Urologists' Perceptions of Active Surveillance and Their Recommendations for Low-risk Prostate Cancer Patients.

OBJECTIVE: To assess practicing urologists' attitudes and perceptions of active surveillance (AS) and other treatment options for low-risk prostate cancer. METHODS: This was a cross-sectional survey of urologists practicing in Michigan and Georgia. Urologists were asked about perceptions and practices pertaining to AS. RESULTS: Overall, 225 urologists completed the survey; 147 (65%) were from Michigan and 78 (35%) were from Georgia. Most urologists reported they provided (99%), discussed (97%), and offered (61%) AS to all of their low-risk patients. Most believed AS is effective (97%) and underused (90%), while 80% agreed that curative therapy (surgery, radiation) is overused in the United States. Although most (79%) endorse that Black men are more likely to have aggressive low-risk disease, 89% reported feeling comfortable recommending AS to Black men. In multivariable analysis, significant provider-related predictors of AS recommendation were practice location, number of years in practice, beliefs pertaining to survival benefit of prostatectomy and effectiveness of AS, and expectation that patients are not interested in AS. The patient characteristics of race, age, life expectancy, fear of cancer progression, and fear of treatment side effects were also significant predictors of AS recommendations. CONCLUSION: Most urologists surveyed stated that AS is effective and underused for low-risk prostate cancer . Overall, urologists are much less likely to recommend AS to younger men and slightly less to Black men. AS recommendations varied by practice location and by years in practice. These findings indicate targeted educational efforts in the US are needed to influence urologists toward greater acceptance of AS.

The Epidemiology of Cancer Among Homeless Adults in Metropolitan Detroit.

BACKGROUND: Homeless individuals suffer and die disproportionately from chronic diseases and disorders. We describe the epidemiology of cancer among homeless persons in metropolitan Detroit. METHODS: A retrospective cohort study was performed using 1973-2014 data from the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry and member of the National Institutes of Health-National Cancer Institute's Surveillance, Epidemiology, and End Results program. Homeless adults were identified through address at diagnosis listed as a homeless shelter, hospital, or supplemental field indicating homelessness. Age-adjusted, sex-specific proportional incidence ratios (PIR) compared cancer incidence proportions by primary tumor site of homeless patients to the nonhomeless referent population. Kaplan-Meier curves depicted unadjusted survival differences in a propensity score matched sample. Differences in 10-year survival were assessed using the score test with a sandwich estimator accounting for matched cluster effects. Statistical tests were two-sided. RESULTS: A total of 388 individuals experienced homelessness at first primary invasive cancer diagnosis. Statistically significantly higher proportions of respiratory system (PIR = 1.51; 95% confidence interval = 1.28 to 1.79) and female genital system (PIR = 1.83; 95% confidence interval = 1.31 to 2.55) cancers were observed among homeless men and women, respectively. Homeless persons had poorer overall and cancer-reported survival compared with a propensity score matched referent population (median: overall survival, 20.0 vs 38.0 months, respectively, P < .001; cancer-reported survival, 38.0 vs 64.0 months, respectively, P < .001). CONCLUSION: Disparities in disease burden exist between adults who are experiencing homelessness compared with the nonhomeless population at cancer diagnosis. These findings provide clinically relevant information to understand the cancer burden in this medically underserved population and suggest an urgent need to develop cancer prevention and intervention programs to reduce disparities and improve the health of homeless persons.

Use of "off the shelf" extracellular matrix graft materials for repair of testicular rupture: a novel technique.

OBJECTIVE: To describe a new technique for repairing traumatic testicular ruptures using readily available graft material. MATERIALS AND METHODS: Surgical management of testicular rupture is often associated with loss of testicular parenchyma because of tissue debridement and concerns of pressure-related ischemia. We present our experience with 3 cases using a novel technique using extracellular matrix graft materials for the reconstruction of tunica albuginea in patients with testicular rupture. We describe a case using bovine pericardium (Neovasc Inc, Richmond, British Columbia) and 2 cases using cadaveric dermis (Coloplast Inc, Minneapolis, MN) to repair complex testicular defects without debridement of extruded testicular parenchyma. RESULTS: No postoperative complications occurred in any of the patients. Long-term follow-up at 18 months for one patient revealed good cosmetic results, with radiographic findings confirming testicular integrity and flow. CONCLUSION: The use of graft material in the repair of testicular rupture helps prevent the loss of testicular parenchyma through a tension-free closure leading to excellent cosmetic and radiographic outcomes.

Ureterocele misdiagnosed as pelvic inflammatory disease in an adolescent.

BACKGROUND: Acute pelvic pain in reproductive-aged women presents a diagnostic challenge. In the case that follows, we report the management of a patient initially misdiagnosed with pelvic inflammatory disease. CASE: A 14-year-old nulligravida who presented with acute pelvic pain was diagnosed with pelvic inflammatory disease and possible tuboovarian abscess. Despite treatment with broad-spectrum parenteral antibiotics, the patient remained febrile with persistent pelvic pain. Com-puted tomography revealed a duplicated right collecting system with the upper pole of the kidney drained by a markedly dilated, tortuous ureter. An infected ureterocele was identified and incised during cystoscopy. CONCLUSION: An infected ureterocele was misdiagnosed as pelvic inflammatory disease. In patients with acute pelvic pain who do not respond to appropriate interventions, it is important to consider alternative diagnoses.

Nephrectomy in the management of metastatic osteosarcoma.

This report discusses a rare case of nephrectomy for metastatic osteosarcoma, the first performed laparoscopically, and proposes such management as a standard of care. A 21-year-old woman with a history of metastatic osteosarcoma involving her right kidney was referred to our institution for evaluation. She was managed with a hand-assisted laparoscopic nephrectomy. An exhaustive review of the English literature pertaining to this disease was performed. To our knowledge, this case represents only the sixth nephrectomy ever reported for metastatic osteosarcoma and the first performed by a laparoscopic approach. In addition, this is the first reported case of this disease invading the renal vein. The literature suggests that the incidence of renal involvement in osteosarcoma is significant and that renal imaging should be mandatory in such patients. When renal metastases are diagnosed, prompt nephrectomy is warranted. A minimally invasive approach in these patients should be considered.

Bladder erosion by an intraperitoneal chemotherapy catheter resulting in catheter protrusion through the external urethral meatus.

BACKGROUND: Chemotherapy remains an essential part of the treatment of advanced ovarian cancer. Intraperitoneal (IP) administration has been demonstrated to provide a survival advantage over intravenous chemotherapy in three phase 3 studies. However, IP catheter complications have been a significant factor in aborting IP therapy. CASE: A 42-year-old woman receiving IP chemotherapy for carcinoma of the ovary presented with complaints of incontinence. Examination revealed the catheter protruding through the external urethral meatus. The reservoir was intact, and the catheter was immobile. Laparoscopic and cystoscopic evaluation demonstrated that the catheter tip had eroded through the dome of the bladder. The catheter was re-secured to the abdominal wall, and the bladder was laparoscopically repaired. IP chemotherapy was resumed 16 days postoperatively without incident. CONCLUSION: This is the first report of an IP catheter eroding through the bladder. Increased usage of IP chemotherapy may offer new challenges in the diagnosis and management of catheter-related complications.

A contemporary evaluation of the auditory hazard of extracorporeal shock wave lithotripsy.

OBJECTIVES: Previous publications have suggested that prolonged exposure to extracorporeal shock wave lithotripsy (ESWL) may lead to hearing damage and that hearing protection should be used. We sought to determine the auditory risk associated with ESWL in regard to patients and operating room personnel in a contemporary setting. METHODS: A single day study was performed during which 5 patients were treated with ESWL via a Dornier Compact Delta lithotripter (Dornier MedTech America Inc, Kennesaw, Georgia). A sound level meter was used to evaluate the noise exposure to the patient, ESWL technician, anesthesia personnel, and the treating urologist. Multiple readings were taken at each station and during each treatment session while the patient was treated at maximum intensity level. These recordings were then averaged and referenced to published Occupational Safety and Health Administration (OSHA) standards. RESULTS: The greatest level of noise exposure was found to be at the head of the patient, with an average reading of 89 decibels (dB). The readings at the lithotripter technician's station averaged 84 dB. The anesthetist and urologist were exposed to average sound levels of 81 and 79 dB, respectively. All readings at each evaluated station evidenced a level of exposure considered safe by OSHA standards, which permit 8 hours of exposure to 90 dB per day. CONCLUSIONS: Contemporary ESWL does not pose a significant auditory hazard to either the patient or operating room personnel by OSHA standards. Thus, in reference to these standards, hearing protection for the parties involved is not considered mandatory.

Antibiotic pretreatment of hydrogel ureteral stent.

PURPOSE: To compare bacterial adhesion to hydrogel-coated and uncoated ureteral stents. The antimicrobial activity of coated and uncoated stents treated with commonly used antibiotic solutions also was evaluated. MATERIALS AND METHODS: Hydrogel coated and uncoated stent segments were dipped in different antibiotic solutions (ciprofloxacin, gentamicin, and cefazolin). Normal saline was used as the control. The segments were incubated in separate broths of Escherichia coli and Enterococcus faecalis to reach the log phase. They were sonicated to free the bacteria, and colony-forming units were determined after 48 hours. To evaluate antibacterial activity, hydrogel-coated and uncoated stent segments were dipped in the above-mentioned antibiotic solutions. Normal saline was used as the control. Segments were incubated in separate Mueller-Hinton agar plates inoculated with E. coli or Enterococcus faecalis, and the zones of inhibition were determined at 24 hours. The duration of antibacterial activity for each bacterium-antibiotic combination also was studied. RESULTS: Hydrogel coating did not significantly reduce bacterial adhesion. Zones of inhibition around stent pieces dipped in antibiotic solutions differed with the organism and the antibiotic. Cefazolin produced a significantly larger zone of inhibition with hydrogel-coated stent, but the duration of antibacterial activity was similar to that of uncoated stent. Hydrophilic coating significantly increased the duration of antibacterial activity of ciprofloxacin and gentamicin. CONCLUSION: Hydrogel coating on the surface of ureteral stents does not prevent or reduce bacterial adhesion. However, after antibiotic treatment, stents exhibit antibacterial activity in the local environment at greater intensity and for a longer time, depending on the bacterium-antibiotic combination.

Anuric renal failure after same-session bilateral atraumatic flexible ureteroscopy.

We report the first known case of anuric renal failure after same-session bilateral atraumatic flexible ureteroscopy for renal calculi. Although, there is no consensus about stenting patients who undergo same-session bilateral ureteroscopy due to the lack of prospective randomized studies; strong consideration should be given to stenting the ureter at least one side to avoid this complication.

Anuric renal failure after same-session bilateral atraumatic flexible ureteroscopy

We report the first known case of anuric renal failure after same-session bilateral atraumatic flexible ureteroscopy for renal calculi. Although, there is no consensus about stenting patients who undergo same-session bilateral ureteroscopy due to the lack of prospective randomized studies; strong consideration should be given to stenting the ureter at least one side to avoid this complication.

Lift-assisted offset lithotomy: positioning for transurethral operations in morbidly obese.

The incidence of morbid obesity is rapidly increasing in the United States. This presents a unique challenge in the diagnosis, management, and surgical treatment of urologic disease. The use of the lithotomy position for transurethral procedures is often not possible because of the body habitus and equipment-specific weight limitations. During positioning, it becomes imperative to maintain the safety of both the patient and the operating room personnel. We present a new, bariatric lift-assisted positioning technique used in the management of a 311-kg morbidly obese man with high-grade, superficial, papillary urothelial carcinoma.

Patient opinion of urologists' reimbursement.

OBJECTIVES: To determine patient assumptions and opinions of the billing and reimbursement process in an urban urologic practice. Healthcare policy and physician reimbursement has been discussed in political and economic forums; however, few studies exist that reflect a patient's perspective of reimbursement issues. METHODS: An anonymous, voluntary 11-question survey was given to 825 patients during a 10-week interval. The instrument measured patient perceptions on the amounts (in percentages) that would, and should, be covered by insurance carriers and collected by their urologist. It also measured the time frames perceived for these events to occur. Our aim was to evaluate their knowledge of office urologic reimbursement. RESULTS: Overall, 532 patients (75%) surveyed believed their insurance would cover 80% to 100% of their bill. A total of 309 patients (49%) thought their urologist would receive 80% to 100% of the bill, and 383 (60%) thought they should receive that level of compensation (P < 0.0001). Respondents with prior surgical contact thought their urologist would (P = 0.004) and should (P = 0.01) be reimbursed at a greater level than those without prior surgical contact. When asked about the time to reimbursement, 340 (73%) thought their doctor would be paid within 6 weeks compared with 453 (95%) who thought their urologist should be paid within that time (P < 0.0001). CONCLUSIONS: The survey responses demonstrated patients' convictions that their urologists should be reimbursed in a timely manner. Additional studies examining both patient and healthcare provider perspectives are needed to better educate both of these groups on the medical billing and reimbursement process.

Stent-change therapy in advanced malignancies with ureteral obstruction.

BACKGROUND AND PURPOSE: To determine if patients with advanced malignancies and resultant ureteral obstruction who are managed with chronic ureteral stent changes have adequate preservation of renal function and an acceptable rate of complications. PATIENTS AND METHODS: A retrospective review was conducted on 28 patients who had a stent to relieve ureteral obstruction caused by cancer. RESULTS: During the study period, 201 stents were placed, a median of 4 (range 1-34) per patient. The mean time from cancer diagnosis to first stent placement was 34 months (range 1-109 months). The median survival after the first stent insertion was 15.3 months (95% CI 15.1, 15.6). Seven patients had worsening renal function and hydronephrosis despite indwelling stents. In these patients, the median time from the first stent to a rising serum creatinine concentration was 17 months (range 1-66 months). No patient required dialysis. Eighteen patients developed a total of 69 urinary tract infections (mean 2.5). Eight patients had a total of 13 episodes of urosepsis. The median infection-free survival was 11.9 months (range 7.7-16.9 months). The median urosepsis-free survival was 28.5 months (range 9.7-47.1 months). Fourteen patients died from their malignancies during the study. CONCLUSIONS: Stent-change therapy is an efficacious way to treat patients with advanced malignancies and ureteral obstruction, many of whom have a short life expectancy. All patients maintained adequate renal function to obviate dialysis. Most patients with stents in place will die before their renal function deteriorates. They may also benefit from treatment strategies designed to avoid the occurrence of frequent urinary infections.