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Daily AM, Popat S, Koenig HG, Fuller TW, Lee UJ. Female pelvic medicine and reconstructive surgery fellows' case logs remained stable during the COVID-19 pandemic. Neurourol Urodyn 2023; 42:1789-1794. [PMID: 37545331 DOI: 10.1002/nau.25261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/12/2023] [Accepted: 07/27/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION During the COVID-19 pandemic and subsequent staffing shortages there was concern about the case volume, and thus competency, of graduating trainees due to reduced surgical volumes. Elective procedures were particularly affected, which includes Female Pelvic Medicine and Reconstructive Surgery (FPMRS) cases. To understand whether FPMRS fellows were affected, we assessed their case logs for changes during the pandemic. METHODS The nationally aggregated case logs of graduating FPMRS fellows, both urology and obstetrics and gynecology (OBGYN), were obtained from the Accreditation Council for Graduate Medical Education. The available academic years (AYs) included 2018-2019, 2019-2020, and 2020-2021. Standard deviation for each index category was derived from the average and 90th percentile data. One-way analysis of variance was used to compare differences in case volumes for tracked index categories between AYs. RESULTS Graduating fellows logged an average of 517.4 (standard deviation [SD] 28.6) and 818.0 (SD 37.9) cases, for urology and OBGYN respectively, over their fellowship training during the examined period. No significant differences in total surgical procedures were found for either specialty between pre-COVID AY 2018-2019 and COVID-affected AYs 2019-2020 and 2020-2021. For urology fellows, gastrointestinal (GI) procedures was the only index case category with a significant difference, and it was a decrease between the two COVID-affected AYs: 2020-2021 compared to 2019-2020 (8.9 vs. 4.2, p = 0.04). For both urology and OBGYN fellows, there was a statistically significant decrease in graft/mesh augmentation procedures from COVID-affected AY 2019-2020 to AY 2020-2021. This may be attributed to the reclassification of mesh removal cases from graft/mesh augmentation procedures to genital procedures in 2020-2021. There was not a significant decrease in these procedures from pre-COVID AY 2018-2019 to the COVID-affected AYs. There were no other statistically significant differences between AYs for OBGYN fellows. CONCLUSIONS Surgical case volumes for FPMRS urology and OBGYN fellows who trained during the COVID-19 pandemic were comparable to those of their pre-pandemic peers. No significant differences between pre-COVID and COVID-affected years were found for either total surgical procedures or index case categories. Despite disruptions in health care nationwide, FPMRS trainee case volumes were largely unaffected.
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Affiliation(s)
- Adam M Daily
- Section of Urology and Renal Transplantation, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Shreeya Popat
- Section of Urology and Renal Transplantation, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Hannah G Koenig
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, Washington, USA
| | - Thomas W Fuller
- Section of Urology and Renal Transplantation, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Una J Lee
- Section of Urology and Renal Transplantation, Virginia Mason Franciscan Health, Seattle, Washington, USA
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Fuller TW. AUTHOR REPLY. Urology 2022; 167:29. [PMID: 36153102 DOI: 10.1016/j.urology.2022.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
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Fuller TW, Daily AM, Buckley JC. Robotic Ureteral Reconstruction. Urol Clin North Am 2022; 49:495-505. [DOI: 10.1016/j.ucl.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Daily AM, DiNatale RG, Koenig HG, Lee UJ, Fuller TW. Effect of COVID-19 on Graduating Urology Resident Case Logs: Analysis of the Accreditation Council of Graduate Medical Education National Data Reports. Urology 2022; 167:24-29. [PMID: 35779710 PMCID: PMC9242693 DOI: 10.1016/j.urology.2022.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/11/2022] [Accepted: 05/10/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the national case logs of the first graduating urologic resident cohorts to have trained during the COVID-19 pandemic for effects on surgical volumes. METHODS The nationally aggregated Accreditation Council for Graduate Medical Education urology resident case logs were obtained for graduates of academic years (AYs) 2015-2016 through 2020-2021. Case volume differences for tracked index categories were compared between AYs with a 1-way analysis of variance. Data were then combined into pre-COVID and COVID-affected resident cohorts and differences in average cases logged were analyzed with 2-tailed student's t-tests. RESULTS Graduating urology residents logged an average of 1322 (SD 24.8) cases over their residency during the examined period. Total cases had multiple statistical differences between AYs but the only index category with a statistically significant decrease for a COVID-affected AY compared to pre-COVID AY was pediatric majors: AY 2020-2021 logged fewer cases than AY 2015-2016 (53.9 vs 63.0, P = .004) and AY 2018-2019 (53.9 vs 61.2, P = .04). When aggregated into pre- and COVID-affected cohorts, both pediatric minor (123.4 vs 117.5, P = .049) and pediatric major (61.4 vs 56.8, P = .003) case averages decreased for the COVID-affected cohort of residents, but no adult index category decreased. CONCLUSION National graduating urology resident surgical volume for adult index categories was maintained through the pandemic. Pediatric cases saw a statistical decrease in volume of questionable clinical significance. This does not eliminate concern that individuals may have experienced a detrimental impact on their resident education.
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Affiliation(s)
- Adam M Daily
- Section of Urology and Renal Transplantation and, Virginia Mason Franciscan Health, Seattle, WA
| | - Renzo G DiNatale
- Section of Urology and Renal Transplantation and, Virginia Mason Franciscan Health, Seattle, WA
| | - Hannah G Koenig
- Research and Academics, Virginia Mason Franciscan Health, Seattle, WA
| | - Una J Lee
- Section of Urology and Renal Transplantation and, Virginia Mason Franciscan Health, Seattle, WA
| | - Thomas W Fuller
- Section of Urology and Renal Transplantation and, Virginia Mason Franciscan Health, Seattle, WA.
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Miller D, Pekala K, Zhang X, Orikogbo O, Rogers D, Fuller TW, Maganty A, Rusilko P. Outcomes of Initial Transcorporal Versus Standard Placement of Artificial Urinary Sphincter in Patients With Prior Radiation. Cureus 2022; 14:e25519. [PMID: 35800826 PMCID: PMC9246464 DOI: 10.7759/cureus.25519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/29/2022] [Indexed: 11/05/2022] Open
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Byrne ER, Fuller TW, Kim S, Said ET, Buckley JC. A narcotic free pathway for postoperative pain following urethroplasty. Can J Urol 2021; 28:10914-10919. [PMID: 34895396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION In an effort to decrease physician contribution to the opioid crisis, we utilized a narcotic free pathway (NFP) after urethroplasty. Our objectives were to demonstrate feasibility of a NFP and identify patients at higher risk for requiring postoperative narcotics. MATERIALS AND METHODS We implemented a NFP for patients undergoing urethroplasty. Pain was assessed using the Likert scale (1-10). Narcotic use was quantified using oral morphine equivalents (OMEs). RESULTS Forty-six patients underwent urethroplasty following the NFP over a 7-month period. Fifteen patients were excluded, leaving 31 patients in the final analysis. Postintervention data was compared to 30 patients who underwent urethroplasty prior to implementation of the NFP. The groups had similar demographics except for a history of heroin abuse (0% preintervention, 12.9% postintervention, p = 0.04). Surgical characteristics were not statistically different aside from length of surgery (183.6 minutes preintervention, 145.5 minutes postintervention, p = 0.01). The mean [SD] perioperative OME use preintervention was 194.9 [151] mg, compared to 40.4 [111.9] mg postintervention (p < 0.001). Six patients postintervention were discharged with a narcotic prescription (mean 27.5 mg OME) compared to 26 patients preintervention (mean 76 mg OME) (p < 0.001). There was no difference in pain scores at any time interval. Patients with a history of chronic opioid use were more likely to require narcotics (OR 5.33, CI 1-28.44). CONCLUSIONS The narcotic free pathway resulted in a dramatic reduction in narcotic prescriptions without a significant difference in postoperative pain scores. Opioid use can be minimized following urethral and perineal surgery.
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Affiliation(s)
- Eileen R Byrne
- Department of Urology, University of California, San Diego, California, USA
| | - Thomas W Fuller
- Department of Urology, Virginia Mason, Seattle, Washington, USA
| | - Sunchin Kim
- Department of Urology, Banner Health, Tucson, Arizona, USA
| | - Engy T Said
- Department of Anesthesia, University of California, San Diego, California, USA
| | - Jill C Buckley
- Department of Urology, University of California, San Diego, California, USA
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Cohen AJ, Cheng PJ, Song S, Patino G, Myers JB, Roy SS, Elliott SP, Pariser J, Drobish J, Erickson BA, Fuller TW, Buckley JC, Vanni AJ, Baradaran N, Breyer BN. Multicenter urethroplasty outcomes for urethral stricture disease for patients with neurogenic bladder or bladder dysfunction requiring clean intermittent catheterization. Transl Androl Urol 2021; 10:2035-2042. [PMID: 34159084 PMCID: PMC8185657 DOI: 10.21037/tau-20-988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population. Methods Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results. Results A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5–5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0–5.3), no patients underwent urinary diversion. Conclusions Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.
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Affiliation(s)
- Andrew J Cohen
- James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Philip J Cheng
- Department of Urology, University of Utah, Salt Lake City, UT, USA
| | - Sikai Song
- Department of Urology, Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, CA, USA
| | - German Patino
- Department of Urology, Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, CA, USA.,Hospital San Ignacio, Bogota, Colombia
| | - Jeremy B Myers
- Department of Urology, University of Utah, Salt Lake City, UT, USA
| | - Samit S Roy
- University of Minnesota, Minneapolis, MN, USA
| | | | | | | | | | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA, USA
| | | | - Benjamin N Breyer
- Department of Urology, Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, CA, USA
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Kim S, Fuller TW, Buckley JC. Robotic Surgery for the Reconstruction of Transplant Ureteral Strictures. Urology 2020; 144:208-213. [PMID: 32645371 DOI: 10.1016/j.urology.2020.06.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/21/2020] [Accepted: 06/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To demonstrate the feasibility and success of a robotic approach to reconstruction of ureterovesical anastomotic strictures in kidney transplants. MATERIALS AND METHODS Between November 2017 and December 2019, a total of 5 patients with transplant ureteral stricture were identified and treated with robot assisted laparoscopic repair. All patients were confirmed to have ureteral stricture with a preoperative antegrade nephrostogram through their nephrostomy tube and cystogram. The patients demographics, ureteral characteristics, type of procedure, and outcomes are reported. RESULTS All patients were diagnosed after evaluation for renal deterioration. The average age of the patients was 49 years old. The average stricture length was 2.5 cm, and the location was variable, though more commonly in the distal ureter. Three patients required a pyelo-vesicostomy, while 2 required a ureteroneocystostomy. The mean length of stay was 2.2 days. Average follow-up was 97 days, with all 5 patients having successful outcomes, no strictures or delayed leaks were identified. There were no wound infections or readmissions within 30 days. CONCLUSION Though a complex repair, the robot-assisted approach to transplant ureter reconstruction using either an end to side neoureterocystotomy or direct pyelo-vesicotomy is technically feasible and successful. Given the many advantages inherent in comparison to an open approach, the robotic repair offers significant advantages to both the patient and the surgeon who is experienced with robotic surgery and reconstructive principles.
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Affiliation(s)
- Sunchin Kim
- Department of Urology, The University of California, San Diego, San Diego, CA.
| | - Thomas W Fuller
- Department of Urology, Virginia Mason Medical Center, Seattle, WA
| | - Jill C Buckley
- Department of Urology, The University of California, San Diego, San Diego, CA
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Pekala KR, Pelzman D, Theisen KM, Rogers D, Maganty A, Fuller TW, Rusilko PJ. The Prevalence of Penile Cancer in Patients With Adult Acquired Buried Penis. Urology 2019; 133:229-233. [PMID: 31369750 DOI: 10.1016/j.urology.2019.07.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the prevalence of penile cancer in patients with adult acquired buried penis (AABP). Penile cancer is a rare but aggressive cancer. Several case reports have recently been published that indicate that AABP may increase the risk of penile cancer. MATERIALS AND METHODS A retrospective review was conducted of adults diagnosed with AABP and penile cancer between January, 2008 and December, 2018 seen at a tertiary referral center. Demographics including age, BMI, comorbidities, etiology of AABP, smoking history, circumcision status, and premalignant lesions (condyloma, lichen sclerosus [LS] carcinoma in situ [CIS]) were recorded. For patients with penile cancer, AJCC staging, grade, TNM staging and treatments were recorded. Basic descriptive statistics were performed for the overall cohort. We used Chi-square tests and Fisher exact tests to compare differences between patients with benign pathology and patients with malignant or pre-malignant pathology. RESULTS We identified 150 patients with the diagnosis of AABP. The prevalence of penile squamous cell carcinoma was 7%. There was a 35% rate of premalignant lesions. This study is limited by its retrospective and single-institution nature. CONCLUSION AABP is a condition that incorporates multiple risk factors for penile cancer. The prevalence of penile cancer appears to be higher in patients with AABP; however, more data are needed to confirm these initial findings. Patients with AABP should be counseled on these risks and should be considered for buried penis repair if a physical examination cannot be performed.
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Affiliation(s)
- Kelly R Pekala
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Daniel Pelzman
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Katherine M Theisen
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Devin Rogers
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Avinash Maganty
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas W Fuller
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul J Rusilko
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
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Unterberg SH, Patel SH, Fuller TW, Buckley JC. Robotic-assisted Proximal Perineal Urethroplasty: Improving Visualization and Ergonomics. Urology 2019; 125:230-233. [DOI: 10.1016/j.urology.2018.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 10/24/2018] [Accepted: 11/03/2018] [Indexed: 01/23/2023]
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Hugar LA, Kafka I, Fuller TW, Taan H, Averch TD, Semins MJ. Trends in renal calculus composition and 24-hour urine analyses in patients with neurologically derived musculoskeletal deficiencies. Int Braz J Urol 2019; 45:572-580. [PMID: 30676304 PMCID: PMC6786099 DOI: 10.1590/s1677-5538.ibju.2018.0531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/05/2018] [Indexed: 11/28/2022] Open
Abstract
Purpose: To better characterize metabolic stone risk in patients with neurologically derived musculoskeletal deficiencies (NDMD) by determining how patient characteristics relate to renal calculus composition and 24-hour urine parameters. Materials and Methods: We performed a retrospective cohort study of adult patients with neurologically derived musculoskeletal deficiencies presenting to our multidisciplinary Kidney Stone Clinic. Patients with a diagnosis of NDMD, at least one 24-hour urine collection, and one chemical stone analysis were included in the analysis. Calculi were classified as primarily metabolic or elevated pH. We assessed in clinical factors, demographics, and urine metabolites for differences between patients who formed primarily metabolic or elevated pH stones. Results: Over a 16-year period, 100 patients with NDMD and nephrolithiasis were identified and 41 met inclusion criteria. Thirty percent (12 / 41) of patients had purely metabolic calculi. Patients with metabolic calculi were significantly more likely to be obese (median body mass index 30.3kg / m2 versus 25.9kg / m2), void spontaneously (75% vs. 6.9%), and have low urine volumes (100% vs. 69%). Patients who formed elevated pH stones were more likely to have positive preoperative urine cultures with urease splitting organisms (58.6% vs. 16.7%) and be hyperoxaluric and hypocitraturic on 24-hour urine analysis (37mg / day and 265mg / day versus 29mg / day and 523mg / day). Conclusions: Among patients with NDMD, metabolic factors may play a more significant role in renal calculus formation than previously believed. There is still a high incidence of carbonate apatite calculi, which could be attributed to bacteriuria. However, obesity, low urine volumes, hypocitraturia, and hyperoxaluria suggest an underrecognized metabolic contribution to stone formation in this population.
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Affiliation(s)
- Lee A Hugar
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ilan Kafka
- Shaare Zedek Medical Center, Jerusalem, Israel
| | - Thomas W Fuller
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Hassan Taan
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Timothy D Averch
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michelle J Semins
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Fuller TW, Pekala K, Theisen KM, Tapper A, Burks F, Rusilko PJ. Prevalence and surgical management of concurrent adult acquired buried penis and urethral stricture disease. World J Urol 2018; 37:1409-1413. [PMID: 30298286 DOI: 10.1007/s00345-018-2514-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/25/2018] [Indexed: 12/01/2022] Open
Abstract
PURPOSE To describe the prevalence and surgical management of coexistent adult acquired buried penis (AABP) and urethral stricture disease. AABP patients often have urinary dribbling with resultant chronic local moisture, infection, and inflammation that combine to cause urethral stricture disease. To date, no screening or surgical management algorithms have been described. METHODS A multi-institutional retrospective study was conducted of the surgical management strategies for patients with concurrent AABP and urethral stricture disease from 2010 to 2017. AABP patient demographics, physical exam findings, and comorbidities were compared between those with and without stricture disease to suggest those that would selectively benefit from screening for stricture disease. RESULTS Of the 42 patients surgically managed for AABP, 13 had urethral stricture disease (31.0%). Stricture location was universal in the anterior urethra. Sixty-one percent (n = 8) of strictures were 6 cm or longer and managed prior to AABP repair with Kulkarni urethroplasty. Patients with urethral stricture disease were significantly more likely to have clinically diagnosed lichen sclerosus (p = 0.00019). There was no significant difference in BMI, age, or comorbidities between patients with and without urethral stricture disease. CONCLUSIONS Extensive anterior urethral stricture is common in patients with AABP. Clinical characteristics cannot predict stricture presence except possibly the presence of lichen sclerosus. Definitive stricture surgical options include extensive Johanson Urethroplasty or Kulkarni Urethroplasty. Kulkarni Urethroplasty prior to AABP repair has the benefits of a single-stage repair, good cosmetic outcome with meatal voiding, and dorsal graft placement to allow safe degloving of the penis in the subsequent AABP repair.
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Affiliation(s)
- Thomas W Fuller
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA, 15213, USA
| | - Kelly Pekala
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA, 15213, USA.
| | - Katherine M Theisen
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA, 15213, USA
| | | | - Frank Burks
- Department Urology, Beaumont Hospital, Royal Oak, MI, USA
| | - Paul J Rusilko
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA, 15213, USA
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Bhargava R, Yu H, Chilukuri AT, Kim J, Yuk SM, Lee SR, Fuller TW, Buckley JC, Bhargava V, Rajasekaran MR. A Novel Endoluminal Ultrasound Imaging Technique to Determine Urethral Luminal Cross-Sectional Area. J Endourol 2018; 32:1087-1092. [PMID: 30191741 DOI: 10.1089/end.2018.0554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) are currently the gold standard imaging technique for diagnosis of urethral stricture and determination of stricture location. However, RUG and VCUG have multiple limitations. These techniques require exposure to ionizing radiation, the quality is operator and patient dependent, there is a moderate degree of invasiveness with urethral catheterization, can have artifacts because of patient positioning that underestimates stricture length. The development of novel imaging modalities without ionizing radiation to accurately evaluate the presence, location, length, and lumen cross-sectional area (CSA) of the urethral stricture would be of great value. The objective of this study was to develop a novel endoluminal ultrasound (ELUS) imaging technique that permits the accurate quantitation of urethral stricture. METHODS Urethral strictures were created in rabbits (n = 5) by electrocautery and an ELUS technique was developed for subsequent luminal imaging. A 3.2F 40 MHz ultrasound (US) probe was introduced transurethrally and infused with US contrast agent. Images were recorded as the catheter was pulled back at a constant speed to acquire tomographic images. Lumen CSA over the entire urethral length was calculated using a custom methodology and validated in our laboratory. RESULTS Urethral luminal CSA over the entire length of urethra before and after experimental stricture development was quantified including the length of stenosis. Intra- and interobserver variability (r = 0.99 for both) was excellent. CONCLUSIONS Feasibility of ELUS as a quantitative technique to determine healthy urethral lumen and stricture CSA was demonstrated. The translational potential for a nonionizing imaging modality to better describe CSA, length, location, and uninvolved urethral CSA of the stricture is a significant improvement over current methodology.
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Affiliation(s)
- Raag Bhargava
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
| | - Hosong Yu
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
| | - Abinav T Chilukuri
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
| | - Jaesoo Kim
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
| | - Seung-Mo Yuk
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
| | - Seung-Ryeol Lee
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
| | - Thomas W Fuller
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
| | - Jill C Buckley
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
| | - Valmik Bhargava
- 2 Division of Cardiology, VA San Diego Healthcare System, University of California , San Diego, San Diego, California
| | - Mahadevan Raj Rajasekaran
- 1 Department of Urology, VA San Diego Healthcare System, University of California , San Diego, California
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Hugar LA, Chaudhry R, Fuller TW, Cannon GM, Schneck FX, Ost MC, Stephany HA. Urologic Phenotype and Patterns of Care in Patients With Megacystis Microcolon Intestinal Hypoperistalsis Syndrome Presenting to a Major Pediatric Transplantation Center. Urology 2018; 119:127-132. [DOI: 10.1016/j.urology.2018.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/23/2018] [Accepted: 05/01/2018] [Indexed: 12/12/2022]
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15
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Theisen KM, Fuller TW, Rusilko P. Surgical Management of Adult-acquired Buried Penis: Impact on Urinary and Sexual Quality of Life Outcomes. Urology 2018; 116:180-184. [PMID: 29625136 DOI: 10.1016/j.urology.2018.03.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/19/2018] [Accepted: 03/22/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess postoperative patient-reported quality of life outcomes after surgical management of adult-acquired buried penis (AABP). We hypothesize that surgical treatment of AABP results in improvements in urinary and sexual quality of life. METHODS Patients that underwent surgical treatment of AABP were retrospectively identified. The Expanded Prostate Cancer Index (EPIC) questionnaire was completed at ≥3 months postoperatively, and completed retrospectively to define preoperative symptoms. EPIC is validated for local treatment of prostate cancer. Urinary and sexual domains were utilized. Questions are scored on a 5-point Likert scale, with higher scores indicating better quality of life. Preoperative scores were compared with postoperative scores. RESULTS Sixteen patients completed pre- and postoperative questionnaires. Mean time from surgery to questionnaire was 12.6 months. There was a significant improvement in 10 of 12 urinary domain questions and 10 of 13 sexual domain questions. Fourteen of 16 patients (87.5%) reported significant improvement in overall sexual function (median score changed from 1.5 to 5, P <.0001). Similarly, 14 of 16 patients (87.5%) reported significant improvement in overall urinary function (median score changed from 1 to 4, P <.0001). CONCLUSION AABP is a challenging condition to treat and often requires surgical intervention to improve hygiene and function. There are limited data on patient-reported quality of life outcomes. We found that surgical management of AABP results in significant improvements in both urinary and sexual quality of life outcomes.
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Affiliation(s)
- Katherine M Theisen
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Thomas W Fuller
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Paul Rusilko
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
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16
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Abstract
PURPOSE OF REVIEW Adult acquired buried penis is a morbid condition characterized by complete entrapment of the phallus as a result of morbid obesity, post-surgical cicatrix formation, or primary genital lymphedema. Hygienic voiding is not possible and urinary dribbling is frequent with accompanying inflammation, skin breakdown, and infection from the chronic moisture. The end result is penile skin fibrosis resulting in permanent functional loss. Herein, we describe the etiology of adult acquired buried penis, advances in its surgical management, and quality of life outcomes with treatment. RECENT FINDINGS Adult acquired buried penis is increasing in incidence as morbid obesity becomes more prevalent. Frequently comorbid conditions affect treatment including those affecting wound healing such a diabetes mellitus. Functional and cosmetic surgical outcomes are being published in greater volume in recent years leading to more refined treatment algorithms. Patient quality of life is greatly improved by definitive surgical management. Adult acquired buried penis is a morbid condition that is increasing in incidence as obesity becomes more commonplace. Surgical management often necessitates surgical lipectomy of the suprapubic fat pad, scrotoplasty, and penile split thickness skin graft. Substantial quality of life improvements have been consistently reported after surgical treatment.
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Affiliation(s)
- Thomas W Fuller
- Department of Urology, The University of Pittsburgh Medical Center, 1350 Locust St Suite G100A, Pittsburgh, PA, 15219, USA
| | - Katherine M Theisen
- Department of Urology, The University of Pittsburgh Medical Center, 1350 Locust St Suite G100A, Pittsburgh, PA, 15219, USA
| | - Anup Shah
- Department of Urology, The University of Pittsburgh Medical Center, 1350 Locust St Suite G100A, Pittsburgh, PA, 15219, USA
| | - Paul J Rusilko
- Department of Urology, The University of Pittsburgh Medical Center, 1350 Locust St Suite G100A, Pittsburgh, PA, 15219, USA.
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Ristau BT, Fuller TW, Rios R, Ho C, Tomaszewski JJ. Withdrawal Notice: Growth Kinetics and Oncologic Outcomes for Small Renal Masses Managed with Active Surveillance: A Review of the Literature. Anticancer Agents Med Chem 2017:ACAMC-EPUB-86850. [PMID: 29141560 DOI: 10.2174/1871520617666171114111053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/12/2017] [Accepted: 06/15/2017] [Indexed: 11/22/2022]
Abstract
The article has been withdrawn at the request of the editor of the journal Anti-Cancer Agents in Medicinal Chemistry. Bentham Science apologizes to the readers of the journal for any inconvenience this may cause. Bentham Science Disclaimer It is a condition of publication that manuscripts submitted to this journal have not been published and will not be simultaneously submitted or published elsewhere. Furthermore, any data, illustration, structure or table that has been published elsewhere must be reported, and copyright permission for reproduction must be obtained. Plagiarism is strictly forbidden, and by submitting the article for publication the authors agree that the publishers have the legal right to take appropriate action against the authors, if plagiarism or fabricated information is discovered. By submitting a manuscript the authors agree that the copyright of their article is transferred to the publishers if and when the article is accepted for publication.
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Affiliation(s)
- Benjamin T Ristau
- Division of Urology, UConn Health, Farmington, CT, USA
- Department of Urology, University of Pittsburgh Medical Center, 3741 Fifth Avenue, Suite 700, Pittsburgh, PA 15213, USA
| | | | - Ricardo Rios
- Division of Urology, UConn Health, Farmington, CT, USA
| | - Cristina Ho
- Division of Urology, UConn Health, Farmington, CT, USA
| | - Jeffrey J Tomaszewski
- Division of Urology, Department of Surgery, MD Anderson Cancer Center at Cooper, Cooper Medical School of Rowan University, Camden, NJ, USA
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18
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Fuller TW, Theisen KM, Rusilko PJ. Author Reply. Urology 2017; 108:238. [DOI: 10.1016/j.urology.2017.05.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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19
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Fuller TW, Theisen K, Rusilko P. Surgical Management of Adult Acquired Buried Penis: Escutcheonectomy, Scrotectomy, and Penile Split-thickness Skin Graft. Urology 2017; 108:237-238. [PMID: 28779991 DOI: 10.1016/j.urology.2017.05.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/06/2017] [Accepted: 05/09/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To demonstrate the surgical management of adult acquired buried penis (AABP). Affected patients have poor sexual function, urinary dribbling with subsequent skin breakdown, mood disturbance, lichen sclerosus with subsequent urethral stricture, and poor quality of life. Previous efforts have described limited repairs including an isolated resection of the escutcheon, which unfortunately often leads to reburying. We present a more extensive surgical repair including escutcheonectomy, scrotoplasty, and penile split-thickness skin graft (STSG) to provide a durable definitive repair. METHODS A retrospective review was conducted of patients managed in 2015-2016. Twelve patients who underwent escutcheonectomy, scrotoplasty, and penile STSG were identified. All patients had morbid obesity as a sole etiology or a significant contributing factor. Outcomes evaluated were surgical complications, reburying of the penis, and graft take rates. RESULTS Twelve patients underwent repair of AABP. All patients had durable unburying at the intermediate-term follow-up (mean of 8 months). The mean patient body mass index was 45.4 ± 13.8. The operative times, the length of stay, and the estimated blood loss were 312 ± 59 minutes, 5.3 ± 1.1 days, and 304 ± 133 cc, respectively. The STSG take rate was 80%-100% (mean of 91.7%). CONCLUSION AABP is a challenging condition to treat. Limited surgical repairs can lead to a reburying of the penis and a progression of urethral disease. Escutcheonectomy, scrotoplasty, and STSG have encouraging intermediate-term outcomes with durable unburying of the penis and good STSG take rates. Further follow-up in larger series is needed, but results are thus far encouraging.
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Affiliation(s)
- Thomas W Fuller
- Department of Urology, The University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Katherine Theisen
- Department of Urology, The University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Paul Rusilko
- Department of Urology, The University of Pittsburgh Medical Center, Pittsburgh, PA
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Jian X, Yu M, Uy J, Fuller TW, Jones C, Shen B, Wang J, Roppolo JR, de Groat WC, Tai C. PD70-07 ROLE OF CANNABINOID RECEPTOR TYPE 1 IN TIBIAL AND PUDENDAL NEUROMODULATION OF BLADDER OVERACTIVITY IN CATS. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.3161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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Fuller TW, Jiang X, Bansal U, Lamm V, Shen B, Wang J, Roppolo JR, de Groat WC, Tai C. Sex difference in the contribution of GABA B receptors to tibial neuromodulation of bladder overactivity in cats. Am J Physiol Regul Integr Comp Physiol 2016; 312:R292-R300. [PMID: 27974317 DOI: 10.1152/ajpregu.00401.2016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/12/2016] [Accepted: 12/12/2016] [Indexed: 01/23/2023]
Abstract
This study investigated the role of γ-aminobutyric acid subtype B (GABAB) receptors in tibial and pudendal neuromodulation of bladder overactivity induced by intravesical administration of dilute (0.5%) acetic acid (AA) in α-chloralose-anesthetized cats. To inhibit bladder overactivity, tibial or pudendal nerve stimulation (TNS or PNS) was applied at 5 Hz and two or four times threshold (T) intensity for inducing toe or anal sphincter twitch. TNS at 2T or 4T intensity significantly (P < 0.05) increased the bladder capacity to 173.8 ± 16.2 or 198.5 ± 24.1%, respectively, of control capacity. Meanwhile, PNS at 2T or 4T intensity significantly (P < 0.05) increased the bladder capacity to 217 ± 18.8 and 221.3 ± 22.3% of control capacity, respectively. CGP52432 (a GABAB receptor antagonist) at intravenous dosages of 0.1-1 mg/kg completely removed the TNS inhibition in female cats but had no effect in male cats. CGP52432 administered intravenously also had no effect on control bladder capacity or the pudendal inhibition of bladder overactivity. These results reveal a sex difference in the role of GABAB receptors in tibial neuromodulation of bladder overactivity in cats and that GABAB receptors are not involved in either pudendal neuromodulation or irritation-induced bladder overactivity.
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Affiliation(s)
- Thomas W Fuller
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xuewen Jiang
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Urology, Qilu Hospital, Shandong University, Jinan, Peoples Republic of China; and
| | - Utsav Bansal
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vladimir Lamm
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bing Shen
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jicheng Wang
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James R Roppolo
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William C de Groat
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Changfeng Tai
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; .,Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
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22
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Jiang X, Yu M, Uy J, Fuller TW, Jones C, Shen B, Wang J, Roppolo JR, de Groat WC, Tai C. Role of cannabinoid receptor type 1 in tibial and pudendal neuromodulation of bladder overactivity in cats. Am J Physiol Renal Physiol 2016; 312:F482-F488. [PMID: 27927655 DOI: 10.1152/ajprenal.00586.2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/28/2016] [Accepted: 12/05/2016] [Indexed: 01/23/2023] Open
Abstract
The role of cannabinoid type 1 (CB1) receptors in tibial and pudendal neuromodulation of bladder overactivity induced by intravesical infusion of 0.5% acetic acid (AA) was determined in α-chloralose anesthetized cats. AA irritation significantly (P < 0.01) reduced bladder capacity to 36.6 ± 4.8% of saline control capacity. Tibial nerve stimulation (TNS) at two or four times threshold (2T or 4T) intensity for inducing toe movement inhibited bladder overactivity and significantly (P < 0.01) increased bladder capacity to 69.2 ± 9.7 and 79.5 ± 7.2% of saline control, respectively. AM 251 (a CB1 receptor antagonist) administered intravenously at 0.03 or 0.1 mg/kg significantly (P < 0.05) reduced the inhibition induced by 2T or 4T TNS, respectively, without changing the prestimulation bladder capacity. However, intrathecal administration of AM 251 (0.03 mg) to L7 spinal segment had no effect on TNS inhibition. Pudendal nerve stimulation (PNS) also inhibited bladder overactivity induced by AA irritation, but AM 251 at 0.01-1 mg/kg iv had no effect on PNS inhibition or the prestimulation bladder capacity. These results indicate that CB1 receptors play an important role in tibial but not pudendal neuromodulation of bladder overactivity and the site of action is not within the lumbar L7 spinal cord. Identification of neurotransmitters involved in TNS or PNS inhibition of bladder overactivity is important for understanding the mechanisms of action underlying clinical application of neuromodulation therapies for bladder disorders.
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Affiliation(s)
- Xuewen Jiang
- Department of Urology, Qilu Hospital, Shandong University, Jinan, Peoples Republic of China.,Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Michelle Yu
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Jamie Uy
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Thomas W Fuller
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Cameron Jones
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Bing Shen
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Jicheng Wang
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - James R Roppolo
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William C de Groat
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Changfeng Tai
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania; and .,Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
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23
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Bansal U, Fuller TW, Jiang X, Bandari J, Zhang Z, Shen B, Wang J, Roppolo JR, de Groat WC, Tai C. Lumbosacral spinal segmental contributions to tibial and pudendal neuromodulation of bladder overactivity in cats. Neurourol Urodyn 2016; 36:1496-1502. [PMID: 27778372 DOI: 10.1002/nau.23159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/26/2016] [Indexed: 11/06/2022]
Abstract
AIMS To determine the spinal segmental afferent contributions to tibial and pudendal inhibition of bladder overactivity. METHODS Intravesical infusion of 0.5% acetic acid was used to irritate the bladder and induce bladder overactivity in anesthetized cats. Tibial or pudendal nerve stimulation was used to suppress the bladder overactivity and increase bladder capacity during cystometry. L5-S3 dorsal roots ipsilateral to the stimulation were exposed by a laminectomy and transected sequentially during the experiments to determine the role of individual dorsal roots in tibial or pudendal neuromodulation. RESULTS Transection of L5 dorsal root had no effect. Transection of L6 dorsal root in four cats produced an average 18% reduction in tibial inhibition, which is not a significant change when averaged in the group of 10 cats. Transection of L7 dorsal root completely removed the tibial inhibition without changing reflex bladder activity or pudendal inhibition. Transection of S1 dorsal root reduced the pudendal inhibition, after which transection of S2 dorsal root completely removed the pudendal inhibition. Transection of S3 dorsal root had no effect. The control bladder capacity was increased only by transection of S2 dorsal root. CONCLUSIONS This study in cats revealed that tibial and pudendal neuromodulation of reflex bladder overactivity depends on activation of primary afferent pathways that project into different spinal segments. This difference may be related to the recent observation in cats that the two types of neuromodulation have different mechanisms of action.
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Affiliation(s)
- Utsav Bansal
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas W Fuller
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xuewen Jiang
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China
| | - Jathin Bandari
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Zhaocun Zhang
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China
| | - Bing Shen
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jicheng Wang
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James R Roppolo
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William C de Groat
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Changfeng Tai
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
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24
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Jiang X, Fuller TW, Bandari J, Bansal U, Zhang Z, Shen B, Wang J, Roppolo JR, de Groat WC, Tai C. Contribution of GABAA, Glycine, and Opioid Receptors to Sacral Neuromodulation of Bladder Overactivity in Cats. J Pharmacol Exp Ther 2016; 359:436-441. [PMID: 27729478 DOI: 10.1124/jpet.116.235846] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/07/2016] [Indexed: 11/22/2022] Open
Abstract
In α-chloralose-anesthetized cats, we examined the role of GABAA, glycine, and opioid receptors in sacral neuromodulation-induced inhibition of bladder overactivity elicited by intravesical infusion of 0.5% acetic acid (AA). AA irritation significantly (P < 0.01) reduced bladder capacity to 59.5 ± 4.8% of saline control. S1 or S2 dorsal root stimulation at threshold intensity for inducing reflex twitching of the anal sphincter or toe significantly (P < 0.01) increased bladder capacity to 105.3 ± 9.0% and 134.8 ± 8.9% of saline control, respectively. Picrotoxin, a GABAA receptor antagonist administered i.v., blocked S1 inhibition at 0.3 mg/kg and blocked S2 inhibition at 1.0 mg/kg. Picrotoxin (0.4 mg, i.t.) did not alter the inhibition induced during S1 or S2 stimulation, but unmasked a significant (P < 0.05) poststimulation inhibition that persisted after termination of stimulation. Naloxone, an opioid receptor antagonist (0.3 mg, i.t.), significantly (P < 0.05) reduced prestimulation bladder capacity and removed the poststimulation inhibition. Strychnine, a glycine receptor antagonist (0.03-0.3 mg/kg, i.v.), significantly (P < 0.05) increased prestimulation bladder capacity but did not reduce sacral S1 or S2 inhibition. After strychnine (0.3 mg/kg, i.v.), picrotoxin (0.3 mg/kg, i.v.) further (P < 0.05) increased prestimulation bladder capacity and completely blocked both S1 and S2 inhibition. These results indicate that supraspinal GABAA receptors play an important role in sacral neuromodulation of bladder overactivity, whereas glycine receptors only play a minor role to facilitate the GABAA inhibitory mechanism. The poststimulation inhibition unmasked by blocking spinal GABAA receptors was mediated by an opioid mechanism.
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Affiliation(s)
- Xuewen Jiang
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - Thomas W Fuller
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - Jathin Bandari
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - Utsav Bansal
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - Zhaocun Zhang
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - Bing Shen
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - Jicheng Wang
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - James R Roppolo
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - William C de Groat
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
| | - Changfeng Tai
- Department of Urology, Qilu Hospital, Shandong University, Jinan, P.R. China (X.J., Z.Z.); Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania (X.J., T.W.F., J.B., U.B., Z.Z., B.S., J.W., C.T.); and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania (J.R.R., W.C.d.G., C.T.)
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25
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Fuller TW, Rycyna KJ, Ayyash OM, Ferroni MC, Mitchell CR, Ohmann E, Wollin DA, Shah O, Miller NL, Semins MJ. Defining the Rate of Primary Ureteroscopic Failure in Unstented Patients: A Multi-Institutional Study. J Endourol 2016; 30:970-4. [PMID: 27301268 DOI: 10.1089/end.2016.0304] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Primary ureteroscopic intervention for kidney or ureteral stones occasionally encounters difficulty with passage of the ureteroscope in the initial procedure. These patients require a second procedure after stenting. We aim to define the contemporary failure rate of primary ureteroscopy (URS) and identify predictive factors that necessitate prestenting. This will assist in preoperative patient counseling, informed consent, and clinical decision-making. MATERIALS AND METHODS We conducted a multi-institutional retrospective review of 535 unstented patients undergoing primary URS from August 2011 to August 2013. The primary outcome was gaining access to the unstented ureter. RESULTS The failure rate for accessing the unstented ureter was 7.7% (41/535). The median age of females with primary ureteroscopic failure was significantly lower than in females who had successful ureteroscopic access (34 vs 52 years; p = 0.0041). There was no difference in the median age of males with access vs failure (58 vs 57 years; p = 0.3683). Proximal ureteral stones had the highest failure rate for ureteral access at 18.28% (p = 0.006). On multivariable logistic regression, proximal ureteral stone location remained a significant predictor of failure when compared to renal stones (odds ratio [OR] 3.14, p = 0.006). When including only ureteral stones in the multivariable analysis, stone location in the proximal ureter compared to the distal ureter remained the only significant predictor of access failure (OR 0.24, p = 0.015). CONCLUSIONS A low overall rate of ureteral access failure in unstented patients is shown. Young female patients and proximal ureteral stones were less likely to be accessed primarily. This study provides information that will help urologists counsel their patients preoperatively regarding their likelihood of failing primary URS necessitating a second procedure. This will also help the patient to make an informed decision during the consent process and may guide urologists on selective prestenting in higher risk patients.
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Affiliation(s)
- Thomas W Fuller
- 1 Department of Urology, The University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Kevin J Rycyna
- 1 Department of Urology, The University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Omar M Ayyash
- 1 Department of Urology, The University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Matthew C Ferroni
- 1 Department of Urology, The University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Christopher R Mitchell
- 2 Deparment of Urologic Surgery, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Erin Ohmann
- 3 New York University Langone Medical Center , New York, New York
| | - Daniel A Wollin
- 3 New York University Langone Medical Center , New York, New York
| | - Ojas Shah
- 4 Columbia University Medical Center , New York, New York
| | - Nicole L Miller
- 2 Deparment of Urologic Surgery, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Michelle J Semins
- 1 Department of Urology, The University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
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Bandari J, Fuller TW, Turner Іі RM, D'Agostino LA. Renal biopsy for medical renal disease: indications and contraindications. Can J Urol 2016; 23:8121-8126. [PMID: 26892051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Percutaneous renal biopsy (PRB) is a safe and effective modality for sampling kidney tissue. In limited circumstances, alternative methods for kidney biopsy may be indicated. Historical contraindications for PRB such as bleeding diathesis, morbid obesity and solitary kidney have been called into question in the literature. We present a review of the literature on PRB and the risks and benefits associated with alternatives. MATERIALS AND METHODS A review of the literature was performed through MEDLINE and PubMed. A total of 726 articles exist under the query, "percutaneous renal biopsy." Large series describing indications, contraindications, procedural methods, and complications were extracted. To further investigate the risks of percutaneous renal biopsy on solitary kidneys, the literature on percutaneous nephrolithotomy (PCNL) and biopsy of transplant kidneys were queried. Summaries of the data were compiled and synthesized in the body of the text. RESULTS Percutaneous renal biopsy is safe and effective in the majority of kidney units for the evaluation of medical renal disease. Rates of bleeding range from 0.3%-7.4%, and nephrectomy rates are exceedingly low (0.1%-0.5%). Bleeding rates in open and laparoscopic approaches are comparable and range from 0%-7.0%, with major complications ranging from 0%-6.1%. CONCLUSIONS The successes of percutaneous methods have called into question traditional contraindications such as solitary kidney, bleeding diathesis, and morbid obesity. In limited cases, alternative methods may be appropriate. We present a review of the literature for the various approaches and their associated complication rates.
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Affiliation(s)
- Jathin Bandari
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Dangle PP, Fuller TW, Gaines B, Cannon GM, Schneck FX, Stephany HA, Ost MC. Evolving Mechanisms of Injury and Management of Pediatric Blunt Renal Trauma--20 Years of Experience. Urology 2016; 90:159-63. [PMID: 26825488 DOI: 10.1016/j.urology.2016.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/11/2016] [Accepted: 01/19/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To review 20 years of a prospectively maintained trauma database to identify changing trends in mechanisms of renal injury, demographics, and management outcomes. MATERIALS AND METHODS Following the approval from the institutional review board, a prospectively maintained trauma database was reviewed for renal trauma patient demographics, management, and mechanisms of injury. Data were reviewed first for the entire cohort and then incrementally to identify mechanisms of injury associated with increasing frequency or grade of injury. RESULTS A total of 228 graded renal injuries were identified from 1993 to 2013. The majority of renal injuries occurred in males (77.2%) >6 years of age (85.1%). Low grade (I-III) injuries were more common (70.6%). The most frequent mechanisms of injury identified were falls, recreational motor vehicle (RMV) accidents, bike accidents, motor vehicle collisions, and sports accidents, in descending order of frequency. RMV-related injuries have become frequent with time despite recommendations against use in the pediatric age population. Surgical intervention was rarely necessary. Over the 20 year study period, 5 nephrectomies (1.4%) were required, whereas 10 endoscopic interventions or percutaneous drainage procedures were needed (2.4%). CONCLUSION The majority of blunt pediatric renal injuries are low grade and can be managed nonoperatively. Nephrectomy is rarely required but is indicated for hemodynamic instability refractory to resuscitation. Pediatric blunt renal trauma secondary to RMV use is increasing despite recommendations against their use in the pediatric population.
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Affiliation(s)
- Pankaj P Dangle
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Thomas W Fuller
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Barbara Gaines
- Department of Pediatric Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Glenn M Cannon
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Francis X Schneck
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Heidi A Stephany
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael C Ost
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
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Fuller TW, Dangle P, Reese JN, Ristau BT, Lyon TD, Jaffe R, Stephany HA. Inflammatory myofibroblastic tumor of the bladder masquerading as eosinophilic cystitis: case report and review of the literature. Urology 2015; 85:921-3. [PMID: 25817116 DOI: 10.1016/j.urology.2015.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 12/20/2014] [Accepted: 01/05/2015] [Indexed: 11/17/2022]
Abstract
A 9-year-old boy presented with gross hematuria of 2 days duration. Cystoscopic evaluation revealed an anterior bladder mass. Pathology was consistent with eosinophilic cystitis, and a steroid regimen was initiated accordingly, but no improvement ensued. Concern for alternate malignant pathology led to open resection and the ultimate diagnosis of inflammatory myofibroblastic tumor of the bladder. Inflammatory myofibroblastic tumor is a rare tumor of the bladder in children and to our knowledge has not previously been associated with a misleading eosinophil-rich mucosal inflammatory response.
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Affiliation(s)
- Thomas W Fuller
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Pankaj Dangle
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeremy N Reese
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Benjamin T Ristau
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Timothy D Lyon
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ronald Jaffe
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Heidi A Stephany
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
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Fuller TW, Ristau BT, Benoit RM. Simultaneous cuff revision and placement of an AdVance male sling for persistent post-prostatectomy urinary incontinence initially managed with AMS 800 artificial urinary sphincter. Can J Urol 2014; 21:7507-7509. [PMID: 25347378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Placement of an artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence after radical prostatectomy. Persistent or recurrent incontinence after AUS placement can occur. Options then include cuff revision or placement of a retrourethral transobturator sling (RTS), among other alternatives. This report describes simultaneous cuff revision and placement of a RTS for management of refractory stress urinary incontinence after radical prostatectomy. This approach obviates the need for additional procedures if one approach fails. This is especially valuable for patients averse to operative intervention and those at high risk for general anesthesia.
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Affiliation(s)
- Thomas W Fuller
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Drake RR, Cazares LH, Jones EE, Fuller TW, Semmes OJ, Laronga C. Challenges to developing proteomic-based breast cancer diagnostics. OMICS 2011; 15:251-9. [PMID: 21332380 DOI: 10.1089/omi.2010.0120] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Over the past decade, multiple genetic and histological approaches have accelerated development of new breast cancer diagnostics and treatment paradigms. Multiple distinct genetic subtypes of breast cancers have been defined, and this has progressively led toward more personalized medicine in regard to treatment options. There still remains a deficiency in the development of molecular diagnostic assays that can be used for breast cancer detection and pretherapy clinical decisions. In particular, the type of cancer-specific biomarker typified by a serum or tissue-derived protein. Progress in this regard has been minimal, especially in comparison to the rapid advancements in genetic and histological assays for breast cancers. In this review, some potential reasons for this large gap in developing protein biomarkers will be discussed, as well as new strategies for improving these approaches. Improvements in the study design of protein biomarker discovery strategies in relation to the genetic subtypes and histology of breast cancers is also emphasized. The current successes in use of genetic and histological assays for breast cancer diagnostics are summarized, and in that context, the current limitations of the types of breast cancer-related clinical samples available for protein biomarker assay development are discussed. Based on these limitations, research strategies emphasizing identification of glycoprotein biomarkers in blood and MALDI mass spectrometry imaging of tissues are described.
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Affiliation(s)
- Richard R Drake
- Cancer Biology and Infectious Disease Research Center, Eastern Virginia Medical School, Norfolk, Virginia 23507, USA.
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Drake RR, White KY, Fuller TW, Igwe E, Clements MA, Nyalwidhe JO, Given RW, Lance RS, Semmes OJ. Clinical collection and protein properties of expressed prostatic secretions as a source for biomarkers of prostatic disease. J Proteomics 2009; 72:907-17. [PMID: 19457353 DOI: 10.1016/j.jprot.2009.01.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 12/25/2008] [Accepted: 01/04/2009] [Indexed: 12/14/2022]
Abstract
The prostate gland secretes many proteins in a prostatic fluid that combines with seminal vesicle derived fluids to promote sperm activation and function. Proximal fluids of the prostate that can be collected clinically are seminal plasma and expressed-prostatic secretion (EPS) fluids. EPS represents the fluid being secreted by the prostate following a digital rectal prostate massage, which in turn can be collected in voided urine post-exam. This collection is not disruptive to a standard urological exam, and it can be repeatedly collected from men across all prostatic disease states. A direct EPS fluid can also be collected under anesthesia prior to prostatectomy. While multiple genetic assays for prostate cancer detection are being developed for the shed epithelial cell fraction of EPS urines, the remaining fluid that contains many prostate-derived proteins has been minimally characterized. Approaches to optimization and standardization of EPS collection consistent with current urological exam and surgical practices are described, and initial proteomic and glycomic evaluations of the of EPS fluid are summarized for prostate specific antigen and prostatic acid phosphatase. Continued characterization of the prostate specific protein components of EPS urine combined with optimization of clinical collection procedures should facilitate discovery of new biomarkers for prostate cancer.
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Affiliation(s)
- Richard R Drake
- Department of Microbiology and Molecular Cell Biology, Center for Biomedical Proteomics, Eastern Virginia Medical School, Norfolk, Virginia 23507, USA.
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Abstract
Inactivation of N-type voltage-sensitive Ca2+ channels (VSCC) with omega-conotoxin (omega-CgTx) in tissue obtained from chicken brain produces a concentration dependent (0.01-0.1 microM) inhibition of K(+)-stimulated Ca2+ influx (delta K+), the rise in [Ca2+]i and acetylcholine (ACh) release. In identical preparations from rat brain, Ca2+ influx and the rise in [Ca2+]i were only marginally affected by much higher (1-10 microM) concentrations of omega-CgTx. The release of ACh, however, was inhibited to the same degree with similar amounts of omega-CgTx as those used in chicken brain. An L-type VSCC inhibitor failed to affect any of these parameters alone, or to augment the effect of omega-CgTx. The results suggest that almost all the VSCC in chicken brain are of the N type and that these channels regulate neurotransmitter release. In rat brain, on the other hand, Ca2+ channels resistant to N- or L-type blockers account for almost 75% of the measurable Ca2+ influx and rise in [Ca2+]i. The conspicuous dissociation between the regulation of Ca2+ influx and ACh release demonstrated in rat brain by using omega-CgTx, suggest that neurotransmitter release is governed by only a small proportion of strategically located N-type, omega-CgTx sensitive, VSCC in the presynaptic terminal.
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Affiliation(s)
- P M Lundy
- Biomedical Defence Section, Defence Research Establishment Suffield, Ralston, Alberta, Canada
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