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Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a debilitating syndrome of unknown etiology often postulated, but not proven, to be associated with microbial infection of the prostate gland. We hypothesized that infection of the prostate by clinically relevant uropathogenic Escherichia coli (UPEC) can initiate and establish chronic pain. We utilized an E. coli strain newly isolated from a patient with CP/CPPS (strain CP1) and examined its molecular pathogenesis in cell culture and in a murine model of bacterial prostatitis. We found that CP1 is an atypical isolate distinct from most UPEC in its phylotype and virulence factor profile. CP1 adhered to, invaded, and proliferated within prostate epithelia and colonized the prostate and bladder of NOD and C57BL/6J mice. Using behavioral measures of pelvic pain, we showed that CP1 induced and sustained chronic pelvic pain in NOD mice, an attribute not exhibited by a clinical cystitis strain. Furthermore, pain was observed to persist even after bacterial clearance from genitourinary tissues. CP1 induced pelvic pain behavior exclusively in NOD mice and not in C57BL/6J mice, despite comparable levels of colonization and inflammation. Microbial infections can thus serve as initiating agents for chronic pelvic pain through mechanisms that are dependent on both the virulence of the bacterial strain and the genetic background of the host.

Objectives To characterize the relationship between pediatric kidney stone disease and the presence of hypertension (HTN), diabetes mellitus (DM), and obesity. In adults, kidney stone disease has been associated with medical comorbidities such as HTN, DM, and obesity. Similar analyses have never been performed for the pediatric population. Methods The 2003 and 2006 Kids' Inpatient Databases were queried to identify subjects treated for kidney stone disease (“International Classification of Diseases” codes 9592.0 and 592.1). The comorbidities of HTN, DM, and obesity were identified using the provided comorbidity software. The risk of kidney stone disease associated with age, sex, and comorbidity status was evaluated using multivariate logistic regression. Results A total of 6 115 443 subjects were evaluated. Of these, 14 245 (0.2%) had a diagnosis of upper tract calculus (4092 boys and 10 045 girls, sex unavailable for 108). Age was the strongest independent predictor of stone risk (P < .0001). HTN was associated with a significantly increased risk of stone diagnosis in children ≤10 years old and DM for children ≤5 years old. Stone risk was not affected by obesity in any age group. Conclusions The results of our study have shown that kidney stone disease is significantly associated with age among all children and both HTN and DM for young children. Although exploratory, these findings are novel and suggest that kidney stone disease among young children might be associated with nonrenal, systemic disease states.

Background Evidence suggests that the urogenital pain of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) may be neuropathic. Methods This randomized, double-blind, placebo-controlled trial was conducted across 10 tertiary care centers in North America to determine whether pregabalin, which has been proved effective in other chronic pain syndromes, is effective in reducing CP/CPPS symptoms. In 2006-2007, 324 men with pelvic pain for at least 3 of the previous 6 months were enrolled in this study. Men were randomly assigned to receive pregabalin or placebo in a 2:1 ratio and were treated for 6 weeks. Pregabalin dosage was increased from 150 to 600 mg/d during the first 4 weeks. The primary outcome was a 6-point decrease in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score. Multiple secondary outcomes were assessed. Results Of 218 men assigned to receive pregabalin, 103 (47.2%) reported at least a 6-point decrease in the NIH-CPSI total score at 6 weeks compared with 35.8% (38 of 106 men) assigned to receive placebo ( P = .07, exact Mantel-Haenszel test, adjusting for clinical sites). Compared with the placebo group, men assigned to receive pregabalin experienced reductions in the NIH-CPSI total score and subscores ( P P = .02), and improvement in total McGill Pain Questionnaire score ( P = .01). Results for the other outcomes did not differ between groups. Conclusion Pregabalin therapy for 6 weeks was not superior to placebo use in the rate of a 6-point decrease (improvement) in the NIH-CPSI total score in men with CP/CPPS. Trial Registration clinicaltrials.gov Identifier:NCT00371033

Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities.

This prospective, open, randomized clinical study compared the efficacy and tolerability of norfloxacin and ciprofloxacin in adult patients with complicated urinary tract infection, defined as infection in the presence of an underlying anatomic or functional abnormality of the urinary tract. Seventy-two patients were randomized, 37 received norfloxacin (400 mg orally twice daily for 10-21 days) and 35 received ciprofloxacin (500 mg orally every 12 hours for 14-21 days). Patients were clinically assessed, and urine cultures were obtained following two to four days of therapy, and five to nine days and four to six weeks after discontinuation of therapy. Seventy-two percent of the norfloxacin group and 79 percent of the ciprofloxacin group were considered cured. This difference was not significant. One failure of norfloxacin therapy was associated with the emergence of resistant Pseudomonas aeruginosa. Following norfloxacin therapy, in 2 patients superinfections developed with resistant organisms (Staphylococcus epidermidis [1] and Pseudomonas maltophilia [1]). Twelve patients, 6 in each group, experienced adverse reactions, which were considered related to the study drug therapy in only four instances. Our results indicated comparable efficacy and tolerability of norfloxacin and ciprofloxacin in the treatment of complicated urinary tract infection in adults.

Uropathogenic Escherichia coli are the leading cause of urinary tract infection. We recently demonstrated that deletion of the O antigen ligase gene, waaL, from the uropathogenic E. coliisolate NU14 results in a strain that stimulates enhanced urothelial cytokine secretion. Because enhanced innate immune responses are of interest in vaccine development, we examined the therapeutic potential of NU14 DeltawaaL as a vaccine for urinary tract infection. NU14 DeltawaaL stimulated enhanced interleukin-6 secretion by mouse macrophages, compared with secretion by the wild type. Mice vaccinated via instillation into the bladder developed protective responses that prevented persistent colonization after bladder challenge with NU14, yet NU14 DeltawaaL failed to persistently colonize the mouse bladder. Inoculation with the vaccine strain protected mice against challenge with a broad range of clinical uropathogenic E. coli isolates and produced immunity that lasted 8 weeks. Therefore, NU14 DeltawaaL is a candidate live-attenuated vaccine for the treatment and prevention of acute and recurrent urinary tract infection by caused by uropathogenic E. coli.

Chronic prostatitis can cause pain and urinary symptoms, and usually occurs without positive bacterial cultures from prostatic secretions (known as chronic abacterial prostatitis or chronic pelvic pain syndrome, CP/CPPS). Bacterial infection can result from urinary tract instrumentation, but the cause and natural history of CP/CPPS are unknown.We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for chronic bacterial prostatitis? What are the effects of treatments for chronic abacterial prostatitis/chronic pelvic pain syndrome? We searched: Medline, Embase, The Cochrane Library and other important databases up to August 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 30 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: 5 alpha-reductase inhibitors, allopurinol, alpha-blockers, biofeedback, local injections of antimicrobial drugs, mepartricin, non-steroidal anti-inflammatory drugs, oral antimicrobial drugs, pentosan polysulfate, prostatic massage, quercetin, radical prostatectomy, sitz baths, transurethral microwave thermotherapy, and transurethral resection.

Urinary tract infections are the second most common infectious disease in humans and are predominantly caused by uropathogenic E. coli (UPEC). A majority of UPEC isolates express the type 1 pilus adhesin, FimH, and cell culture and murine studies demonstrate that FimH is involved in invasion and apoptosis of urothelial cells. FimH initiates bladder pathology by binding to the uroplakin receptor complex, but the subsequent events mediating pathogenesis have not been fully characterized. We report a hitherto undiscovered signaling role for the UPIIIa protein, the only major uroplakin with a potential cytoplasmic signaling domain, in bacterial invasion and apoptosis. In response to FimH adhesin binding, the UPIIIa cytoplasmic tail undergoes phosphorylation on a specific threonine residue by casein kinase II, followed by an elevation of intracellular calcium. Pharmacological inhibition of these signaling events abrogates bacterial invasion and urothelial apoptosis in vitro and in vivo. Our studies suggest that bacteria-induced UPIIIa signaling is a critical mediator of bladder responses to insult by uropathogenic E. coli., Author Summary Urinary tract infections (UTI) are the second most common infectious disease in humans and are predominantly caused by uropathogenic E. coli (UPEC). In vitro and in vivo studies have demonstrated that UPEC induce several responses in the bladder, including inflammation, rapid onset of bladder cell death, and bacterial invasion of bladder cells. This last event, invasion, is now also thought to underlie recurrent UTI. Although members of the highly-expressed “uroplakin” proteins serve as bladder receptors for UPEC binding, it was unclear how UPEC binding to uroplakin receptors caused signals within bladder cells that mediate rapid cell death and bacterial invasion. Here, we show that another uroplakin, uroplakin III, which is associated with the receptor transduces signals within the cell in response to UPEC binding. UPEC causes elevated calcium within bladder cells, and this elevation requires phosphorylation of uroplakin III by a specific kinase. Blocking these events blocks both bladder cell death and bacterial invasion of bladder cells by UPEC. Thus, uroplakin III is the mediator of key events in UTI pathogenesis.

In men with chronic prostatitis-chronic pelvic pain syndrome, treatment with alpha-adrenergic receptor blockers early in the course of the disorder has been reported to be effective in some, but not all, relatively small randomized trials.We conducted a multicenter, randomized, double-blind, placebo-controlled trial to evaluate the efficacy of alfuzosin, an alpha-adrenergic receptor blocker, in reducing symptoms in men with chronic prostatitis-chronic pelvic pain syndrome. Participation in the study required diagnosis of the condition within the preceding 2 years and no previous treatment with an alpha-adrenergic receptor blocker. Men were randomly assigned to treatment for 12 weeks with either 10 mg of alfuzosin per day or placebo. The primary outcome was a reduction of at least 4 points (from baseline to 12 weeks) in the score on the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) (range, 0 to 43; higher scores indicate more severe symptoms). A 4-point decrease is the minimal clinically significant difference in the score.A total of 272 eligible participants underwent randomization, and in both study groups, 49.3% of participants had a decrease of at least 4 points in their total NIH-CPSI score (rate difference associated with alfuzosin, 0.1%; 95% confidence interval, -11.2 to 11.0; P=0.99). In addition, a global response assessment showed similar response rates at 12 weeks: 33.6% in the placebo group and 34.8% in the alfuzosin group (P=0.90). The rates of adverse events in the two groups were also similar.Our findings do not support the use of alfuzosin to reduce the symptoms of chronic prostatitis-chronic pelvic pain syndrome in men who have not received prior treatment with an alpha-blocker. (ClinicalTrials.gov number, NCT00103402.)

Percutaneous nephrolithotomy (PNL) is the treatment of choice for patients with large or complex renal calculi. Although injuries to intra-abdominal organs are rare during PNL, splenic injuries have been reported. The management of a splenic injury after PNL is not well defined; therefore, we performed a study to define a management strategy for such an event.A retrospective, multi-institutional study was performed to identify all cases of splenic injury that occurred during PNL. All procedures were performed as a single-stage operation, with percutaneous access obtained in the operating room by the urologist. A review of patient records and imaging was conducted to identify treatment strategies and outcomes.Three patients were identified as having undergone a transsplenic PNL. All puncture sites were upper pole, supracostal access of the left kidney. All cases of injury were identified after the procedure, with two stable patients' injuries identified on postoperative CT scan, and a third patient presenting with significant bleeding at removal of the nephrostomy tube. The spleen-preserving, conservative management strategy was successful, because no patients needed exploratory surgery.Splenic injury is a rare complication sustained most commonly during supracostal, upper-pole access to the left renal unit. When patients are hemodynamically stable, this complication can be conservatively managed, with prolonged nephrostomy drainage and observation in a monitored setting before and after nephrostomy tube removal.

This article comes from Clinical Evidence, a new resource for clinicians produced by the BMJ Publishing Group. Clinical Evidence is an extensively peer-reviewed publication that summarizes the best available evidence on the effects of common clinical interventions gleaned from thorough searches and appraisal of world literature. The second issue is now available with an updated and expanded range of topics. Please visit www.evidence.org for more information.

Purpose: The chronic pelvic pain syndrome is characterized by pelvic pain, voiding symptoms and varying degrees of inflammation within expressed prostatic secretions. We evaluated the chemokines monocyte chemoattractant protein 1 (CCL2) and macrophage inflammatory protein-1α (CCL3) in expressed prostatic secretions to identify marker increases associated with inflammatory (IIIA) and noninflammatory (IIIB) chronic pelvic pain syndrome. In addition, chemokine levels were correlated with clinical pain as determined by the National Institutes of Health chronic prostatitis symptom index.Materials and Methods: Expressed prostatic secretions were collected by digital rectal examination, and evaluated by enzyme linked immunosorbent assays for monocyte chemoattractant protein 1 and macrophage inflammatory protein-1α in 154 patients including controls (13), those with benign prostatic hyperplasia (54), chronic pelvic pain syndrome IIIA (37) and IIIB (50). Monocyte chemoattractant protein 1 and macrophage inflammato...

The diagnosis and management of prostatitis and pelviperineal pain is a challenge to the clinician. Careful examination of the prostatic fluid and bacteriologic cultures to differentiate bacterial from nonbacterial prostatitis are essential. Antimicrobial therapy is effective in the majority of men with acute or chronic bacterial prostatitis. Nonbacterial prostatitis is the most common type of prostatitis. The etiology is unknown and treatment with repeated antimicrobial therapy is ineffective. Alpha-blocking agents may relieve symptomatology. Pelviperineal pain may be of prostatic origin but other nonprostatic causes should be sought.

We treated 15 men who had chronic bacterial prostatitis refractory to trimethoprim-sulfamethoxazole and/or carbenicillin with 400 mg. norfloxacin twice daily for 28 days. All pathogens were susceptible to norfloxacin and absent in prostatic fluid cultures obtained during therapy. One patient had negative post-therapy prostatic fluid cultures but was lost to followup at 1 month. Of the 14 patients followed for at least 6 months 9 (64%) were cured of the original infection, including 6 who have remained uninfected and have had negative prostatic secretion and urine cultures for at least 2 years (1), 1 year (2) or 6 months (3). In 3 patients urinary tract infections recurred with new pathogens at 6, 560 and 820 days after post-therapy negative prostatic fluid cultures. Bacterial prostatitis with the original pathogen recurred in 5 patients within 2 months of completing therapy. The bacteria remained susceptible to norfloxacin but could not be eradicated with 30 to 90 days of additional norfloxacin therapy. Cures were achieved in 9 of 12 patients with Escherichia coli, none of 2 with Pseudomonas prostatitis and 3 of 5 with prostatic calculi. No patient experienced significant adverse effects. The data suggest that norfloxacin is effective and safe for the treatment of refractory chronic bacterial prostatitis.

SUMMARY Our suggestions for the use of antimicrobials in patients undergoing prostatectomy are summarized in Table 2. The use of antimicrobial prophyhxis perioperatively for patients without bacteriuria remains controversial. Some authors recommend 5 , 15 , 16 , 24 and others do not recommend 9 , 18 , 20 , 32 antimicrobial prophylaxis. We do not recommend perioperative prophylaxis for low-risk patients without previous urinary tract infections or an indwelling urethral catheter. We do recommend that patients with risk factors that increase the rate or consequence of urinary tract infection, those with previous urinary tract infections, or those with indwelling urethral catheters, even though the urine shows no growth, receive perioperative antimicrobial prophylaxis. Antimicrobial therapy is mandatory for patients with preoperative bacteriuria. The drug must be selected according to the susceptibility of the pathogen, and the duration of treatment must be guided by the severity of the infection. At the time of catheter removal, antimicrobial prophylaxis is probably beneficial, and antimicrobial therapy is essential if bacteriuria is present prior to catheter removal. All patients must have cultures after catheter removal and antimicrobial therapy if a urinary tract infection is identified.

One hundred thirty-one patients of urologists and infectious disease specialists were entered into an open trial of norfloxacin in the therapy of urinary tract infections (UTIs). All patients were evaluable for tolerability and 98 were evaluable for efficacy. The patient population in this study was older (mean age 53 years) and had more underlying urogenital disorders (30%) or recent invasive urologic procedures (20%) than the typical patient population with UTIs. Over 50% of the patients had infections due to organisms other than Escherichia coli, including Pseudomonas aeruginosa (14), Klebsiella pneumoniae (5), Enterobacter spp (3) and Group D streptococcus (6). Clinical and bacteriologic cure rates were 90 and 91%, respectively. Side effects occurred in 5 patients and were generally mild.

In seven studies of complicated and recurrent urinary tract infections, 285 patients were treated with norfloxacin 400 mg b.i.d. for 7-90 days. The majority of the patients were men, and many were elderly. Underlying diseases included nephrolithiasis, pyelonephritis, prostatism, bacterial prostatitis, prostate cancer, retroperitoneal fibrosis, quadriplegia/paraplegia, neurogenic bladder, and urethral stricture. Many of the infections were due to Pseudomonas aeruginosa or other multiply resistant strains. More than 95% of the pretreatment bacterial isolates were susceptible to norfloxacin. The bacteriologic cure rate ranged from 67 to 100%. Of 45 patients with chronic bacterial prostatitis, 40 (89%) were cured. Few failures of treatment were due to the emergence of bacterial resistance. Of 29 recurrent infections, 6 (20%) were caused by resistant bacteria. Both clinical and laboratory adverse reactions were infrequent and minor, and rarely required discontinuation of therapy. Norfloxacin appears to be an effective drug with an excellent safety profile for the treatment of complicated and recurrent UTIs.

We report the urological, orthopedic and neurological complications of primary closure of classic bladder exstrophy using modern staged repair of exstrophy.An approved database identified 137 males and 57 females with classic bladder exstrophy who underwent primary repair by 1 of 2 surgeons in 23 years. A total of 185 patients underwent primary closure using modern staged repair of exstrophy with or without osteotomies, whereas 9 underwent delayed primary closure with epispadias repair at age 12 months. Of the patients 63 received osteotomies. Mean age at closure was 60 days and mean followup was 9 years.There were 14 major complications (11%) and 27 minor complications (14%). Major urological complications included bladder prolapse or dehiscence in 6 male patients (3%), which was successfully reclosed. Major orthopedic complications, including osteotomy nonunion in 2 cases, leg length inequality in 1 and persistent joint pain in 1, developed in 4 of the 63 patients (6%) who underwent osteotomy. Major neurological complications included femoral nerve palsy in 4 patients (2%). There were 21 minor urological complications (11%), including posterior bladder outlet obstruction in 4 cases, urethrocutaneous fistula in 2, suprapubic tube removal in 2, intrapubic stitch erosion in 4, febrile urinary tract infection in 6 and surgical site infection in 3. Six patients (3%) had minor orthopedic complications, including pelvic osteomyelitis in 1, pin site infection in 3 and a pressure sore from immobilization in 1.Closure of bladder exstrophy is a safe surgery with an acceptable risk of complications. A critical review of outcomes provides insight to further refine the technique and manage complications when they develop.

OBJECTIVE To compare the clinical and bacteriological efficacy and the clinical safety of a 1-day with a 3-day regimen of an extended-release formulation of ciprofloxacin (ciprofloxacin XR) given as antimicrobial prophylaxis to men undergoing transrectal needle biopsy of the prostate (TRNBP). PATIENTS AND METHODS This was a multicentre, prospective, international, double-blind study in patients who required TRNBP. Patients were randomized to receive oral ciprofloxacin XR 1000 mg as either a 1-day or a 3-day regimen. Single doses were given at 24 h before, 2–3 h before, and 24 h after TRNBP. Patients in the 1-day regimen had placebo instead of the first and third doses of ciprofloxacin. RESULTS Of 497 patients enrolled, 247 were randomized to 1-day ciprofloxacin XR and 250 to the 3-day regimen. In the population valid for microbiological efficacy, the final assessment identified bacteriological success (primary efficacy endpoint) in more patients who had the 3-day regimen (98%) than in those who received the 1-day regimen (94.8%, 95% confidence interval, CI, − 6.1%, 0.8%), although the difference was not statistically significant. In this population, the clinical response at the final visit was 98.5% and 96.7% for patients receiving the 3-day and the 1-day regimens, respectively (95% CI − 5.2%, 0.8%). However, in the clinical efficacy population the clinical success rate was significantly greater for the 3-day (99.0%) than for the 1-day regimen (95.8%; 95% CI − 6.4%, − 0.3%). In a multivariate analysis, patients with diabetes mellitus and patients with a history of prostatitis had higher microbiological and clinical failure rates, respectively, than those without such conditions. For these patients, all failures occurred among those treated with the 1-day regimen. CONCLUSION As defined by bacteriological success in the population assessed for microbiological efficacy, prophylaxis with one dose of ciprofloxacin XR was statistically no worse than a 3-day regimen. However, in all efficacy analyses, bacteriological and clinical success rates were consistently lower for the 1-day than for the 3-day treatment. Thus, for selected patients undergoing TRNBP, there might be a role for 3-day preventive therapy with ciprofloxacin XR.

The challenge to tailor antibiotic choices to the individual patient as well as the specific procedure is ever increasing in the modern era of multi-drugresistant organisms and increasingly complex patients and surgeries. The urologist faces decisions every day in both clinical practice and the operating room setting on how to effectively utilize antibiotics while taking into account individual patient factors as well as procedural factors. The goals of minimizing the incidence of infections and limiting morbidity from infections are shared by clinicians across the specialties ranging from Cardiology, to Orthopedics, to Infectious Disease, to Obstetrics, to Pediatrics, to Internal Medicine. Collaboration on the part of the physicians is key to managing individual patients with infections that require treatment and in procedures that necessitate prophylaxis. Judicious use of antibiotics in the appropriate doses for the indicated duration helps to limit the development of resistant organisms and to maintain the efficacy of broad spectrum antibiotics for the continued treatment of patients in the future. In this issue of Urologic Clinics, we focus on antibiotic management in cases specific to the

Summary Background Elevated body mass index (BMI) is a well-known risk factor for perioperative complications in adults, but has not been investigated in children undergoing urologic procedures. Given the low rate of complications associated with urologic surgery, a large sample is required for their characterization, but BMI is frequently not available in administrative databases. Here we report results from the first nationally based, prospectively assembled cohort analyzed with respect to the association of BMI with 30-day postoperative events for pediatric urologic procedures. Objective To determine the association of elevated BMI with overall 30-day postoperative events and wound complications in a large national sample of children undergoing urologic procedures. Study design We queried the 2012 Pediatric National Surgical Quality Improvement Program database (NSQIP), defining obesity as a BMI above the 95th percentile and overweight above the 85th percentile, per CDC definitions. We used BMI Results 2871 patients aged 2–18 years were analyzed. Of these, 420 (14.6%) were overweight and 440 (15.3%) were obese. A summary of 30-day events and complications is shown in the structured abstract table. On multivariate analysis adjusting for age, gender, class of procedure, and comorbidity, BMI remained a significant risk factor for 30-day events when comparing BMI ≥85th percentile to BMI 85th percentile on multivariate analysis. Discussion Overweight/obese status increased the odds of overall complications by 36%, and of wound complications by 140%. In adults there is a known profound effect of body composition on wound complications, but in children this association is less clear, and has not been studied in the pediatric urologic literature on a large scale. The mechanisms linking BMI to pediatric postoperative complications are unclear, but cytokine mechanisms or changes in the response to inflammation have been postulated. Limitations of this study include restriction to those urologic procedures included in ACS-NSQIPP and sorted into broad general categories. We did not control for secondary procedures. BMI/BMI percentile may not be appropriate measures of body composition in patients with atypical body habitus or proportions (e.g. myelomeningocele). Conclusion BMI in the pediatric NSQIP urologic population was found to be associated with overall complication after adjustment for case type and preoperative comorbidity in a large national sample assembled for assessment of perioperative outcomes. An exploratory analysis uncovered more than two-fold increase in odds of wound complication in obese/overweight patients compared with a normal weight referent population. These results may be useful in preoperative counseling patients regarding perioperative risk. Table . Association of BMI with 30-day postoperative events in children after urologic procedures. BMI BMI ≥85th percentile Full cohort p a Any complication b 82 (4.1%) 58 (6.7%) 140 (4.9%) 0.003 Urinary tract infection 38 (1.9%) 25 (2.9%) 63 (2.2%) 0.10 Postoperative bleeding 26 (1.3%) 15 (1.7%) 41 (1.4%) 0.35 Any wound complication 21 (1.0%) 23 (2.7%) 44 (1.5%) 0.002 Superficial surgical site infection 9 (0.5%) 13 (1.5%) 22 (0.8%) 0.005 Deep surgical site infection 3 (0.2%) 4 (0.5%) 7 (0.2%) 0.21 c Organ space infection 2 (0.1%) 5 (0.6%) 7 (0.2%) 0.02 c Dehiscence 9 (0.5%) 3 (0.4%) 12 (0.4%) 0.71 Reoperation within 30 days 27 (1.3%) 17 (2.0%) 44 (1.5%) 0.21 Readmission within 30 days 78 (3.9%) 46 (5.3%) 124 (4.3%) 0.08 Any 30-day event 150 (7.5%) 92 (10.7%) 242 (8.4%) 0.004 Odds of any 30-day event (unadjusted) – 1.49 (1.13–1.95) – 0.004 Odds of any 30-day event (multivariable) – 1.36 (1.03–1.82) – 0.034 Odds of wound complication (unadjusted) – 2.60 (1.34–4.73) – 0.002 Odds of wound complication (multivariable) – 2.36 (1.28–4.35) – 0.006 a Obtained using logistic regression. b In addition to complications shown, there were no cases of acute kidney injury, embolic events, or neurologic events. c Obtained using two-tailed Fisher's exact test because of small cell count.

Angiosarcoma of the bladder is extremely rare and carries a dismal prognosis because of the uniformly high-grade and aggressive tumor biology of the neoplasm. We report the long-term disease-free survival of 1 patient, treated with multimodal therapy, whom we have previously reported on. Six years after the initial presentation, the patient died, and the postmortem analysis revealed no evidence of residual disease. Our case represents the longest reported survival of a patient with angiosarcoma of the bladder.

Throughout the past century, we have refined our understanding of prostatitis, moving from using a primarily clinical definition to considering it as a complex inflammatory condition. The inconsistency in identifying uropathogens in patients with symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has led to controversy in therapeutic management. There is compelling evidence that the normal prostate has minimal inflammation and no bacteria. Clinicians using the Meares/Stamey criteria identified uropathogens localized to the prostate in only 6% to 8% of CP/CPPS patients. This suggests that bacteria may have a role in less than 10% of men with CP/CPPS. That some patients respond to antimicrobials could suggest that eradication of bacteria reduces symptoms. However, the beneficial effect of antimicrobial drugs may not be due to their antibacterial action, but to their anti-inflammatory action. The normal prostate shows minimal inflammation, but only 50% of CP/CPPS patients exhibit prostatic leukocytosis. Prudence demands that we examine the function of the white blood cells--the cytokines produced. Several basic science advances allowed new avenues of research regarding the detection of molecular evidence of causative uropathogens. New research brings new controversy and unexpected findings, but further refines our understanding of the immune system and the CP/CPPS disease process.

The Meares-Stamey 4-glass test is the standard method of assessing inflammation and the presence of bacteria in the lower urinary tract in men presenting with the chronic prostatitis syndrome. However, most urologists do not use it in daily practice because of the time and difficulty in performing it, as well as the additional expense. We evaluated a simpler test, the 2-glass pre-massage and post-massage test, and compared it with the Meares-Stamey 4-glass test to detect inflammation and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome.The study population included 353 men enrolled in the National Institutes of Health Chronic Prostatitis Cohort study with baseline leukocyte counts and 2-day bacterial cultures on specimens obtained from a standard 4-glass test (VB1, VB2, expressed prostatic secretions, VB3). The chi-square test was performed to assess associations of white blood cell counts in expressed prostatic secretions and VB3. A receiver operating characteristic curve was constructed to determine the optimal cut point of white blood cells in VB3 in predicting white blood cells in expressed prostatic secretions. Sensitivity and specificity of VB3 cultures predicting expressed prostatic secretions and positive Meares-Stamey results were calculated from 2 x 2 contingency tables.Analysis of binary leukocyte outcomes (no white blood cells vs any white blood cells) suggests that white blood cells tend to be present in expressed prostatic secretions when there are any white blood cells in VB3, p0.0001, the optimal cut point being white blood cell counts of 3 in VB3 (best predictive ability with area under ROC 0.771) to predict 5+ in expressed prostatic secretions with a sensitivity of 76% and specificity of 70%. The optimal cut point of white blood cells in VB3 to predict 10 white blood cells in expressed prostatic secretions was 4 (62% sensitivity and 75% specificity). Uropathogens localizing to expressed prostatic secretions or VB3 confirms a positive 4-glass Meares-Stamey localization test. The sensitivity and specificity of a VB3 localizing culture only in predicting a positive Meares-Stamey 4-glass test result for any uropathogen were 44% to 54% (depending on definition) and 100%, respectively. The pre-massage and post-massage test predicted a correct diagnosis in more than 96% of subjects.The value of localizing leukocytes and uropathogens to prostate specific specimens remains controversial in chronic heavily pretreated patients, but these data may help direct therapy (anti-inflammatory or antimicrobial) when obtained at first presentation. The pre-massage and post-massage test has strong concordance with the 4-glass test and is a reasonable alternative when expressed prostatic secretions are not obtained.

Purpose: We compared baseline and post-therapy prostate specific antigen (PSA) in patients with chronic bacterial prostatitis who were treated with levofloxacin or ciprofloxacin. Materials and Methods: Subset analysis was done using a randomized, multicenter, doubleblind, active control trial of 500 mg levofloxacin daily for 28 days vs 500 mg ciprofloxacin twice daily in 28 days in men with chronic bacterial prostatitis. Results: Of the 377 men in the intent to treat population, including 197 treated with levofloxacin and 180 treated with ciprofloxacin, 35 on levofloxacin and 37 on ciprofloxacin with baseline PSA greater than 4 ng/ml were included in this analysis. Excluded from analysis were 2 levofloxacin treated patients with extremely high PSA at baseline (62 and 103 ng/ml, respectively). Mean baseline PSA SD in the patients analyzed was 8.33 4.46 ng/ml, which decreased to 5.36 3.82 ng/ml after therapy. There was no significant difference in the mean change in PSA between the levofloxacin and ciprofloxacin groups. Approximately 42% of patients with increased baseline PSA had a post-therapy PSA of 4 ng/ml or less. Of patients who were microbiologically evaluable and had normalized PSA after therapy levofloxacin eradicated the pathogen in 90.9% (10 of 11). However, of patients in whom post-therapy PSA remained increased the microbiological eradication rate was 69.2% (9 of 13). Similarly 93.3% of the ciprofloxacin group (14 of 15 patients) with normalized post-therapy PSA experienced microbiological eradication compared with 61.5% (8 of 13) with continued increased PSA after therapy. Conclusions: Approximately 20% of patients diagnosed with chronic bacterial prostatitis had increased PSA. A significant decrease in PSA was observed in these patients after treatment with levofloxacin or ciprofloxacin. An association was observed between bacterial persistence and the likelihood that PSA would return to normal.

Purpose: We evaluated the long-term efficacy of the male bulbourethral sling procedure in the treatment of post-radical prostatectomy urinary incontinence. Materials and Methods: Between October 1994 and June 2000, 95 patients with post-radical prostatectomy incontinence underwent bulbourethral sling placement with tetrafluoroethylene bolsters at our hospital. Ultimately 71 of these patients responded to our questionnaire and they were classified into 2 groups. Group 1 consisted of 62 patients who had not undergone prior radiation therapy and group 2 consisted of 9 who had undergone radiation therapy before the sling procedure. Patients were asked to respond to questions regarding continence status as well as the validated Incontinence Quality of Life and International Prostate Symptom Score questionnaires. Results: Mean followup from the most recent sling procedure was 4 years (range 0.27 to 6.55). Average patient age at questionnaire response was 74 years. A total of 86 procedures were performed on 71 patients. Of the 71 patients 7 underwent either sling removal or artificial urinary sphincter placement and were excluded from questionnaire analysis. Including retightening procedures 68% of the patients (72% of group 1, 43% of group 2) required 2 or less pads daily. Of the patients 36% (42% of group 1 and 14% of group 2) required 0 pads. Conclusions: The male bulbourethral sling procedure remains an effective treatment for post-prostatectomy incontinence at 4-year followup.

Background Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is principally defined by pain in the pelvic region lasting more than 3 months. No cause of the disease has been established, and therapies are empirical and mostly untested. Antimicrobial agents and alpha-adrenergic receptor blockers are frequently used. Objective To determine whether 6-week therapy with ciprofloxacin or tamsulosin is more effective than placebo at improving symptoms in men with refractory, long-standing CP/CPPS. Design Randomized, double-blind trial with a 2 x 2 factorial design comparing 6 weeks of therapy with ciprofloxacin, tamsulosin, both drugs, or placebo. Setting Urology outpatient clinics at 10 tertiary care medical centers in North America. Patients Patients were identified from referral-based practices of urologists. One hundred ninety-six men with a National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score of at least 15 and a mean of 6.2 years of symptoms were enrolled. Patients had received substantial previous treatment. Measurements The authors evaluated NIH-CPSI total score and subscores, patient-reported global response assessment, a generic measure of quality of life, and adverse events. Interventions Ciprofloxacin, 500 mg twice daily; tamsulosin, 0.4 mg once daily; a combination of the 2 drugs; or placebo. Results The NIH-CPSI total score decreased modestly in all treatment groups. No statistically significant difference in the primary outcome was seen for ciprofloxacin versus no ciprofloxacin (P = 0.15) or tamsulosin versus no tamsulosin (P > 0.2). Treatments also did not differ significantly for any of the secondary outcomes. Limitations Treatment lasting longer than 6 weeks was not tested. Patients who had received less pretreatment may have responded differently. Conclusion Ciprofloxacin and tamsulosin did not substantially reduce symptoms in men with long-standing CP/CPPS who had at least moderate symptoms.

Urinary tract infections are most commonly caused by type 1-piliated Escherichia coli (UPEC) and result in urothelial apoptosis, local cytokine release and neutrophil infiltration. A human urothelial cell line was incubated with various E. coli isolates and was then characterized by flow cytometry. UPEC induced rapid urothelial apoptosis that was dependent upon interactions mediated by type 1 pili. Laboratory isolates expressing type 1 pili-induced approximately 50% less apoptosis. UPEC blocked activity of a NF-kappaB-dependent reporter in response to inflammatory stimuli by stabilizing IkappaBalpha and UPEC rapidly altered cellular signalling pathways. Finally, blocking NF-kappaB activity increased the level of the laboratory strain-induced apoptosis to the level of apoptosis induced by UPEC. These results suggest that UPEC blocks NF-kappaB and enhances type 1 pili-induced apoptosis as a component of the uropathogenic programme.

A 19-year-old woman with a known allergy to iodinated contrast presented with intermittent, gross hematuria of 2 years' duration. The patient was scheduled to undergo cystoscopy with bilateral retrograde pyelography, because this is considered a safe alternative to intravenous pyelography or computed tomography. Because of her contrast allergy, the patient completed a 13-hour steroid preparation before the procedure. However, within minutes of extubation, she developed an anaphylactoid reaction and, despite appropriate management, required reintubation and subsequent transfer to the intensive care unit. The patient was subsequently extubated 8 hours later and recovered completely.

Inactivation of the tumor suppressor genes p53 and Rb are two of the most common genetic alterations in cancer cells. We use a mouse model to dissect the consequences of compromising the function of either of these genes on the maintenance of genomic stability. Thirteen cell lines established from skin tumors of mice expressing either the E6 or E7 oncoprotein of the human papillomavirus (HPV) type 16 under control of the keratin 14 promoter were analyzed by comparative genomic hybridization, spectral karyotyping and fluorescence in situ hybridization, reverse transcription-PCR, and mutation analysis. Deducing from the wealth of molecular cytogenetic data available from human cancers, we hypothesized that the more benign tumors in mice expressing E7 would be distinct from the more aggressive lesions in E6 transgenic mice. Tumorigenesis in E6-expressing mice required specifically the selection and maintenance of cells with extra copies of chromosome 6. Aneuploidy of chromosome 6 was independent of activating mutations in H-ras on chromosome 7. Expression of either E6 or E7 resulted in centrosome aberrations, indicating that each viral oncoprotein interferes independently with the centrosome cycle. Although centrosome aberrations are consistent with development of aneuploidy, no direct correlation was evident between the degree of aneuploidy and the percentage of cells with aberrant centrosomes. Our results show that although aneuploidy and centrosome aberrations are present in tumor cells from mice expressing either E6 or E7, tumorigenesis via E6 requires copy number increases of mouse chromosome 6, which is partially orthologous to human chromosome 3q, a region gained in HPV-associated carcinomas.