Current Practice Patterns in the Surgical Management of Benign Prostatic Hyperplasia

OBJECTIVE

To use American Board of Urology (ABU) case log data to elucidate practice patterns for benign prostatic hyperplasia (BPH) surgery. Several surgical modalities have been introduced in recent decades causing significant practice variation.

MATERIALS AND METHODS

We retrospectively analyzed ABU case logs from 2008-2021 to assess trends in BPH surgery. We created logistic regression models to identify surgeon-sided factors associated with utilization of each surgical modality.

RESULTS

We identified 6,632 urologists who logged 73,884 surgeries for BPH. Transurethral resection of the prostate (TURP) was the most commonly performed BPH surgery in all but 1 year, and odds of performing a TURP increased year-over-year (OR 1.055, 95% CI [1.013,1.098], P = .010). The use of holmium laser enucleation of the prostate (HoLEP) did not change over time. HoLEP was more likely to be performed by urologists with higher BPH surgical volume (OR 1.017, CI [1.013, 1.021], P < .001) and with endourology subspecialization (OR 2.410, CI [1.45, 4.01], P = .001). Prostatic urethral lift (PUL) utilization increased significantly since its introduction in 2015 (OR 1.663, CI [1.540, 1.796], P < .001). PUL currently comprises over one third of all BPH surgeries logged.

CONCLUSION

In the face of newer technologies, TURP remains the most common surgery for BPH in the United States. PUL has been rapidly adopted while HoLEP comprises a consistent minority of cases. Surgeon age, patient age, and urologist subspecialization were associated with use of certain BPH surgical approaches.

Wrist-Spanning Fixation of Radiocarpal Dislocation: A Cadaveric Assessment of Ulnar Translation

Background: Radiocarpal dislocations represent a high-energy wrist injury that can occur with or without concomitant fractures about the wrist. Poor outcomes are often due to radiocarpal instability and secondary ulnar translation. The purpose of this cadaveric study is to determine if there is any difference in the radiographic parameters in a wrist dislocation model given the different location of distal fixation. Methods: Ten paired fresh cadaver upper extremities were fluoroscopically evaluated with posterior-anterior (PA) and lateral views. We created a radiocarpal dislocation model and applied a dorsal bridge plate to either the second or third metacarpal. Repeat PA and lateral fluoroscopic views were obtained for evaluation of radial inclination, radial height, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, scapholunate angle, radial rotation index, and four indices for ulnar translation (Taleisnik, Gilula, McMurtry, and Chamay). Results: Bridge plate application to the second metacarpal resulted in a significantly greater incidence of ulnar translation compared to the third metacarpal. Application to either metacarpal resulted in extension of the carpus relative to the radius. Conclusions: A more anatomic radiocarpal relationship was restored more often when distal fixation of the dorsal wrist-spanning bridge plate was applied to the third metacarpal. Further investigation is warranted to determine clinical relevance of these findings in conjunction with clinical and radiographic outcomes.

The management of clenched fist injuries with local anaesthesia and field sterility

Clenched fist injury is associated with a high risk of infectious complications and is commonly managed with formal irrigation and debridement in the operating theatre. The purpose of this study was to determine outcomes associated with irrigation and debridement of clenched fist injuries under local anaesthesia using field sterility outside the operative theatre. In this single centre study, 232 patients were identified with clenched fist injury and 210 were treated with a standard protocol beginning with administration of intravenous antibiotics and then irrigation and debridement at the bedside. Primary outcome measures were the need for repeat debridement and complications. Secondary outcome measures included factors associated with the need for repeat debridement. Fifteen of the 210 patients (7%) required repeat debridement. Patients with cultures positive for gram-negative organisms had a significantly increased risk of repeat debridement. Irrigation and debridement under local anaesthesia using field sterility results in an acceptably low risk of complications or need for repeat debridement.Level of evidence: IV.

Fatal Cytomegalovirus Infection in an Adult with Inherited NOS2 Deficiency

BACKGROUND

Cytomegalovirus (CMV) can cause severe disease in children and adults with a variety of inherited or acquired T-cell immunodeficiencies, who are prone to multiple infections. It can also rarely cause disease in otherwise healthy persons. The pathogenesis of idiopathic CMV disease is unknown. Inbred mice that lack the gene encoding nitric oxide synthase 2 (Nos2) are susceptible to the related murine CMV infection.

METHODS

We studied a previously healthy 51-year-old man from Iran who after acute CMV infection had an onset of progressive CMV disease that led to his death 29 months later. We hypothesized that the patient may have had a novel type of inborn error of immunity. Thus, we performed whole-exome sequencing and tested candidate mutant alleles experimentally.

RESULTS

We found a homozygous frameshift mutation in NOS2 encoding a truncated NOS2 protein that did not produce nitric oxide, which determined that the patient had autosomal recessive NOS2 deficiency. Moreover, all NOS2 variants that we found in homozygosity in public databases encoded functional proteins, as did all other variants with an allele frequency greater than 0.001.

CONCLUSIONS

These findings suggest that inherited NOS2 deficiency was clinically silent in this patient until lethal infection with CMV. Moreover, NOS2 appeared to be redundant for control of other pathogens in this patient. (Funded by the National Center for Advancing Translational Sciences and others.).

Tuberculosis and impaired IL-23-dependent IFN-γ immunity in humans homozygous for a common TYK2 missense variant

Inherited IL-12Rβ1 and TYK2 deficiencies impair both IL-12- and IL-23-dependent IFN-γ immunity and are rare monogenic causes of tuberculosis, each found in less than 1/600,000 individuals. We show that homozygosity for the common TYK2 P1104A allele, which is found in about 1/600 Europeans and between 1/1000 and 1/10,000 individuals in regions other than East Asia, is more frequent in a cohort of patients with tuberculosis from endemic areas than in ethnicity-adjusted controls (P = 8.37 × 10^-8; odds ratio, 89.31; 95% CI, 14.7 to 1725). Moreover, the frequency of P1104A in Europeans has decreased, from about 9% to 4.2%, over the past 4000 years, consistent with purging of this variant by endemic tuberculosis. Surprisingly, we also show that TYK2 P1104A impairs cellular responses to IL-23, but not to IFN-α, IL-10, or even IL-12, which, like IL-23, induces IFN-γ via activation of TYK2 and JAK2. Moreover, TYK2 P1104A is properly docked on cytokine receptors and can be phosphorylated by the proximal JAK, but lacks catalytic activity. Last, we show that the catalytic activity of TYK2 is essential for IL-23, but not IL-12, responses in cells expressing wild-type JAK2. In contrast, the catalytic activity of JAK2 is redundant for both IL-12 and IL-23 responses, because the catalytically inactive P1057A JAK2, which is also docked and phosphorylated, rescues signaling in cells expressing wild-type TYK2. In conclusion, homozygosity for the catalytically inactive P1104A missense variant of TYK2 selectively disrupts the induction of IFN-γ by IL-23 and is a common monogenic etiology of tuberculosis.

Flea bite hypersensitivity: new aspects on the involvement of mast cells

A study was performed to test the effect of sensitization to flea antigen, followed by exposure to fleas on mast cells (MCs), their subtypes, and IgE+ cells. Biopsies were taken from flea-sensitized dogs (n=28) and non-sensitized dogs (n=5) that had been exposed to fleas. Control groups consisted of flea-sensitized (n=12) and non-sensitized dogs (n=9) that were not exposed to fleas. Biopsies, taken before, 24 and 72 h after local flea exposure, were stained with haematoxylin and eosin (H&E), toluidine blue, a double labelling technique for MC chymase and tryptase and anti-IgE. An intradermal test for flea antigen was performed and serum titres of allergen-specific IgE and IgG were measured. Significantly higher numbers (P<0.001) of double labelled MCs compared to toluidine blue stained MCs were detectable in flea-sensitized dogs independent of flea exposure. In contrast, in non-sensitized dogs, the number of toluidine blue stained MCs and the number of double labelled MCs did not differ. In flea-sensitized dogs after flea exposure the percentage of C-MC was significantly increased at day 1 (P<0.001) and day 3 (P<0.001), whereas the percentage of TC-MCs decreased significantly at day 1 (P<0.001) and day 3 (P<0.05). The percentage of T-MCs decreased (P<0.05 day 0 versus day 1; P<0.05 day 0 versus day 3). No significant difference was detectable after toluidine blue staining and staining for IgE+ cells between the groups nor between the MC density and the number of IgE+ cells. All flea-sensitized dogs had positive skin tests to flea antigen and high serum titres of flea-specific serum IgE and IgG antibodies. In non-sensitized dogs, these results were negative. Our data provide strong evidence for an upregulation of MC proteases during the process of sensitization and a generalized selective release of mast cell tryptase after exposure to the antigen.

A comparison of rate-response toxicity tests with Aphidius rhopalosiphi (Hymenoptera: Aphidiidae) using glass, leaves and whole plants as substrate

Rate-response toxicity tests on Aphidius rhopalosiphi were carried out with seven plant protection products using three different test systems. The first type of test system conformed to the standard laboratory testing guidelines and consisted of two treated glass plates fitted into a metal frame, which created an enclosure for the wasps. In the second type of test system, the plant protection products were applied to two bean-leaf disks mounted on agar filled dishes, which were fitted to a transparent plastic frame. The third type of test system consisted of potted barley plants, which were treated and covered with an acrylic cylinder. Adult wasps were exposed to the dried residues of the products for 48 h before wasp mortality was assessed. For each product and test system, the LR50 value (application rate at which 50% mortality of the wasps occurs) was determined with a Bayesian Probit analysis. Technically, rate-response testing was feasible with all three test systems, and rate-response relationships could be established. The results support a sequential testing scheme, as the LR50 values increased from 'glass plate test' to 'excised leaf test' to 'whole plant test' with all tested products. The LR50 values were 7.8-340 times higher on whole plants than on glass plates. Because of the variability of this factor, a numerical safety factor cannot be used to substitute extended laboratory testing for regulatory purposes.

The response of lymphocyte beta-adrenergic receptors to chronic propranolol treatment in depressed patients, schizophrenic patients, and normal controls

The ability of beta-adrenergic receptors to adapt to reductions in stimulation might be impaired in depressed or schizophrenic patients. To test this hypothesis 12 normal controls, 12 depressed patients resistant to tricyclic antidepressants, and 8 chronic schizophrenic patients were treated with propranolol 160 mg/day for 10 days. A previous study had reported that this dose regimen led to a rise in lymphocyte beta-adrenergic receptors in normal volunteers. Blood was sampled before propranolol treatment and 60 hr after the last propranolol dose. There were no significant differences between any of the groups in lymphocyte beta-adrenergic receptors after 10 days of propranolol treatment.

Choroidography and photography of the long ciliary nerve and artery

A noninvasive technique that allows photography of the choroidal vasculature and the long ciliary nerve and artery is described. It does not make use of any injectable contrast material. A simple single lens reflex camera with its close-up lens, mounted on a stand, was used to take illustrative choroidograms.