 mg Guaifenesin per day as part of his treatment for asthma. He had a past history of a guaifenesin stone removed ureteroscopically. His current presentation was with a 9 mm by 6 mm stone in the upper left ureter, seen on CT scan, and treated initially with a ureteral stent and hydration. After 3 weeks, the stone had disappeared, as confirmed by repeat CT scan. The genesis and treatment of guaifenesin stones is discussed.

Hyperbaric oxygen for the treatment of fournier's gangrene.

PURPOSE: Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. Groups at many institutions have initiated routine adjuvant hyperbaric oxygen (HBO) therapy. We examined whether HBO has made a difference in the morbidity, mortality and costs associated with treating this disease. We also analyzed predictors of extended hospital stay and mortality. MATERIALS AND METHODS: The records of patients with the hospital discharge diagnoses of Fournier's gangrene, necrotizing fasciitis, gangrene of the genitalia and scrotal gangrene from 1993 to 2002 were reviewed. Data concerning clinical presentation characteristics, hospital stay, complications, hospital charges and outcomes, including graft failure and death, were analyzed. RESULTS: A total of 42 patients were identified and followed a median 4.2 years. Of the patients 16 underwent surgical debridement and antibiotic therapy alone, and 26 were treated with HBO plus surgery and antibiotics. Overall disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of nonHBO and in 19% of HBO cases, of which the most common was myocardial infarction. The skin graft failure rate was 6% (nonHBO) and 8% (HBO). Physical disability was a statistically significant predictor of extended hospital stay (p <0.01). There was a trend toward a correlation between known coronary artery disease and death (p = 0.2). A statistically significant difference was noted in average daily hospital charges in nonHBO vs HBO cases ($2,552 vs $3,384 daily, p <0.01). CONCLUSIONS: These data do not support routine HBO in the treatment of Fournier's gangrene. There was a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill.

Practice patterns in the treatment of large renal stones.

PURPOSE: To determine the current practice patterns of a large group of urologists in the treatment of large renal stones. MATERIALS AND METHODS: A survey was sent to all actively practicing members of the North Central Section of the American Urological Association. The questions pertained to age, time in practice, type of practice, time devoted to treating stones, residency training, case scenarios with treatment options, and whether they or a radiologist performed percutaneous access. The data were statistically analyzed. RESULTS: The response rate was 51% (564/1102 surveys returned). Three quarters (73%) of the urologists were comfortable performing percutaneous nephrolithotomy (PCNL), and 35% gave reasons they do not perform PCNL. Only 11% of those performing PCNL routinely obtained the percutaneous access themselves. Trends in the analysis included: (1) those trained to perform PCNL during residency were more often comfortable with this procedure; (2) younger urologists were more comfortable performing PCNL, even if they had been in practice for only a short time; (3) urologists in private practice were nearly as comfortable performing PCNL as were academic urologists; (4) urologists not comfortable with PCNL more often recommended SWL over PCNL as a primary treatment for moderate/large renal stones; and (5) few urologists routinely obtained percutaneous access themselves. CONCLUSIONS: Many urologists trained in recent years are comfortable performing PCNL. The type of training received influences treatment recommendations, and percutaneous access is most often obtained by/in conjunction with radiologists. This information may be useful in guiding residency training programs in the preparation of residents for the treatment of large renal stones.