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The article discusses the publication of Version 3.0 of the CLER Pathways to Excellence, which provides expectations for an optimal clinical learning environment to achieve safe and high-quality patient care. The CLER Pathways are organized into six focus areas and serve as a tool to promote discussions and actions to optimize the clinical learning environment. Version 3.0 introduces a new focus area on Diversity, Equity, and Inclusion (DEI), recognizing the importance of diverse and inclusive clinical learning environments. The CLER Program aims to continually inform accreditation and improve patient safety and healthcare quality. [Extracted from the article]

OBJECTIVES To assess the interpretation of modern criteria for evaluating surgical margins (SMs), by examining the incidence of positive SMs (PSMs) and subsequent biochemical recurrence in a single-surgeon series of radical prostatectomy (RP) at two institutions, as the criteria for determining PSMs after RP are subject to individual interpretation, and this might explain some of the variability in biochemical recurrence rates with different rates of PSMs. PATIENTS AND METHODS We reviewed 301 consecutive perineal RPs by one surgeon (T.K.) at Emory University Hospital (EUH) and the Medical University of South Carolina (MUSC), with each pathology department using modern criteria to evaluate the SMs. The SM status and biochemical recurrence (BCR) were analysed, the latter defined as a prostate-specific antigen level of ≥0.2 ng/mL. RESULTS There were 158 perineal RPs at EUH followed by 143 at MUSC. PSMs were reported in 39 patients (24.7%) at EUH, whereas six (4.2%) were positive at MUSC. The overall BCR rates were similar between the groups, but BCR within margin-positive cases was 100% at MUSC vs 25.6% at EUH ( P < 0.01). The presence of tumour at <1 mm from the margin did not increase the rate of BCR compared to those with obvious negative SMs ( P = 0.731). CONCLUSION In this single-surgeon series, using the same criteria to evaluate the SMs resulted in significantly different PSM rates and margin-positive BCR rates between the institutions. Although the reason for these differences is difficult to determine, the study shows clearly that tumour within 1 mm of the margin should not be classified as margin-positive. [ABSTRACT FROM AUTHOR]

The article comments on the article "Sexual Health Issues in Men With Cancer," by Raanan Tal and John P. Mulhall. It explores issues in which cancer in men affects sexual health. The article discusses how sexual health affects the psychological adjustment of patients and coping with the stages of cancer.

The article explores early penile rehabilitation post-pelvic and prostate surgery. A survey of International Society of Sexual Medicine members revealed that 87% of the 301 respondents included rehabilitation strategy in their treatment regiment. The author says that physicians should be aware of the difference between post-prostatectomy erectile dysfunction treatment and penile rehabilitation because the two have different objectives for their respective rehabilitation.

This article describes the process of building a system-wide, interprofessional peer support program at the onset of the COVID-19 pandemic. With limited resources, but with a dedicated team driven by the desire to provide psychological first aid, nurse leaders from a large academic medical center developed a peer support program, inclusive of 16 hours of peer supporter training and quarterly continuing education. To date, this program has 130 trained peer supporters who offer peer support, active listening, and close partnerships with the health care system and university employee assistance programs. This case study shares lessons learned and considerations on how leaders can initiate their own local peer support programs., (2023 by Elsevier Inc. All rights reserved.)

Background: The objective of the current study was to characterize and identify factors associated with perceptions of risk of infertility among adult male survivors of childhood cancer., Methods: A total of 1233 adult male survivors from the Childhood Cancer Survivor Study who were without a history of disease recurrence or subsequent malignancy reported their perceptions of their risk of infertility compared with men never diagnosed with cancer. Survivors were a median age of 37.8 years (range, 22.0-58.7 years) and were 28.4 years from their diagnosis (range, 21.4-39.2 years). Multivariable logistic regression evaluated factors associated with perceptions of risk., Results: Overall, 35.9% of the survivors (443 of 1233 survivors) reported perceptions of their risk of infertility that were discordant with their actual risk based on previous cancer treatment exposures. Discordant perceptions were equally common among men exposed to gonadotoxic therapies (36.3%; 311 of 857 men) and those with no history of gonadotoxic exposure (35.1%; 132 of 376 men). Survivors who fathered children (odds ratio [OR], 4.14; 95% confidence interval [95% CI], 2.74-6.24), had no survivor-focused health care (OR, 3.07; 95% CI, 1.57-5.99), were nonwhite (OR, 2.28; 95% CI, 1.10-4.75), and were of lower income were more likely to report no increased risk of infertility after gonadotoxic treatment. Perceptions of increased risk of infertility among men with no history of gonadotoxic treatment were predicted by never having fathered a child (OR, 1.88; 95% CI, 1.17-3.03), recent participation in survivor-focused health care (OR, 2.11; 95% CI, 1.01-4.42), and higher educational achievement., Conclusions: Many male survivors of childhood cancer are unaware of how their cancer treatments could impact their reproductive health, underscoring the need for all patients to receive education regarding their risk of infertility throughout the continuum of cancer care. Cancer 2018;124:2447-55. © 2018 American Cancer Society., (© 2018 American Cancer Society.)

Introduction: With survival rates higher than 80%, the number of survivors from pediatric cancer continues to increase. Late effects resulting from cancer and cancer therapy are being characterized, but little information exists on sexual health for men who have survived childhood cancer., Aim: To assess erectile dysfunction (ED) in men who survived childhood and adolescent cancers and to identify potential risk factors for ED., Methods: In total, 1,622 men and 271 eligible brothers in the Childhood Cancer Survivor Study cohort completed the Male Health Questionnaire, which provided information on sexual practices and sexual function. Combined with demographic, cancer, and treatment information from medical record abstraction, results of the Male Health Questionnaire were analyzed using multivariable modeling. The International Index of Erectile Function was used to identify ED in subjects., Main Outcome Measure: International Index of Erectile Function., Results: Survivors (mean age = 37.4 years, SD = 7.3 years) reported significantly lower sexual activity in the year before the survey than the brothers (mean age = 38.8 years, SD = 8.5 years) without cancer. ED was reported by 12.3% (95% CI = 10.4-14.3) of survivors and 4.2% (95% CI = 2.0-7.9) of brothers. Survivors showed significantly higher relative risk (RR) for ED (RR = 2.63, 95% CI = 1.40-4.97). In addition to older age, survivors who were exposed to higher-dose (≥10 Gy) testicular radiation (RR = 3.55, 95% CI = 1.53-8.24), had surgery on the spinal cord or nerves (RR = 2.87, 95% CI = 1.36-6.05), prostate surgery (RR = 6.56, 95% CI = 3.84-11.20), or pelvic surgery (RR = 2.28, 95% CI = 1.04-4.98) were at higher risk for ED., Conclusion: Men who have survived childhood cancer have a greater than 2.6-fold increased risk for ED and certain cancer-specific treatments are associated with increased risk. Attention to sexual health, with its physical and emotional implications, and opportunities for early detection and intervention in these individuals could be important., (Published by Elsevier Inc.)

Introduction: The study objective was to determine the impact of remote monitoring and supervision (RMS) in integrated endourology suites (IES) on residents achieving endoscopic training milestones., Materials and Methods: Twenty-one urology residents evaluated RMS in IES using a 25-question survey. IES provided audio-visual communication for faculty to supervise residents remotely. Questionnaire used a linear visual scale of 1-10 to assess acceptability (8 questions), impact on training (10 questions), supervision level (1 question), and pre- and post-training milestone self-assessments (6 questions). Improvements in Patient Care Milestone #7 (upper/lower tract endoscopic procedures) and Patient Care Milestone #9 (office-based procedures) were analyzed., Results: Twenty-one urology residents (out of potential 23) evaluated RMS in IES using a 25-question survey (91.3% response rate). Overall RMS acceptability and satisfaction was high (mean score = 9.1/10) with a majority (95.2%) feeling comfortable being alone with the patient. Residents reported positively on the following parameters: autonomy without compromising safety (8.7), supervision level (8.6), achieving independence (8.4), education quality (8.3), learning rate (8.1), clinical decision-making (8.0), and reducing case numbers to achieve proficiency (7.6). Residents perceived no issues with under- or over-supervision, and a majority (76.2%) expressed that RMS should be standard of training in residency programs. Residents reported mean level increases of 2.5 and 2.8 (out of 5) in Patient Care Milestones for endoscopic procedures and office-based procedures, respectively (p < 0.0001)., Conclusions: RMS in integrated endourology suites may enhance resident education and endoscopic training. The study demonstrated an increase in competency levels reported by residents trained using RMS.

Previous studies have described racial and socioeconomic disparities in the treatment of infertility. Patient factors such as attitudes and awareness may be contributing factors. Since primary care is often the setting that serves as an entry into other areas of medicine, we sought to evaluate men's attitudes and awareness of male infertility in the primary care setting. To do this, we performed a cross-sectional survey of men's attitudes toward men's health issues in 210 men from two primary care clinic waiting rooms in Atlanta, Georgia. The survey was self-administered with closed-ended question items and was approximately 20 min in length. Of the 310 men approached, 210 agreed to participate and returned completed surveys. Overall, 52% of men said they were "very" or "somewhat" familiar with infertility and 25% were familiar with treatments for infertility. Some men had heard of surgery (21%) and medication (35%) as treatments for male infertility. Awareness and familiarity with the condition was greater in high socioeconomic status men (i.e. college graduates or those with income >$100 k per year) but did not differ by race on multivariate analysis. Attitudes toward infertility varied by race with non-Caucasian men being more likely to indicate that infertility is a serious condition, to be concerned about infertility, and to believe it decreases a man's quality-of-life. Therefore, a lack of awareness, but not negative attitudes, may contribute to previously-described disparities in the treatment of infertility.

Introduction: In the era of evidence-based medicine, all physicians who communicate with patients need numerical literacy (numeracy). Single-institution studies suggest imperfect numeracy among medical students. Therefore, we sought to examine numeracy and understanding of risk analysis among medical students and surgical residents at several institutions., Methods: Following a validated 3-item numeracy questionnaire, 308 medical students and 50 surgical residents from 4 institutions were asked whether they would recommend adjuvant chemotherapy for a patient based on presented survival data. Main outcome measures included numeracy, understanding of risk with a question requiring simple calculation of risk reduction, and confidence in understanding risk reduction using a Likert score (0 = no confidence and 7 = complete confidence). Binary logistic regression analysis identified predictors of misunderstanding of risk and Pearson correlation coefficients measured differences in confidence by level of training and numeracy., Results: Students across institutions did not differ demographically and were grouped by educational level. Of all participants, 69.0% had perfect basic numeracy (score = 3), with no significant difference in numeracy across training levels (p = 0.433). Mean (standard deviation) confidence in recommending treatment increased from 4.5 (1.6) for first-year medical students to 4.8 (1.1) for fourth-year medical students, and 4.9 (1.5) for surgical residents (p = 0.580). Controlling for other demographics, poorly numerate students had a 7-fold increased likelihood (odds ratio: 7.330; 95% confidence interval: 1.384-38.809) of misunderstanding risk compared with more numerate students., Conclusions: A significant number of students at various levels of medical training lack numeracy skills, which increases misunderstanding and miscommunication of risk that can be communicated to patients and families. This deficiency could potentially affect patient safety and care., (Copyright © 2014. Published by Elsevier Inc.)

Purpose: We describe a simple and effective method to reduce the risk of infection after prostate biopsy., Materials and Methods: A total of 1,642 consecutive prostate biopsy procedures during a 4-year period (2008 to 2012) were included in the study. Inclusion criteria consisted of pre-biopsy negative urine culture, bisacodyl enema and fluoroquinolone antibiotics (3 days). Formalin (10%) was used to disinfect the needle tip after each biopsy core. All patients were monitored for post-biopsy infection. The rate of infection was compared to that of a historical series of 990 procedures. Two ex vivo experiments were conducted to test the disinfectant effectiveness of formalin against fluoroquinolone resistant Escherichia coli, and another experiment was performed to quantitate formalin exposure., Results: Post-biopsy clinical sepsis with positive urine and blood cultures (quinolone resistant E. coli) developed in 2 patients (0.122%). Both patients were hospitalized, treated with intravenous antibiotics and had a full recovery without long-term sequelae. Mild uncomplicated urinary infection developed in 3 additional patients (0.183%). All were treated with outpatient oral antibiotics and had a complete recovery. The overall rate of urinary infection and sepsis using formalin disinfection was approximately a third of that of a prior series (0.30% vs 0.80%, p=0.13). Ex vivo experiments showed a complete lack of growth of fluoroquinolone resistant E. coli on blood and MacConkey agars after exposure to formalin. The amount of formalin exposure was negligible and well within the safe parameters of the Environmental Protection Agency., Conclusions: Formalin disinfection of the biopsy needle after each prostate biopsy core is associated with a low incidence of urinary infection and sepsis. This technique is simple, effective and cost neutral., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The correct length of a ureteral stent is important in minimizing postplacement discomfort and stent migration. We describe and validate a method to accurately measure the ureteral length., Materials and Methods: The ureteral length in 48 patients undergoing ureteral stent placement for urolithiasis was measured by computed tomography (CT) (total thickness of axial slices between the ureteropelvic junction and ureterovesical junction) and adjusted up by 20%. The adjusted CT measurement of ureteral length was compared with direct intraoperative measurement using scatter plot and Pearson correlation coefficient. Correlation coefficients were also calculated between intraoperative ureteral length and various body habitus measurements such as the height, weight, and waist circumference., Results: Median patient age was 62 years. The median stone diameter was 7.5 mm (1-20). The ratio of left- to right-sided stones was 2:1. The stone location was in the proximal ureter in 45.8%, distal ureter in 37.5%, kidney in 10.4%, and midureter in 6.3%. Symptoms included adnominal/flank pain (93.8%) followed by nausea/vomiting (39.6%) and gross hematuria (16.7%). Median creatinine was 1.4 (0.8-3.6 mg/dl) and median WBC was 8.6 (2.8-17.6). The median ureteral length was 25.8 cm (19.2-29.4) on the CT scan and 25.5 cm (19.0-29.0) on the intraoperative measurement (p=0.57). The Pearson correlation coefficient between the two measurements was 0.979. In contrast, the height, weight, and waist circumference correlated poorly with intraoperative ureteral length measurements (r=0.34, 0.19, and 0.40, respectively)., Conclusion: CT-measured ureteral length adjusted up by 20% is a reliable method to accurately measure the true ureteral length. This method is superior to traditional indirect methods that rely on body habitus measurements.

Objective: To evaluate a model of elective postoperative clinic appointments after a minor urological procedure and to compare it to the traditional practice of routine appointments., Methods: A total of 104 consecutive patients undergoing adult circumcision under local anesthesia were divided into 2 groups; group A (n = 45) received routine postoperative clinic appointments and group B (n = 59) were given the option to make an appointment on an as-needed basis. Both groups received detailed postoperative instructions on the early signs of symptoms of potential adverse events. The 2 groups were compared regarding demographics, clinical profile, postoperative recovery, and outcome., Results: Group A patients ("routine appointments") were younger (51 vs 60 years, P <.0001) and included fewer African Americans (57.8% vs 78.0%, P <.03) compared to group B patients ("elective appointments"). Postoperative clinic appointments were categorized as unnecessary in 84.4% (38/45) and 71.1% (42/59) of the patients in groups A and B, respectively. Of the remaining 17 patients in group B who elected to make an appointment, only 1 patient (1.7%) had a true procedure-related issue that justified the visit and required management. Overall, there was no statistical difference between the 2 groups with regard to the number of patients with perceived postoperative issues (P = .36)., Conclusion: The traditional practice of routine clinic appointments after uncomplicated adult circumcision is medically unnecessary and provides little value in the majority of cases. The practice of open access elective postoperative evaluation based on clearly defined clinical criteria is efficacious, safe, convenient, and enhances resource utilization., (Published by Elsevier Inc.)

Purpose: To report on integrated endourology suites (IES), remote monitoring and supervision (RMS) of urology residents and to evaluate patients' opinions, acceptance, and satisfaction level with IES and RMS., Patients and Methods: Patients undergoing flexible cystoscopy in the IES with RMS were surveyed using a questionnaire. All procedures were performed by junior urology residents (UR-1 level) using RMS. Patients were studied using a nine-question survey to evaluate their comfort level, acceptance, and level of satisfaction with RMS. Six questions used a scale of 1 to 10 (1=strongly disagree; 10=strongly agree), and the remaining three questions solicited a "yes" or "no" response., Results: 100 patients were studied (59% Caucasians, 40% African Americans, and 1% Hispanic). Median age was 63 years. The highest level of education was middle school in 2% of patients, high school in 55%, undergraduate in 33%, and postgraduate in 10%. Patients scored a mean of 9.50/10 (highly satisfactory) regarding their comfort with RMS; 96% scored ≥ 7, 4% scored 5 to 6, and none scored <5. Patients were satisfied having a urology resident perform the procedure (9.48/10), other residents and medical students watch the procedure (9.41/10), a video camera in the room (9.40/10), and two-way sound communication (9.40/10). None perceived compromise to their privacy or quality of care., Conclusions: RMS in IES is highly acceptable to patients undergoing endoscopic procedures. RMS has the potential to positively impact residency training, efficiency, regulatory compliance, safety, and productivity.

Introduction: Studies have shown an association between erectile dysfunction and sedentary lifestyle in middle-aged men, with a direct correlation between increased physical activity and improved erectile function. Whether or not this relationship is present in young, healthy men has yet to be demonstrated., Aim: The aim of this study was to assess the association between physical activity and erectile function in young, healthy men., Main Outcome Measures: The primary end points for our study were: (i) differences in baseline scores of greater than one point per question for the International Index of Erectile Function (IIEF); (ii) differences in baseline scores of greater than one point per question for each domain of the IIEF; (iii) exercise energy expenditure; and (iv) predictors of dysfunction as seen on the IIEF., Methods: The participants were men between the ages of 18 and 40 years old at an academic urology practice. Patients self-administered the Paffenbarger Physical Activity Questionnaire and the IIEF. Patients were stratified by physical activity into two groups: a sedentary group (≤1,400 calories/week) and an active group (>1,400 calories/week). Men presenting for the primary reason of erectile dysfunction or Peyronie's disease were excluded., Results: Seventy-eight patients had complete information in this study: 27 patients (34.6%) in the sedentary group (≤1,400 kcal/week) and 51 patients (65.4%) in the active group (>1,400 kcal/week). Sedentary lifestyle was associated with increased dysfunction in the following domains of the IIEF: erectile function (44.4% vs. 21.6%, P = 0.04), orgasm function (44.4% vs. 17.7%, P = 0.01), intercourse satisfaction (59.3% vs. 35.3%, P = 0.04), and overall satisfaction (63.0% vs. 35.3%, P = 0.02). There was a trend toward more dysfunction in the sedentary group for total score on the IIEF (44.4% vs. 23.5%, P = 0.057), while sexual desire domain scores were similar in both groups (51.9% vs. 41.2%, P = 0.37)., Conclusions: We have demonstrated that increased physical activity is associated with better sexual function measured by a validated questionnaire in a young, healthy population. Further studies are needed on the long-term effects of exercise, or lack thereof, on erectile function as these men age., (© 2011 International Society for Sexual Medicine.)

Objectives: To investigate the impact of additional biopsy cores on prostate cancer diagnosis among US veterans. The reported rate of positive biopsy results varies from 20% to 40%., Methods: We analyzed 1546 consecutive initial prostate biopsy procedures (8-core and 12-core biopsy protocols) at the Atlanta VA Medical Center. Both biopsy protocols targeted the peripheral zone. Cancer detection rates were compared between the 2 protocols in univariate and multivariate analyses with results expressed as odds ratios and corresponding 95% confidence intervals. Characteristics of cancer detected were also compared. Sensitivity analyses were performed for different population subgroups., Results: The overall positive biopsy rate was 49.9%, 51.2% in the 8-core group and 49.2% in the 12-core group. There was no difference between the 2 biopsy groups (adjusted odds ratio = 0.97, 95% confidence interval = 0.76-1.25). Advanced age and high body mass index were significantly associated with higher likelihood of prostate cancer, whereas larger prostate volumes were associated with lower risk., Conclusions: In this large series of prostate biopsy procedures, in which the peripheral zone was well targeted, there was no evidence that 12-core biopsy improved the likelihood of prostate cancer diagnosis compared with 8-core biopsy. As such, the results of this cohort from a US veteran population suggest that targeting the peripheral zone is more important than the absolute number of biopsy cores. However, in certain subgroups of patients with specific clinical characteristics, such as those with very large prostates, more cores may be required. Further studies are needed to identify such characteristics., (Published by Elsevier Inc.)

Background: The incidence of urolithiasis is twofold to threefold higher in men than in women. Several animal studies have suggested an association between testosterone levels and the formation of kidney stones. Specifically, castration has been shown to decrease stone formation in rat models. The association between testosterone and stone formation in humans, however, has not been well investigated., Patients and Methods: Early morning total and free testosterone levels were recorded for 55 male patients. Participants completed a demographics questionnaire, and clinical records of enrolled subjects were reviewed. When available, stone composition was determined in the stone formers. Mann-Whitney tests and logistic regression models were used to examine the data., Results: Of the 55 patients, 25 had no history of urolithiasis and 30 had a history of urolithiasis. Although the differences between the two groups were not statistically significant, the stone formers compared with stone-free controls tended to be older (median age 48.4 vs 36.5 years, P = 0.072) and have higher serum levels of testosterone (median serum concentration 384 vs 346 ng/dL, P = 0.112). In the multivariate analyses, after adjusting for age and body mass index, the testosterone-related odds ratio was 1.004 with a corresponding P value 0.051., Conclusions: Male stone formers were found to have higher serum total testosterone levels compared with a similar cohort without stones. This result is consistent with several animal models that have demonstrated that testosterone is a risk factor for stone formation. Our findings warrant confirmation in a larger, prospective study. There are potential therapeutic implications if testosterone is found to be a risk factor in urolithogenesis.

Objectives: To review the associations between measured variables in Penile Doppler ultrasound procedures. Penile Doppler ultrasound is useful in the evaluation of erectile dysfunction, but there is no uniform standard of performing the procedure. It is generally believed that a peak systolic velocity > 30 cm/s, minimal venous leak, and resistive index > 0.8 are essential for adequate erection. While the arterial parameters are well studied, data on the predictive value of time to peak flow are lacking., Methods: Penile duplex Doppler ultrasounds performed for either erectile dysfunction or Peyronie's disease evaluation were reviewed. Clinical records, International Index of Erectile Function scores, and ultrasound variables were examined. "Fast" responders reached maximal peak systolic velocity (PSV) < or = 10 minutes, whereas "slow" responders reached maximal PSV between 15 and 25 minutes., Results: Of 146 total patients, 36 (25%) were fast responders and 110 (75%), slow responders. No preprocedural characteristics, including the Erectile Function domain score of the International Index of Erectile Function, predicted time to peak flow. Compared with the fast responders, slow responders had higher mean PSV (left: 33.9 +/- 19.5 vs 25.0 +/- 11.7 cm/s, P = .01; and right: 36.4 +/- 21.3 vs 25.0 +/- 13.3 cm/s, P = .002). There was also a higher percentage of patients with average PSV > 30 cm/s in slow responders (58% vs 36%, P = .02)., Conclusions: There were no significant differences in baseline characteristics between slow and fast responders. However, slow responders did seem to have significantly better arterial flow parameters, although penile dimensions, cavernosal artery diameter, Erectile Function domain scores, and subjective rigidity were similar., (2010 Elsevier Inc. All rights reserved.)

Utilization of nuclear bone scans for staging newly diagnosed prostate cancer has decreased dramatically due to PSA-driven stage migration. The current criteria for performing bone scans are based on limited historical data. This study evaluates serum PSA and Gleason grade in predicting positive scans in a contemporary large series of newly diagnosed prostate cancer patients. Eight hundred consecutive cases of newly diagnosed prostate cancer over a 64-month period underwent a staging nuclear scan. All subjects had histologically confirmed cancer. The relationship between PSA, Gleason grade, and bone scan was examined by calculating series of crude, stratified, and adjusted odds ratios with corresponding 95% confidence intervals. Four percent (32/800) of all bone scans were positive. This proportion was significantly lower in patients with Gleason score or=8 (18.8%, p < 0.001). Among patients with Gleason score 30 ng/ml compared to or=8, the rate was significantly higher (27.9 vs. 0%) when PSA was >10 ng/ml compared to 30 ng/ml. However, for patients with a high Gleason score (8-10), we recommend a bone scan if the PSA is >10 ng/ml.

It is estimated that 1.2 million Americans are infected with HIV. With advances in treatment and improved survival, HIV-positive patients are increasingly reaching an age when prostate cancer becomes a health issue. While there have been some reports in the literature reporting lower incidence of prostate cancer in HIV population cohorts, these studies have focused on younger populations, where we expect a lower incidence of prostate cancer. Our study involves patients over a 5.5 year period from a busy referral Veterans Medical Center referred to our urology clinic with either elevated PSA or abnormal DRE. Of these patients referred to our clinic, there is a markedly higher rate of prostate cancer in HIV patients when compared to our HIV-negative or HIV-unknown population. Though one may surmise a referral bias, in our highly regulated system, we use identical referral criterion for both HIV-positive and HIV-negative patients. Though this is a study with admittedly limited numbers, we believe this report is important because it is one of the first studies to address prostate cancer in a older cohort of patients who are referred because of suspicion for prostate cancer.

Bladder involvement occurs in 1%-4% of cases of inguinal hernias. Among obese men aged 50 to 70, the incidence may reach 10%.1,2 The diagnosis of bladder involvement is often difficult to delineate at the time of presentation and may only become apparent at the time of herniorrhaphy. Surgical management pertaining to the approach, repair and potential need for bladder resection may challenge the surgeon. We report a series of 4 cases of large inguinoscrotal bladder hernias and provide a literature review. Our goal is to highlight the clinical presentation and the decisive issues surrounding the diagnosis and management of this condition.

Background: As digital rectal examination (DRE) remains an essential part of a routine physical examination, it is important to understand its diagnostic value in different circumstances., Aim: To quantify sensitivity, specificity and predictive value of DRE as a predictor of biopsy-confirmed prostate cancer in the US Veteran population., Methods: The study group included 628 consecutive patients who underwent transrectal biopsy for suspected prostate cancer due to abnormal digital examination of the prostate, elevated serum prostate specific antigen (PSA) or both. The DRE results reported in this study are documented during physical examinations that were performed after referral for biopsy. The relation between DRE results and positive biopsy was examined while taking into consideration demographic and clinical patient characteristics., Results: Among men with normal PSA the adjusted odds ratio (OR) reflecting the association between abnormal DRE and positive prostate biopsy was 0.53 with a 95% confidence interval (CI) from 0.27 to 1.06. In the presence of a moderately elevated (4.1-10 ng/mL) PSA, the OR was 1.07 (0.72-1.60). When serum PSA exceeded 10 ng/mL, the OR was 2.15 (1.12-4.43). The positive predictive value of an abnormal DRE varied widely from as high as 81% to as low as 14% depending on the other patient characteristics., Discussion: These results indicate that DRE results are most informative when evaluated in conjunction with other clinical and demographic information.