Peak retrograde flow can serve as a valuable tool in predicting persistent, progressive and new onset asymmetry. Varicoceles associated with a peak retrograde flow of 38 cm per second or greater and 20% or greater asymmetry should be considered for varicocelectomy at initial presentation. Patients with peak retrograde flow greater than 30 cm per second need to be monitored carefully. Those with peak retrograde flow less than 30 cm per second are less likely to require surgery.
Purpose
We compared clinical outcomes, and identified predictors of cancer specific and overall survival after radical cystectomy in patients with urothelial carcinoma with squamous differentiation and those with pure squamous cell carcinoma.
Materials and Methods
We reviewed data on 2,031 patients treated with radical cystectomy and pelvic lymph node dissection at a single high volume referral center. Of these patients 78 had squamous cell carcinoma and 67 had squamous differentiation. Survival estimates by histological subtype were described using Kaplan-Meier methods. Within histological subtypes pathological stage, nodal invasion, soft tissue margins, age and gender were evaluated as predictors of cancer specific survival and overall survival using univariate Cox regression.
Results
Median followup was 44 months. Of 104 patient deaths 60 died of their disease. We did not find a statistically significant difference between survival curves of patients with squamous cell carcinoma and squamous differentiation (log rank overall survival p = 0.6, cancer specific survival p = 0.17). Positive soft tissue margins were associated with worse cancer specific survival (HR 6.92, 95% CI 2.98–16.10, p ≤ 0.0005) and overall survival (HR 3.68, 95% CI 1.84–7.35, p ≤ 0.0005) in patients with pure squamous cell carcinoma. Among patients with squamous differentiation, pelvic lymphadenopathy was associated with decreased overall survival (HR 2.52, 95% CI 1.33–4.77, p = 0.004) and cancer specific survival (HR 3.23, 95% CI 1.57–6.67, p = 0.002).
Conclusions
There appears to be no evidence of a difference in cancer specific survival or overall survival between patients with squamous cell carcinoma and those with squamous differentiation treated with radical cystectomy and pelvic lymph node dissection. Patients with squamous differentiation and tumor metastases to pelvic lymph nodes should be followed more closely, and adjuvant treatment should be considered to improve survival. Wide surgical resection is critical to achieve local tumor control and improve survival in patients with squamous cell carcinoma.
Laparoscopic lymphatic sparing varicocelectomy is preferable to an open or laparoscopic Palomo repair that does not preserve the lymphatics. It has a significantly lower incidence of postoperative hydroceles, especially those requiring surgical intervention, and still maintains a low incidence of persistence/recurrence. The procedure is especially advantageous for bilateral varicocelectomy.
Purpose
Surgical treatment options for renal masses include radical versus partial nephrectomy and the open versus laparoscopic approach. Using American Board of Urology case log data, we investigated contemporary trends in these treatment options and how surgeon and practice characteristics may influence these trends.
Materials and Methods
Annualized case log data for nephrectomies were obtained from the American Board of Urology for all urologists certifying or recertifying, from 2002 to 2010. We evaluated the trends in nephrectomy use. Logistic regressions were used to evaluate surgeon and practice characteristics as predictors for partial and laparoscopic procedures.
Results
From the 3,852 case logs submitted by non-pediatric urologists, 48,384 nephrectomies were analyzed. From 2002 to 2010, the proportion of annual nephrectomies that were performed as open radical nephrectomies gradually decreased from 54% to 29%. During the same period, there was a moderate gradual increase of laparoscopic radical nephrectomy usage, from 30% to 39%. The proportion of open partial nephrectomy remained stable at 15% while laparoscopic partial nephrectomy increased from 2% to 17%. On multivariable analysis, usage of partial nephrectomy and laparoscopy was predicted by a urologist’s annual nephrectomy volume, initial or recertification status, subspecialty, practice area size, and geographic region.
Conclusions
Since 2002, usage of laparoscopic nephrectomy and partial nephrectomy has increased. However, the diffusion of these techniques is not uniform. Initial certification, higher surgical volume, and practicing in areas over 1,000,000 and northeast region were associated with higher usage of laparoscopy and partial nephrectomy. Factors that affect the adoption of these techniques require further research.
Purpose
Several options exist for the surgical correction of male stress urinary incontinence including periurethral bulking agents, artificial urinary sphincters and the recently introduced male urethral slings. We investigated contemporary trends in the use of these treatments.
Materials and Methods
Annualized case log data for incontinence surgeries from certifying and re-certifying urologists were obtained from the American Board of Urology, ranging from 2004 to 2010. Chi-squared tests and logistic regression models were used to evaluate the association between surgeon characteristics (type of certification, annual volume, practice type, and practice location) and the use of incontinence procedures.
Results
Among 2,036 non-pediatric case logs examined, the number of incontinence treatments reported for certification has steadily increased over time (p = 0.008) from 1,936 to 3,366 treatments per year from 2004 to 2010. Nearly one-fifth of urologists reported placing at least one sling. The proportion of endoscopic procedures decreased from 80% of all incontinence procedures in 2004 to 60% in 2010, but they remained the exclusive incontinence procedure performed by 49% of urologists. An urologist’s increased usage of endoscopic treatments was associated with a decreased likelihood of performing a sling procedure (OR=0.5, p<0.0005). Artificial urinary sphincter usage remained stable accounting for 12% of procedures.
Conclusions
Incontinence procedures are on the rise. Urethral slings have been widely adopted and account for the largest increase among treatment modalities. Endoscopic treatments continue to be commonly performed and may represent over usage in the face of improved techniques. Further research is required to validate these trends.
Asymmetry can be a transient phenomenon. Patients with initial asymmetry can end up with significant asymmetry, and many with significant asymmetry can have catch-up growth. However, when patients have a peak retrograde flow of 38 cm per second or greater on duplex Doppler ultrasound in association with 20% or greater asymmetry spontaneous catch-up growth is unlikely to occur.
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