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To determine the effectiveness of 2 different continuous quality improvement interventions in an integrated community urology practice. We specifically assessed the impact of audited physician feedback on improving physicians' adoption of active surveillance for low-risk prostate cancer (CaP) and adherence to a prostate biopsy time-out intervention.The electronic medical records of Genesis Healthcare Partners were analyzed between August 24, 2011 and September 30, 2020 to evaluate the performance of 2 quality interventions: audited physician feedback to improve active surveillance adoption in low-risk CaP patients, and audited physician feedback to promote adherence to an electronic medical records embedded prostate biopsy time-out template. Physician and Genesis Healthcare Partners group adherence to each quality initiative was compared before and after each intervention type using ANOVA testing.For active surveillance, we consistently saw an increase in active surveillance adoption for low risk CaP patients in association with continuous audited feedback (P.001). Adherence to the prostate biopsy time-out template improved when audited feedback was provided (P.001).The implementation of clinical guidelines into routine clinical practice remains challenging and poses an obstacle to the improvement of United States healthcare quality. Continuous quality improvement should be a dynamic process, and in our experience, audited feedback coupled with education is most effective.

Objective To investigate the impact of prostate-specific antigen density (PSAD) on existing prostate cancer (PCa) active surveillance (AS) protocols. Methods Prospectively maintained database on men with PCa who underwent radical prostatectomy was reviewed retrospectively. Demographic data and pathologic characteristics of patients who fulfilled the AS inclusion criteria under the National Comprehensive Cancer Network (NCCN), Prostate Cancer Research International Active Surveillance (PRIAS), and University of California, San Francisco (UCSF) guidelines were examined. Results Of 930 patients, 231, 280, and 325 fulfilled the NCCN, PRIAS, and UCSF AS criteria, respectively. The frequencies of advanced disease on surgical pathology (upstaging and/or upgrading) were 31.6% (NCCN), 35.4% (PRIAS), and 34.2% (UCSF) of the study cohorts. PSAD was significantly higher in patients with advanced disease compared with that in patients with nonadvanced disease in all 3 AS schemas. Modifying the PRIAS and UCSF criteria using the NCCN's lower PSAD cutoff of 0.15 ng/mL 2 decreased the rates of the advanced disease significantly to 33.5% and 31.4%, respectively. Using the receiver operating characteristic curve analysis, the optimal PSAD cutoff level for the prediction of advanced disease was 0.085 ng/mL 2 (sensitivity/specificity of 76.7%/50.6% in NCCN and 75.6%/49.7% in PRIAS). Conclusion Among patients with low-risk PCa who underwent radical prostatectomy, PSAD is a predictor of advanced disease at the time of surgery. Adopting a lower PSAD threshold of 0.085 ng/mL 2 decreased the risk of the advanced disease to 17.5%-21.7%. Therefore, PSAD should be part of all AS guidelines.

Objectives. To evaluate the efficacy of botulinum toxin A in the treatment of children with detrusor hyperreflexia caused by myelomeningocele and the effects of this treatment on neuropathic bladder and bowel dysfunction. Methods. In a prospective study, 26 children with myelomeningocele (20 boys and 6 girls, mean age 6.9 years) were included. All patients had been nonresponders to medical treatment and required clean intermittent catheterization. Under cystoscopic guidance, 10 IU/kg of botulinum toxin A was injected into the detrusor muscle, sparing the trigone and ureteral orifices. In each patient, urinary incontinence grade and improvement in parameters of interest in the evaluation of bowel dysfunction were assessed before and 4 months after injection. Conventional urodynamic studies to determine maximal bladder capacity and maximal detrusor pressure and voiding cystoureterography were also performed. Results. Four months after procedure, 19 patients (73%) had become completely dry between clean intermittent catheterizations, and the total improvement in urine incontinence was 88%. The mean maximal detrusor pressure was decreased to 83.2 4.6 cm H2O from the baseline of 139.3 11.2 (P 0.01). The average maximal bladder capacity increased from 102.8 6.3 mL to 270.2 9.5 mL (P 0.01). Of the 15 patients who had varying degrees of vesicoureteral reflux before the procedure, 11 (73%) had decrease in the vesicoureteral reflux grade. Also, bowel dysfunction improved in 10 (66%) of the 15 patients. Conclusions. Botulinum toxin A appears to be a safe, minimally invasive procedure for the management of neuropathic bladder and bowel dysfunction in children with myelomeningocele. UROLOGY 68: 1091‐1097, 2006. © 2006 Elsevier Inc.

Objectives To investigate the effects of morphine on reperfusion injury due to testicular torsion-detorsion (T/D). Methods We divided 36 adult male Sprague-Dawley rats into six groups. Testicular ischemia was achieved by twisting the right testis 720° counterclockwise for 1 hour, and reperfusion was allowed for 4 hours after detorsion. The baseline group was for basal normal values. The sham-operated group served as the control group. The T/D group underwent 1 hour of testicular torsion and 4 hours of detorsion. The morphine group received pretreatment with intravenous morphine sulfate (10 mg/kg) just before detorsion. The naltrexone group received an intravenous injection of naltrexone HCl (20 mg/kg) 15 minutes before detorsion. The naltrexone/morphine group received intravenous administration of naltrexone HCl (20 mg/kg) 15 minutes before detorsion and morphine sulfate (10 mg/kg) just before detorsion. Results The ipsilateral malondialdehyde levels in the T/D group were significantly greater than in the control and baseline groups. Moreover, the ipsilateral testicular malondialdehyde values in the morphine group were significantly lower than in the T/D and naltrexone/morphine groups. Also, significant decreases occurred in catalase and superoxide dismutase activities in the T/D group compared with the control and baseline groups. These values were significantly greater in the morphine group than in the T/D and naltrexone/morphine groups. The ipsilateral testes of all groups that underwent testicular torsion showed similar histopathologic changes. Conclusions Morphine increased the ipsilateral intratesticular antioxidant markers during the reperfusion phase after unilateral testicular torsion, which was eventually reflected in lower testicular malondialdehyde levels. Furthermore, this effect was mediated through the opioid receptors.