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The U.S. Food and Drug Administration has approved a new use for Xiaflex (collagenase clostridium histolyticum) as the first FDA-approved medicine to treat men with bothersome curvature of the penis, a condition known as Peyronie's disease.
The Effect of Intracavernosal Avanafil, a Newer Phosphodiesterase-5 Inhibitor, on Neonatal Type 2 Diabetic Rats With Erectile Dysfunction - Corrected Proof
Objective: To determine the effect of avanafil, a novel phosphodiesterase-5 inhibitor, on the treatment of erectile dysfunction associated with type 2 diabetes mellitus (T2DM).Methods: In 2-day-old rats, T2DM was induced by single intraperitoneal injection of 90 mg/kg of streptozotocin (STZ; i.p.). Erectile responses were evaluated after 10 weeks on intracavernosal injection of avanafil (1 μM) to anesthetized rats and data expressed as intracavernosal pressure (ICP)/mean arterial pressure and total ICP. The relaxant and contractile responses of corpus cavernosum (CC) strips were obtained in vitro studies.Results: ICP/mean arterial pressure and total ICP responses were significantly reduced in T2DM rats compared with controls. Avanafil partially restored diminished ICP responses in diabetic rats. In CC strips from the diabetic group, electrical field stimulation (1-20 Hz)–induced relaxation responses were markedly enhanced by 45%, whereas acetylcholine (ACh; 10−8-10−3)–induced relaxation responses were diminished by 73%. In addition, phenylephrine (PE; 10−8-10−3) and electrical field stimulation (1-40 Hz)–induced contractile responses were significantly reduced in the diabetic group compared with controls. CC relaxant responses to sodium nitroprusside (SNP, 10−8-10−3) and avanafil (10−8-10−3) were unaltered in both groups.Conclusion: The cavernous injection of avanafil in T2DM rats resulted in partial improvement in erectile responses. These findings suggest that intracavernosal administration of avanafil might be beneficial for the treatment of erectile dysfunction in patients with T2DM.
Acute kidney injury, a condition that is common but often asymptomatic, may be more deadly than a heart attack, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN). The findings suggest that follow-up and surveillance may be critical to protect the health of individuals who develop this form of kidney damage.
HIV can infect transplanted kidneys in HIV-positive recipients even in the absence of detectable virus in the blood, according to a study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN). The study's investigators also developed a simple urine test to diagnose such infections.
Guidelines from the Kidney Disease: Developing Global Guidelines (KDIGO) organization call for wider statin use among patients with chronic kidney disease (CKD). KDIGO updated its clinical practice guidelines for lipid management in patients with CKD earlier in 2013.
Does Neoadjuvant Androgen Deprivation Therapy Before Primary Whole Gland Cryoablation of the Prostate Affect the Outcome? - Corrected Proof
Objective: To evaluate the effect of neoadjuvant androgen deprivation therapy (NADT) on the outcomes for primary whole gland prostate cryoablation (CRYO). NADT before CRYO has sometimes been used for prostate volume reduction, with some theoretical benefit toward improving disease control. NADT has been shown to be beneficial for biochemical disease-free survival (bDFS) with radiotherapy but not in conjunction with radical prostatectomy.Methods: We retrospectively compared risk-stratified cohorts according to whether they had received NADT. bDFS was defined using the Phoenix criteria, and postoperative morbidity and complications were compared.Results: A total of 1761 men had undergone NADT before CRYO and 2727 had not. No differences were found in the incidence of postoperative incontinence, pad use, potency, or fistula formation. The rate of urinary retention at 12 months was slightly lower for those who had not undergone NADT (0.8% vs 1.2%, P = .015). No difference was found in bDFS between the NADT and non-NADT men (66.9% vs 66.5% at 5 years). When stratified by risk, however, a statistically significant difference was found between the NADT and non-NADT men only in the intermediate-risk cohort (71.3% vs 65.9%; P < .013).Conclusion: bDFS was statistically similar between the NADT and non-NADT men, except in the intermediate-risk cohort, with slightly improved survival for those undergoing NADT. No significant difference was found in the complication rates. These data do not support the routine use of NADT for men undergoing primary whole gland cryoablation, although its use could be considered for men with larger prostates or men in the intermediate-risk category.
Although this study has significant flaws, including no method of determining the clinical endpoints used for NADT, completion such as PSA response and volume reduction, and a possible selection bias, its conclusions are interesting.
Objective: To introduce a novel method to successfully evacuate severe clot retention in the bladder.Methods: A total of 22 male patients were treated using our method for severe clot retention. The bladder was irrigated with 40,000 U chymotrypsin in 50 mL of 5% sodium bicarbonate using a Foley catheter (20F-24F) for 30 minutes. The clots were then easily mobilized and evacuated using continuous saline irrigation and suction with a 60-mL syringe. The procedure was repeated 2-4 times until all the blood clots had been evacuated.Results: Of the 22 patients, 19 were successfully treated using this method, with clot retention thoroughly resolved.Conclusion: The chymotrypsin and sodium bicarbonate irrigation technique is safe, inexpensive, and a successful method to evacuate severe clot retention.
Use of Antegrade Reverse-thermosensitive Polymer During Percutaneous Nephrolithotomy to Prevent Fragment Migration: Initial Experience - Corrected Proof
Introduction: Our objective was to evaluate the feasibility and initial performance of Backstop reverse thermosensitive polymer to prevent antegrade stone fragment migration during percutaneous nephrolithotomy.Technical Considerations: Backstop was used during 5 percutaneous nephrolithotomy procedures to prevent stone migration into the ureter. Backstop was placed into the upper ureter under direct vision with a flexible nephroscope or with fluoroscopic guidance. Ultrasonic lithotripsy was then performed. Each patient was evaluated for the following: stone-free rate (postoperative computed tomography), rate of antegrade fragment migration, need for subsequent procedures, and complication rate. The average stone burden was 806 mm2. Backstop was successfully deployed in all cases. Average procedure length was 106 minutes. Three patients were rendered stone free, 1 patient retained 2 1-mm fragments in the kidney, and 1 patient retained multiple fragments in the kidney, distal ureter, and bladder, all of which were <3 mm. No patient required a secondary procedure, and there were no adverse events.Conclusion: Backstop appears to be feasible, safe, and easy to use. Backstop should be administered every 45 minutes for longer cases, and warm saline should be used during the case to prevent dissolution. A randomized controlled trial with a larger study population is needed to further evaluate these initial findings.
Percutaneous Microwave Ablation of Renal Cell Carcinoma Is Safe in Patients With a Solitary Kidney - Corrected Proof
Objective: To present the results of clinical outcomes after microwave ablation (MWA) of renal cell carcinoma in patients with a solitary kidney without causing impairment to the uninvolved renal parenchyma and renal function.Methods: Between 2006 and 2012, 14 solitary kidney patients with 16 tumors underwent percutaneous ultrasound-guided MWA at our institution. The tumor diameters ranged from 1.0 to 8.4 cm. The serum creatinine and urea levels of each patient before MWA, 1 day after MWA, and the most recent occasion on record at our institution were collected. Moreover, all the patients were followed up using contrast enhanced ultrasound and computed tomography or magnetic resonance imaging at 1, 3, and 6 months and every 6 months thereafter. The technical success, survival rates, and complications were accessed. Patients were available for clinical and laboratory evaluations at a median follow-up time of 9.5 months (range, 1-56.4).Results: Complete ablation was achieved in 15 of 16 (93.8%) lesions after 1 or 2 MWA sessions; however, 2 of 14 (14.3%) patients died of widespread metastasis. The renal function was essentially preserved, and no patients require dialysis. No major complications were observed.Conclusion: MWA is a safe and effective treatment option for patients with a solitary kidney who suffer from inoperable renal cell carcinoma. The complication rate is low, and excellent tumor control can be achieved without deterioration of the residual renal function.
Matched Comparison of Robotic vs Laparoscopic Nephroureterectomy: An Initial Experience - Corrected Proof
Objective: To compare our initial robotic-assisted nephroureterectomy (RAN) experience with a well-established practice of performing laparoscopic nephroureterectomy (LN) to treat upper tract urothelial carcinoma (UTUC).Methods: We reviewed our prospectively maintained minimally invasive surgery database. Patients who underwent RAN from April 2009 to December 2011 were matched by pathologic tumor stage and age (±10 years) to those who underwent LN.Results: Twenty-two matched pairs were evaluated. Mean operative time (298 vs 251 minutes) and estimated blood loss (EBL, 380 vs 233 mL) were significantly higher for RAN, with a greater need for transfusion in this group. Complication rates were similar. The RAN group trended toward more frequent lymph node dissection and greater median node count when lymph node dissection was performed (59% vs 27% [P = .07] and 5.5 vs 1.0 [P = .13]). After a median follow-up of 10 months for RAN and 15 months for LN, no significant difference was seen in the rate of bladder (36% vs 37%) or distant (32% vs 23%) recurrence, with similar median time to any recurrence (9 months vs 4 months, P = .32).Conclusion: RAN was associated with higher operative time and blood loss likely because of more frequent use of node dissection, robot repositioning, and technical inexperience. Lymph node dissection was more frequently performed with RAN, which reflects surgeon practice patterns. When a lymph node dissection was performed, the median node count was greater with RAN. Our initial experience with RAN suggests that this is an acceptable approach for the management of UTUC.
Laparoscopic and percutaneous thermal ablation of small renal lesions has demonstrated a reduction in operative toxicity relative to extirpative approaches better approximating the risk of treatment with the potential medical consequences of these lesions. The incidental diagnosis of such lesions and the rising overall incidence of renal cancer have provided a stimulus for better innovation in ablation techniques. This article explores a new technology, microwave heating, for the ablation of renal masses in a solitary kidney. However, not everything new is better, and not every renal mass is small. The instructions that accompany microwave equipment inform the surgeon about the size of the ablation zone created when using specific energy for a predetermined duration of time. Importantly, clinical research has revealed the microwave ablation zones to be highly variable, smaller than predicted, and with a risk of heat injury to the collecting system. Therefore, the choice of lesions for ablation and the technical considerations about probe placement are critical for successful treatment. Renal masses >5 cm are unlikely to be completely ablated with even multiple needle placements ultimately subjecting the patient to several procedures. Overall, the ablation literature is distorted by varying radiographic definitions of successful ablation, the belief systems around using multiple treatments to ablate a single mass and the debate between cold vs heat energy to destroy tissue. Finally, oncologic efficacy data might be obscured by including benign lesions treated with ablation.
Microwave ablation (MWA) has obtained excellent outcomes in managing small hepatocellular carcinoma, but it is still a relatively new technique to treat small renal tumors. Our intermediate-term research demonstrated that MWA was a safe and effective technique for the management of small renal cell carcinoma (RCC) in selected patients. Guan et al considered that MWA could achieve similar therapeutic effect compared with partial nephrectomy.
Primary Cryosurgery for Clinically Localized Prostate Cancer – Do Perioperative Tumor Characteristics Correlate With Post-treatment Biopsy Results? - Corrected Proof
Objective: To investigate the rate and predictive factors of positive post-treatment biopsy in men treated with primary cryosurgery for localized prostate cancer.Methods: A retrospective review was performed of all patients treated with primary cryosurgery at a single institution between 1999 and 2012. Perioperative prostate-specific antigen (PSA) levels, Gleason score, and number of positive preoperative biopsy cores were obtained and correlated with postoperative biopsy results. Patients were stratified according to the risk classification system of D'Amico to low-, intermediate-, or high-risk groups.Results: Sixty-five men were treated with primary cryosurgery, and 57 of 65 (88%) of them underwent postoperative biopsy on average 9 months after the treatment. Eleven of 57 patients (19%) were found to have persistent tumor on post-treatment biopsy. Men who had positive biopsy had significantly higher perioperative PSA levels than men who had negative biopsy (preoperative PSA 12.5 vs 6.2, P = .002; post-operative PSA nadir 4.3 vs 0.71, P = .005); however, no independent predictor was found on a multivariate analysis. Gleason score and number of positive preoperative biopsy cores did not predict tumor persistence. Positive biopsy results were found more often in the intermediate- and high-risk patients, although this was not statistically significant (low risk 9%, intermediate risk 20%, and high risk 27%).Conclusion: Perioperative PSA levels, Gleason score, or number of positive pretreatment biopsy cores do not predict failure after primary cryosurgery for clinically localized prostate cancer. Our findings suggest that physicians, who offer primary cryosurgery to patients with localized prostate cancer, should consider offering post-treatment biopsy to patients to assure adequate cancer control.
Place of Ultrasonography in Predicting Vesicoureteral Reflux in Patients With Mild Renal Scarring - Corrected Proof
Objective: To evaluate the role of renal ultrasonography (USG) in predicting vesicoureteral reflux (VUR) in children with mild renal scarring determined by dimercaptosuccinic acid scintigraphy performed after attack of urinary tract infections (UTI).Methods: Dimercaptosuccinic acid scintigraphy, voiding cystourethrography (VCUG), and renal USG findings were evaluated retrospectively in children with UTI. Each kidney was evaluated as a separate renal unit (RU). RUs with severe scarring were excluded from the study. RUs having mild scarring with and without abnormal USG findings (group 1 and group 2, respectively) were compared in terms of the presence of VUR.Results: There were a total of 228 patients (70 men, mean age 47.06 ± 44.14 months) and 456 RUs. Of the 185 RUs with mild scarring, 55 had abnormal USG findings (group 1), whereas 130 had normal USG findings (group 2). The rates of VUR and severe VUR (≥grade 4) were higher in group 1 compared with group 2 (69% vs 43%, P = .001 and 35% vs 7% respectively, P <.001). The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio of USG findings in predicting VUR in RU with mild scarring were 68%, 80%, 38%, 93%, and 8.2, respectively.Conclusion: Normal renal USG findings exclude a diagnosis of high-grade VUR to a large extend in children with UTI and mild renal scarring. Refraining from invasive VCUG might be a reasonable approach in these patients provided that no other predisposing factors for UTI and/or renal scarring present.
Outcomes After Photoselective Vaporization of the Prostate and Transurethral Resection of the Prostate in Patients Who Develop Prostatic Obstruction After Radiation Therapy - Corrected Proof
Objective: To compare the need for repeat treatment or urinary diversion in patients undergoing transurethral resection of the prostate (TURP) compared with photoselective vaporization of the prostate (PVP) after brachytherapy or external beam radiation therapy (EBRT).Methods: The prostate cancer database of Cleveland Clinic includes 3600 patients who have undergone prostate brachytherapy and 2500 patients who have undergone EBRT. We cross-referenced these patients with the electronic medical record to identify patients who required PVP or TURP after radiation. The primary outcome was the need for any further intervention after PVP or TURP, including bladder neck incision, repeat TURP, or permanent supravesicular diversion.Results: Sixty of the 3600 patients (1.7%) required prostate reduction surgery after brachytherapy. Of these 60 patients, 19 of 40 (47.5%) who underwent TURP required further intervention, and 10 of 20 patients (50%) who underwent PVP required subsequent intervention. Twenty-eight of the 2500 patients (1.1%) required prostate reduction surgery after EBRT. Of these 28 patients, 5 of 18 patients (27.8%) who underwent TURP required further intervention, and 5 of 10 patients (50%) who underwent PVP required subsequent intervention. Following either type of radiation there was not a significant difference in the need for further treatment based on the type of surgery (P >.999 for brachytherapy; P = .412 for EBRT). The median time between radiation and prostate reduction surgery is 20.2 months (range, 14.6-27.6) after brachytherapy and 53.3 months (range, 27.5-53.3) after EBRT (P = .0005).Conclusion: This study suggests that PVP and TURP are comparable in treating prostatic obstruction after brachytherapy or EBRT. However, obstruction after brachytherapy occurs earlier compared with after EBRT.