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Purpose: Perioperative pelvic floor muscle training can hasten recovery of bladder control and reduce severity of urinary incontinence following radical prostatectomy. Nevertheless, most men undergoing prostatectomy do not receive this training. The purpose of this trial was to test the effectiveness of interactive mobile telehealth (mHealth) to deliver an evidence-based perioperative behavioral training program for post-prostatectomy incontinence., Materials and Methods: This was a 3-site, 2-arm, randomized trial (2014-2019). Men with prostate cancer scheduled to undergo radical prostatectomy were randomized to a perioperative behavioral program (education, pelvic floor muscle training, progressive exercises, bladder control techniques) or a general prostate cancer education control condition, both delivered by mHealth for 1-4 weeks preoperatively and 8 weeks postoperatively. The primary outcome was time to continence following surgery measured by the ICIQ (International Consultation on Incontinence Questionnaire) Short-Form. Secondary outcomes measured at 6, 9 and 12 months included Urinary Incontinence Subscale of Expanded Prostate Cancer Index Composite; pad use; International Prostate Symptom Score QoL Question and Global Perception of Improvement., Results: A total of 245 men (ages 42-78 years; mean=61.7) were randomized. Survival analysis using the Kaplan-Meier estimate showed no statistically significant between-group differences in time to continence. Analyses at 6 months indicated no statistically significant between-group differences in ICIQ scores (mean=7.1 vs 7.0, p=0.7) or other secondary outcomes., Conclusions: mHealth delivery of a perioperative program to reduce post-prostatectomy incontinence was not more effective than an mHealth education program. More research is needed to assess whether perioperative mHealth programs can be a helpful addition to standard prostate cancer care.

Purpose: Bone scans (BS) are a low-value test for asymptomatic men with low-risk prostate cancer. We performed a quality improvement intervention aimed at reducing BS for these patients., Methods and Materials: The intervention was a presentation that leveraged the behavioral science concepts of social comparison and normative appeals. Participants were multidisciplinary stakeholders from the Radiation Oncology and Urology services at a Veterans Affairs hospital. We determined the baseline rate of BS by retrospectively analyzing cases of asymptomatic men with newly diagnosed low-risk prostate cancer. For social comparison, we presented contemporary peer BS rates in the United States-including Veterans Affairs hospitals. For normative appeals, we reviewed guidelines from various professional groups. To analyze the effect of this intervention, we performed a quasi-experimental, uncontrolled, before-and-after study., Results: During the 1-year period before the intervention, 32 of 37 patients with low-risk prostate cancer (86.5%) received a BS. The contemporary peer rate was approximately 30%. All reviewed guidelines recommended against BS. During the 1-year period after the intervention, the rate of BS was reduced to 65.5% (19 of 29 patients; P = .043 by one-sided Fisher's exact test)., Conclusions: We observed a modest reduction in guideline-discordant BS after the quality improvement intervention. BS rates might be influenced by initiatives that combine social comparisons with appeals to professional norms.

The treatment of renal cell carcinoma has evolved tremendously over the years. Initially the entire kidney was removed along with the renal tumor despite the size or extent of the mass. Early attempts to remove tumors with a normal surrounding parenchymal margin showed equivalent oncologic results in small renal masses. Attempts to preserve more renal parenchyma in patients with compromised renal function led to the enucleation of renal masses by blunt dissection following the natural plane between the peritumor pseudocapsule and the renal parenchyma. Enucleation of renal tumors has been especially useful for renal preservation in patients with preoperative renal insufficiency, solitary kidneys, multiple renal lesions and hereditary renal cell carcinoma syndromes. Comparable long-term progression and cancer-specific survival has been shown with tumor enucleation and standard partial nephrectomy. However, there has been considerable controversy regarding the safety of renal tumor enucleation due to histopathologic findings of pseudocapsule tumor invasion. Current data suggest that tumor enucleation is a safe alternative for small renal masses that are locally confined on preoperative imaging, easily delineated intraoperatively and do not appear to grossly invade beyond the pseudocapsule.

Introduction: High-frequency jet ventilation (HFJV) during shock wave lithotripsy (SWL) has been reported using older lithotripsy units with larger focal zones. We investigated how HFJV affects the clinical parameters of SWL using a newer lithotripsy unit with a smaller focal zone., Methods: We reviewed all patients who underwent SWL by a single surgeon (KVA) from July 2006 until December 2007 with the Siemens Lithostar Modularis (Siemens AG, Erlangen, Germany). Either HFJV or conventional anesthetic techniques were used based on the anesthesiologists' preference. Preoperative imaging was reviewed for stone size, number and location. Total operating room time, procedure time, number of shocks and total energy delivery were analyzed. Postoperative imaging was reviewed for stone-free rates., Results: A total of 112 patients underwent SWL with 80 undergoing conventional anesthesia, and 32 with HFJV. Age, body mass index, preoperative stone size and number were not significantly different between the groups. The HFJV group required significantly less total shocks (3358 vs. 3754, p = 0.0015) and total energy (115.8 joules vs. 137.2 joules, p = 0.0015). Total operating room time, SWL procedure time and postoperative stone-free rates were not significantly different., Conclusions: Previous studies using older SWL units with larger focal zones have demonstrated that HFJV can be effective in reducing total shocks and total energy. Our data is consistent with these studies, but also shows benefit with newer units that have narrower focal zones.

The objective of this study is to describe a single-center experience of caval thrombectomy in patients with renal cell carcinoma (RCC) and tumor thrombus extension into the inferior vena cava (IVC). We retrospectively reviewed 23 patients undergoing radical nephrectomy with caval thrombectomy. Follow-up included an office visit and computed tomography scan. Statistical comparisons were made using 2-sample t tests. Patients' ages ranged from 32 to 83 years (mean, 62 years; 18 male, 5 female). Tumor size ranged from 3 to 21 cm (mean, 8.6 cm). Tumor thrombus staging was based on the Nevus classification: level I (2/23), II (6/23), III (13/26), IV (2/23). Tumor thrombi were removed by means of digital extraction (20), Fogarty embolectomy (2), or endarterectomy (1-caval wall invasion). Lateral venorrhaphy was used for IVC repair in all cases. Hepatic mobilization and suprahepatic clamping were necessary in 14 patients. Clamp times were significantly different between the suprahepatic (SH) and infrahepatic (IH) groups (15 vs 9.4 minutes, P < .012). Mean blood loss was also significantly different (3.2 L vs 2 L, P < .045). In the SH group, 2 patients developed postoperative atrial fibrillation and 2 patients died (respiratory failure; missed enterotomy). The IH group had no perioperative morbidity or mortality. Median followup was 15 months (range, 1-54 months). Follow-up imaging was available for 19/23 patients. Ninety-five percent of patients had a patent IVC (18). One SH patient developed an IVC stenosis/thrombosis 12 months postoperatively with successful thrombolysis and stenting. There was a 16% (3/19) recurrence rate in follow-up, with all patients demonstrating renal vascular invasion and high Fuhrman grade upon final pathologic evaluation. Caval thrombectomy can be performed safely during radical nephrectomy for RCC with tumor thrombus extension. The need for suprahepatic clamping is associated with longer clamp times, increased blood loss, and increased morbidity and mortality. Lateral venorrhaphy with primary repair avoids complicated caval reconstructions and results in high patency rates, despite a not insignificant recurrence rate.

Fistulae between the vasculature and the ureter are rare. We describe a communication between the ureter and the sac of an aortic aneurysm following abdominal aortic aneurysm repair.

Objectives: To determine the incidence of benign pathologic findings at partial nephrectomy for a solitary renal lesion when preoperative imaging is reviewed by an experienced team of academic genitourinary radiologists., Methods: From 1996 to 2004, 143 patients underwent resection of a solitary renal lesion for presumed renal cell carcinoma amenable to partial nephrectomy. Our experienced team of genitourinary radiologists interpreted all preoperative imaging scans. Of the 143 patients, 44 underwent partial nephrectomy for a solitary lesion less than 2 cm, 85 for a lesion 2 to 4 cm, and 14 for a lesion greater than 4 cm., Results: Of the 143 solitary masses resected, 23 revealed benign pathologic findings (16.1%). Ten lesions (43.5%) were angiomyolipomas (AMLs), eight (34.8%) were oncocytomas, three (13.0%) were benign Bosniak-type cysts, and one each was a low-grade spindle cell lesion most consistent with mesoblastic nephroma, and a metanephric adenoma., Conclusions: A significant fraction of small solitary renal masses presumed to be renal cell carcinoma had benign pathologic findings on resection, despite thorough expert radiologic review. Management should favor parenchyma-sparing approaches, because resection serves not only a therapeutic but also a diagnostic function. Patients should be counseled accordingly when faced with the diagnosis of renal mass.

Purpose: The standard of care for muscle invasive transitional cell carcinoma of the bladder is radical cystectomy. Definitive therapy may often be delayed for various reasons. We assessed whether pathological stage and survival correlated with the length of time between diagnosis of muscle invasion and cystectomy., Materials and Methods: The records of 290 consecutive patients who underwent radical cystectomy between February 1987 and July 2000 were reviewed. Of 265 (91.4%) cystectomies performed for transitional cell carcinoma data were available for 247 (85.2%) and 189 (65.2%) patients were identified who underwent surgery for muscle invasive disease (T2 or greater). The interval between diagnosis of muscle invasion and cystectomy was calculated for each patient. Patients were divided into groups based on time to surgery as group 1-less than 4 weeks, 2-4 to 6 weeks, 3-7 to 9 weeks, 4-10 to 12 weeks, 5-13 to 16 weeks, and 6-greater than 16 weeks. Exploratory univariate and multivariate analyses were performed to test the association of time lag with clinical features and postoperative survival., Results: Mean patient age was 66 years (range 37 to 84) and overall 3-year Kaplan-Meier estimated survival was 59.1% +/- 4% (median followup 36 months). For all patients mean interval from diagnosis to cystectomy was 7.9 weeks (range 1 to 40). Extravesical disease (P3a or greater) or positive nodes were identified in 84% (16 of 19) of patients when the delay was longer than 12 weeks, compared with 48.2% (82 of 170) in those with a time lag of 12 weeks or less (p < 0.01). Similarly 3-year estimated survival was lower (34.9% +/- 13.5%) for patients with a surgery delay longer than 12 weeks compared to those with a shorter interval 62.1% +/- 4.5% (hazards ratio 2.51, 95% CI 1.30-4.83, p = 0.006). When adjusted for nodal status, and clinical and pathological stages the interval was still statistically significant (adjusted hazards ratio 1.93, 95% CI 0.99-3.76, p = 0.05)., Conclusions: In patients undergoing radical cystectomy a delay in surgery of greater than 12 weeks was associated with advanced pathological stage and decreased survival. Although this relationship persisted after adjusting for nodal status, and clinical and pathological stages, the presence of lymph node metastasis remained the strongest predictor of patient outcome.

Objective: To evaluate variations in prostate cancer detection relevant to the number and areas of biopsy cores., Methods: Ninety patients with elevated prostate-specific antigen levels, abnormal physical examination findings, or both had ultrasound examinations plus biopsies. Forty-nine patients had 11 biopsies, and 41 patients had 6 biopsies. The numbers of cancers detected were compared on a patient-by-patient basis and by all biopsy sites grouped together. An analysis of the relationship between a positive gray scale sonographic finding and the presence of adenocarcinoma was done., Results: On a patient-by-patient basis, 43% of patients who had 11 biopsies had adenocarcinoma. In patients who had 6 biopsies, 32% had adenocarcinoma. Thirty-eight percent of the additional cancers found in the 11-biopsy group were in 5 additional areas not sampled in the 6-biopsy group. Of the total of 539 biopsy specimens obtained in the 11-biopsy group, 56 (10%) had adenocarcinoma; 43% of these 56 were positive in the 5 additional areas not sampled in the 6-biopsy group. No statistical differences (P > .05) were found for mean age, mean prostate-specific antigen level, and mean volume in the groups with 11 and 6 biopsies. This indicated that the observed difference was not related to any of these factors. Similar pathologic data were found for patients with prostatic intraepithelial neoplasia., Conclusions: Our data indicate the added value of additional biopsy sites over the usual 6 biopsies to increase the yield of adenocarcinoma and prostatic intraepithelial neoplasia detected. The added biopsy sites of the central and midperipheral glands were areas where additional specimens positive for adenocarcinoma and prostatic intraepithelial neoplasia were obtained.

The relationship between male reproductive function and the blood plasma level of epidermal growth factor (EGF) is of interest in the light of the role that circulating EGF appears to play in regulating mouse spermatogenesis. We measured the concentrations of EGF in the blood plasma of 39 fertile men (sperm count > 20 x 10(6)/ml) and compared them with those of 31 infertile men (sperm < 20 x 10(6)/ml). Blood plasma levels of follicle stimulating hormone (FSH), luiteinising hormone (LH), prolactin and testosterone were also determined. The infertile patients had mean blood plasma EGF concentrations of 0.75 +/- 0.10 ug/L. The value was significantly lower than that of the fertile group (1.28 +/- 0.14 ug/L; P < 0.005). There were statistically significant differences between the fertile and infertile groups in sperm count, sperm viability, mean forward progression, testosterone, LH and FSH (P values between 0.0001 and 0.023). There was no significant difference in the prolactin concentrations between the two groups. Although overall average blood plasma EGF concentrations are significantly lower in the infertile males, regression analysis failed to reveal any direct relationships among the various parameters studied.

Laparoscopic pelvic lymphadenectomy is a satisfactory alternative to open lymphadenectomy for staging prostate cancer. Specific information obtained by endorectal coil magnetic resonance imaging may be used to predict the most likely side for lymph node metastases. These criteria may be used to define side selection for performing a unilateral laparoscopic lymphadenectomy without the risk of missing contralateral nodes that may be positive. A unilateral dissection when feasible reduces operative time and morbidity.

The natural history of renal cell carcinoma is often unpredictable and even bizarre. We report a case of solitary late recurrence of renal cell carcinoma presenting as a duodenal ulcer and review the relevant literature.

Ten patients with urothelial malignancies involving a solitary functioning renal unit were treated at our center for an average of 24 months or until death. These patients were all managed by parenchyma-sparing methods, including percutaneous as well as ureteroscopic tumor resection. Of our patients 9 have received adjunctive chemotherapy in the form of bacillus Calmette-Guerin instillations. At the time of this report 5 of our patients were alive without evidence of disease, 4 were alive with evidence of either residual or recurrent neoplasia and 1 was dead of disease 5 years after original presentation. Patients with higher grade tumors or carcinoma in situ did less well than patients with low grade disease. We present an analysis of our experience with this complex patient population and discuss the implications of these data within the context of a growing literature on the topic of upper tract urothelial malignancy.

Although extracorporeal shock waves have been used to treat kidney stones for several years, little is known to their effect on developing tissue. In order to determine if lithotripsy has any negative effects on development, immature rabbits were used to study the relationship of extracorporeal shock waves to renal and skeletal growth. Rabbits in both the control and treatment groups had metallic clips placed surgically to demarcate the kidneys. Following unilateral kidney and femoral head treatment of the respective study groups with the Dornier Lithotripter Model HM-3, the rabbits were allowed to grow to maturity (six months). Plain radiographs were taken at three months. There was no significant difference between control and study groups when length of the kidneys or femurs, the diameter of the femoral heads, or the rabbits weights were compared. At six months of age, the rabbits were weighed, then sacrificed. The kidneys and femurs were removed. Comparisons between the control and study groups were then made for weight of the rabbit, weight and volume of the individual kidneys, femoral length, and femoral head diameter. Following these measurements sectioning and histologic examinations were done. In all parameters grossly and histologically, there was no statistically significant difference. It is concluded from this study that treatment with extracorporeal shock waves does not adversely affect overt rabbit renal or bone growth, making treatment of pediatric patients with ESWL appear safe in regard to these parameters. Future studies will be directed at confirming these findings in children.

Benign prostatic hyperplasia is probably the most common neoplasm in man, and carcinoma of the prostate now leads the list of newly diagnosed malignancies in males. Even though there is no known direct etiologic relationship between these disorders, they are by no means mutually exclusive; if a man lives long enough, he is likely to be afflicted by one or both. Although most men will not require surgery, the increasing size of the geriatric population and the frequency of these disorders result in a problem of impressive magnitude from both a medical and a socioeconomic standpoint. Newer diagnostic and therapeutic modalities continue to evolve in this rapidly changing field. In many areas, further investigation is required to determine the true value of certain techniques, such as transrectal ultrasonography for screening or magnetic resonance imaging for staging of prostate cancer. Controversy now exists regarding the relative safety of transurethral and open surgical techniques for benign disease, and further comparisons will need to be made with the newer, less invasive interventional and pharmacologic techniques that are being developed. Will the advances in radical surgery result in improved survival of patients with localized prostate cancer? These and other questions will need to be addressed by the primary care physicians, geriatricians, and urologists who care for these patients.

Without question, significant changes, and for the most part significant advances, have been made in the management of patients with urolithiasis during the past decade. The newer therapeutic measures have generally made it easier for patients to be treated, but the decision-making process for the urologist has become more complex. In the past, the issue whether to follow a patient with a stone or to intervene with surgery or transurethral cystoscopic basketing was decided based on well-established guidelines that had developed over many years. Today, the indications for intervention appear to be less stringent, and in the minimally symptomatic or asymptomatic patient who would not have been operated on previously, there appears to be an expanding desire for prophylactic management. For whatever reasons, once it has been established that a stone is present and the decision has been made to intervene, subsequent decisions regarding the technical approach may also not be as simple as in the past. Ten years ago, for example, a stone in the abdominal ureter was removed by a ureterolithotomy, and the principal decision involved placement of the incision. Today, the same calculus may be approached by ESWL with or without a stent, by antegrade percutaneous techniques, or by retrograde ureteroscopic techniques using rigid or flexible endoscopes with baskets, ultrasonic lithotrites, or lasers. Although the specific indication for specific techniques continue to evolve, it has become evident that information obtained by the radiographic evaluation of the urinary tract is critical in the decision-making process. The intravenous urogram, including the initial plain film, remains the primary diagnostic modality and, in the absence of extenuating clinical features, is often the sole test required to make a decision regarding the best therapeutic modality. A variety of clinical features from the history or physical examination, or concerns raised by the intravenous urogram, may necessitate alternative or additional techniques to better define the anatomy, the renal function, or other pathology. The urologist therefore needs to be familiar with the information that can be obtained from the uroradiologist's vast armamentarium in order to make the most appropriate recommendations to the patient for diagnosis and management.

While the goal of percutaneous management of renal and ureteral calculi is stone extraction or disintegration, perforation of the renal pelvis or ureter may allow stones or stone fragments to become extruded during endourologic manipulations. The authors have encountered six such patients: two with renal and four with ureteral calculi. Three stones were extruded into the perinephric or periureteric tissues during nephroscopy, two during attempted dislodgement with a balloon catheter, and one during antegrade passage of a ureteral catheter. All patients were managed conservatively by means of nephrostomy drainage and, in the four cases of ureteral laceration, ureteral stenting. Follow-up study, ranging from 12 to 24 months, has documented a benign clinical and radiological course. No ureteral strictures have ensued. In the absence of infected urine, urothelial laceration with calculus extrusion appears to be a benign occurrence and may be managed conservatively.

From June 1985 to November 1986, 17 patients with calculi in horseshoe kidneys presented to our hospital for evaluation and possible treatment with extracorporeal shock wave lithotripsy. Of these patients 14 were treated with extracorporeal shock wave lithotripsy; the calculi in 2 could not be localized and focused at the F2 focal point, and 1 was asymptomatic and has been followed conservatively. Four patients required repeat extracorporeal shock wave lithotripsy. Adjunctive procedures included preoperative retrograde catheter placement (5 patients), postoperative percutaneous nephrostolithotomy (1), ureteroscopy for ureteral fragments (2) and placement of a double pigtail stent (1). Of 14 patients 11 (79 per cent) have been rendered free of fragments with extracorporeal shock wave lithotripsy and adjunctive measures as needed. We conclude that most patients with calculi in a horseshoe kidney can be managed primarily with extracorporeal shock wave lithotripsy.

Imipramine hydrochloride was administered to five male horses (400-500 kg b.wt.): one experienced young stallion, two mature normal breeding stallions, one 5-year-old stallion with erection and ejaculatory dysfunction, and one long-term castrated male horse. Oral imipramine treatment (100 to 600 mg, twice daily) led to frequent erection and masturbation while at rest in the stall in a nonsexual context. Intravenous imipramine treatment over a range of doses (50 to 1000 mg) similarly induced erection and masturbation in all animals. Erection typically occurred within 10 minutes after injection, and the erection and masturbation continued intermittently for 1 to 2 hours. These erections proceeded as during sexual excitement to a normal firmness and eventual engorgement of the glans penis. Two stallions ejaculated while masturbating. Mild ataxia and drowsiness appeared at the higher doses, but the animals remained responsive to auditory, visual, and tactile stimuli. Erection and masturbation were often interrupted by activities about the barn or the approach of the handler, suggesting cortical inhibitory control of the erection. When tested in a sexual context immediately following IV treatment (500 mg), the two mature breeding stallions bred normally. The 5-year-old stallion, which had not ejaculated over several months of breeding attempts, spontaneously ejaculated following IV imipramine treatment. Subsequently, this stallion has ejaculated during copulation while on low dose oral (100 mg. twice daily) imipramine treatment. Plasma total androgens increased during treatment in these stallions. The long-term castrate showed erection and masturbation following IV imipramine treatment, suggesting that the effect of imipramine is not testosterone dependent.

A research protocol to evaluate the prevention of deep vein thrombosis in sequential patients undergoing prostatectomy is presented. There is an overall incidence of deep vein thrombosis in 8 per cent of patients. There was no advantage with intermittent leg compression when compared with elastic stockings.

Urolithiasis involving the upper urinary tract is a multifactorial disease that remains a significant health problem. A variety of intrinsic and extrinsic factors influence the incidence of disease in individuals and in all populations. At the level of the kidney, natural physicochemical processes result in crystalluria and the formation and growth of stones. Urinary supersaturation of some degree must be present but its significance may be altered by changes in urinary volume, pH, epitaxial relationships, and the presence or absence of naturally occurring inhibitors. A variety of environmental parameters acting through effects on the local urinary conditions determine which patients among a group of people inherently at risk will form stones. The above factors are considered herein with regard to the four major types of stone disease encountered today.

Many commonly used drugs can interfere with male sexual function, either by decreasing libido, interfering with erectile function, or causing absent seminal emission or retrograde ejaculation. Although drug-related effects on sexual function may be difficult to distinguish from the effects of organic disease, anxiety, or depression, it is important for the physician to be aware of the drugs most commonly associated with sexual dysfunction. This article considers these drugs and the potential mechanism by which they exert their adverse effects.

Stone fragments that develop after extracorporeal shock-wave lithotripsy (ESWL) may lodge within the ureter. This column of fragments is referred to as a "steinstrasse" (plural, steinstrassen). We evaluated the first 1000 patients treated with ESWL at our institution to determine the frequency of steinstrasse formation, the clinical course of patients with steinstrassen, and the types of intervention, if any, required. Steinstrassen were seen in 20% of 1000 patients treated with ESWL. In 65% of the patients studied, the steinstrassen passed spontaneously. Of the remaining patients, all but 3% required treatment for ureteral obstruction. Seventy-five percent were treated urologically (ureteroscopy, ureteral catheterization), but 25% required radiologically directed intervention, either percutaneous nephrostomy or fluoroscopically monitored retrograde ureteral catheter/stent placement. Twenty-seven percent of our patients with persistent steinstrassen had silent obstruction. In view of the insidious manner in which kidney function may be jeopardized by steinstrassen, they should be managed with great circumspection. Radiologists dealing with steinstrassen should be skillful in both antegrade and retrograde methods of urinary tract intervention.

Routine follow-up urography demonstrated pseudoureteroceles caused by impacted calculus fragments in the distal portion of the ureter in five patients who had undergone extracorporeal shock wave lithotripsy of renal calculi 4-6 weeks before. Although all five patients showed some degree of obstruction at the time of follow-up urography, four were asymptomatic. Either small isolated fragments (two patients) or a column (steinstrasse) of fragments (three patients) was responsible for the abnormality. Two patients required further intervention to relieve the obstruction.

Extravasation of glycine irrigant during percutaneous ultrasonic lithotripsy has caused a transurethral resection syndrome consisting of hypertension, confusion and hyponatremia. With a rabbit model this complication is recreated with the intraperitoneal instillation of 1.5 per cent glycine solution tagged with 14carbon-glycine. Significant quantitative absorption of glycine into blood and other organs is demonstrated. A review of the literature reveals few guidelines as to the choice of irrigant for intrarenal endoscopy. Since this procedure involves no electric current it is suggested that physiological saline rather than glycine be used for ultrasonic stone disintegration.