Board-certified Urologists Research Articles

Adult Anterior Urethral Strictures: A National Practice Patterns Survey of Board Certified Urologists in the United States

We determined the methods and patterns of the evaluation of and treatment for adult anterior urethral stricture disease by practicing urologists in the United States. A nationwide survey of practicing members of the American Urological Association was performed by a mailed questionnaire. A total of 1,262 urologists were randomly selected from all 50 states, of whom 431 (34%) completed the questionnaire. Most urologists (63%) treat 6 to 20 urethral strictures yearly. The most common procedures used by those surveyed for urethral strictures were dilation (92.8%), optical internal urethrotomy (85.6%) and endourethral stent (23.4%). Minimally invasive procedures are used more frequently that any open urethroplasty technique. Furthermore, most urologists (57.8%) do not perform urethroplasty surgery. When used, the most common urethroplasty surgeries performed were end-to-end anastomotic urethroplasty, perineal urethrostomy and ventral skin graft urethroplasty. Few urologists (4.2%) performed buccal mucosa grafts. For a long bulbar urethral stricture or short bulbar urethral stricture refractory to internal urethrotomy 20% to 29% of respondents would refer to another urologist, while 31% to 33% would continue to manage the stricture by minimally invasive means despite predictable failure. Of the urologists 74% believed that the literature supports a reconstructive surgical ladder, in which urethroplasty is only performed after repeat failure of endoscopic methods. Most urologists in the United States have little experience with urethroplasty surgery. Most urologists erroneously believe that the literature supports a reconstructive surgical ladder for urethral stricture management. Unfamiliarity with the literature and inexperience with urethroplasty surgery have made the use of endoscopic methods inappropriately common.

Treatment Choice and Quality of Care for Men With Localized Prostate Cancer

Variations in patterns of care and treatment outcomes suggest differences in the quality of care for men treated for localized prostate cancer. We sought to compare adherence with quality indicators for prostate cancer care among men treated with radical prostatectomy or external beam radiation therapy. We sampled 5230 men diagnosed in 2000 or 2001 with early-stage prostate cancer from 984 facilities reporting to the National Cancer Data Base. Our analytic cohort includes 2604 men (from 770 facilities) treated with radical prostatectomy or external beam radiation. Subject-level compliance with the RAND quality indicators for localized prostate cancer care, stratified by treatment. We applied sampling weights to obtain national estimates of quality indicator adherence. The weighted samples represent 24,547 and 27,125 men treated with radical prostatectomy or external beam radiation therapy, respectively. Compliance with several quality indicators approached 100% in both treatment groups; however treatment-specific variations were noted. Men receiving radiation were less likely than those undergoing surgery to be treated in facilities with a board-certified urologist (odds ratio [OR] = 0.4, 95% confidence interval [95% CI] = 0.2-0.8). Adherence with process of care indicators was appreciably higher among radiation subjects, including documentation of clinical stage (OR = 7.5, 95% CI = 4.8-11.9), pretherapy assessment of urinary (OR = 2.8, 95% CI = 1.9-4.2) and sexual (OR = 1.6, 95% CI = 1.2-2.2) function, and discussion of treatment options (OR = 1.8, 95% CI = 1.1-2.9). Documented compliance with process of care quality indicators among men with localized prostate cancer appears superior for those treated with external beam radiation compared with those treated surgically.

Adult Anterior Urethral Strictures: A National Practice Patterns Survey of Board Certified Urologists in the United States

Adult Anterior Urethral Strictures: A National Practice Patterns Survey of Board Certified Urologists in the United States

Interstitial cystitis and panic disorder: a potential genetic syndrome.

Evidence from a genetic linkage study had suggested a possible syndrome in some families with panic disorder (PD). This syndrome includes bladder problems (possibly urinary interstitial cystitis [IC]), thyroid disorders, chronic headaches/migraine, and/or mitral valve prolapse. In 19 multiplex families with PD, one marker (D13S779) on chromosome 13 gave a logarithm of odds score of more than 4 when individuals with any of the syndrome conditions were analyzed as affected. Families with the bladder problems yielded the highest logarithm of odds scores. These findings were replicated in an extended sample of 60 families. Whereas PD had been well characterized by direct interview, the urologic problems had been found only via medical history checklists and records. A case review by a board-certified urologist suggested they could be IC. To determine whether patients diagnosed as having IC by urodynamics and/or cystoscopy and their first-degree relatives (FDRs) have increased rates of the syndrome conditions, thus validating that the bladder problems observed in the linkage study could be IC and providing further support for the panic syndrome. Case-control and family history study. Two metropolitan urology clinics. One hundred forty-six probands (67 with IC and 79 with other urologic disorders) and 815 FDRs. Lifetime rates of syndrome conditions in probands and FDRs who were blind to urologic or psychiatric diagnoses in the proband. Compared with patients without IC, patients with IC had a significantly higher lifetime prevalence of PD (controlling for age and sex) (odds ratio, 4.05; 95% confidence interval, 1.22-13.40; P =.02) and a higher lifetime prevalence of any of the syndrome disorders (controlling for age and sex) (odds ratio, 2.22; 95% confidence interval, 0.89-5.54; P =.09). First-degree relatives of probands with (vs without) IC were significantly more likely to have PD, thyroid disorder, urologic problems, and any of the syndrome disorders (controlling for age and sex of the relative and sex of the proband) (adjusted odds ratio, 1.95; 95% confidence interval, 1.13-3.38; P =.02). These results in relatives were not influenced by PD in probands, and did not change substantially when controlling for the proband-relative relationship, modeling age as a categorical (vs continuous) variable, or excluding FDRs with PD. There were no interactions between proband IC status and sex of the relative. The increased frequency of seemingly disparate disorders in patients with IC and their FDRs is consistent with the genetic linkage findings in families with PD. These findings suggest that the bladder problems observed in the linkage study may be IC. The hypothesis that there is a familial, possibly pleiotropic, syndrome that may include IC, PD, thyroid disorders, and other disorders of possible autonomic or neuromuscular control deserves further investigation.

Role of IMRT in reducing penile doses in dose escalation for prostate cancer

Purpose: In three-dimensional conformal radiotherapy (3D-CRT), penile tissues adjacent to the prostate are exposed to significant doses of radiation. This is likely to be a factor in development of posttreatment erectile dysfunction. In this study, we investigate whether intensity-modulated radiation therapy (IMRT) leads to lower radiation exposure to proximal penile tissues (PPT) when compared with 3D-CRT. Methods and materials: Ten randomly selected patients with clinically localized prostate cancer constituted the study group. Using identical structure sets, 3D-CRT and IMRT plans were designed for each patient. For IMRT, both tomographic (TOMO) and step-and-shoot (SS) techniques were used. Treatment plans were developed using 18 MV photons for 3D-CRT, 6 MV photons for TOMO, and 6 MV and 18 MV photons for SS plans. The PPT up to the beginning of the penile shaft (usually measuring 2–3 cm) was outlined by a team composed of a board-certified urologist and a radiation oncologist. The outlined PPT was subdivided into three segments (P1, P2, P3), and the radiation dose to each segment and to the entire structure was calculated. In addition, PPT was subdivided into corporal cavernosa (CC) and corpus spongiosum (bulb). The prostate dose was escalated from 73.8 Gy to 81 Gy to 90 Gy. Target D 95 (dose to 95% volume), critical structure D 5 (dose to 5% volume), and D mean (mean dose) were used in the comparison among treatment plans. Because 3D-CRT uses larger field margins than does IMRT, target and critical structure doses were recalculated in 3D-CRT plans employing field margins obtained from IMRT plans. Planning target volumes in original and modified 3D-CRT plans were the same. Results: Compared with 3D-CRT plans, the mean PPT doses were reduced by 40.2%, 43.6%, and 46.2%, respectively, at the three prescription dose levels in TOMO plans. The average D mean for CC was lower by 46.4%, 48.4%, and 51.4%, whereas the average bulb D mean was reduced by 44.2%, 44.9%, and 47.9%, respectively. There was also considerable sparing of P1, with a reduction in average D mean of 41.9%, 45.5%, and 48.5% compared with 3D-CRT. All differences between 3D-CRT and IMRT doses were statistically significant ( p < 0.001). Similar improvements were noticed in maximum doses (D 5) for penile structures. The percent dose reduction with IMRT plans improved as prostate dose was escalated. When compared with 3D-CRT plans with reduced fields, IMRT plans showed slightly smaller but still significant improvements in critical structure doses ( p < 0.001). Compared with SS plans, TOMO plans produced improved sparing of dose to critical structures. Conclusions: IMRT allows for dose escalation in prostate cancer while keeping penile tissue doses significantly lower compared to conformal radiotherapy. This may result in improved potency rates over current results observed with 3D-CRT.

Prospective comparison of hand-assisted laparoscopic devices

Objectives. To evaluate and compare the three commercially available first-generation hand-assisted laparoscopic (HAL) devices in a prospective, randomized fashion. HAL nephrectomy has become an increasingly popular surgical modality. Methods. Sixty-seven board-certified urologists each performed two HAL nephrectomies in a porcine laboratory, using two different hand devices, at a learning course sponsored by the American Urological Association. At the completion of the laboratory session, each surgeon was asked to complete a 12-question survey designed to evaluate the different hand-assist devices. Results. Thirty-nine surgeons used the HandPort, 47 used the Intromit, and 47 used the Pneumosleeve. No statistical differences were found in the ratings among the three devices within any category. No device scored better than 8.1 in any category, and the overall satisfaction was less than 7.7 in all three groups. Although not statistically significant, the Intromit device had the highest ratings in the following categories: instructions, maintenance of pneumoperitoneum, exchange of laparotomy pads, retrieval of specimens, sturdiness, and overall satisfaction. The HandPort had the highest failure rate. Conclusions. HAL relies heavily on devices that allow the hand to be introduced into the laparoscopic environment. The three available devices are all effective, yet each have their specific advantages and disadvantages. In terms of overall satisfaction, no device scored greater than 7.7. The results of this study suggest that the need for improvement by all three manufacturers is significant and have helped to better identify these areas.

Early Experience with the First Pre-connected 3-Piece Inflatable Penile Prosthesis: The Mentor Alpha-1

The aim of this clinical investigation was to obtain preliminary treatment outcome data concerning the Mentor Alpha-1, the first 3-piece inflatable penile prosthesis with pre-connected tubing between the pump and the penile cylinders. The study was designed to be the first multi-institutional treatment outcome report for any clinically available penile prosthesis with data analysis to be independent of the participating surgeons. A total of 12 board-certified urologists of mixed surgical training backgrounds and practices implanted the Alpha-1 device in 112 consecutive patients. With a mean of 27 ± 5 months of followup the surgical complication rate included a 4% mechanical malfunction, 2% infection rate and 9% reoperation rate. Patient experience with the implanted device was computed from information on 96 of the 112 patients who returned a questionnaire. Of the patients 82% stated that the device fulfilled expectations as a treatment for impotence and 83% had improved sexual intercourse by 8 weeks after implantation. Patient satisfaction was computed on a scale of 12 equally weighted interrelated variables. Of the patients 77% recorded 9 or more cumulative satisfaction points. Patient and physician questionnaire data were analyzed for their relation to the cumulative prosthesis satisfaction score. A significant difference in cumulative scores was found for physician reported long-term postoperative problems (mean satisfaction score 8.1 for patients with problems versus 10.2 for patients without problems, p = 0.018). The Alpha-1, with its feature of pre-connected tubing, is a reliable 3-piece inflatable penile prosthesis associated with a high level of patient satisfaction.

Surgical and Urologic Manpower in the United States, 1969 to 1978

Between 1969 and 1978 the number of board-certified urologists increased by 71 per cent, while the population of the United States increased by 8.2 per cent. In 1978 the ratio of board-certified urologists to population was 1:32,416 and 326 of 370 first-year residency positions available in urology in the United States were filled. If we continue to produce urologists at the present rate the urologist to population ratio will be approximately 1:25,972 by year 2000. Thus, it appears that there are now too many urologists being trained yearly, which was indicated by 68 per cent of the academic program directors surveyed in 1979. In fact, to restore the ratio of urologist to population approximating 1:35,000 by year 2000 the number of urologists being trained yearly should be reduced to 156 or by approximately 50 per cent. The only reasonable chance of achieving a reduction in urologists being trained in the near future is by voluntary decreases in the size of training programs. There are many consequences of overproduction of urologists, including unnecessary surgery, atrophy of skills among practitioners and diminution of major training programs because of lack of patient referrals. Therefore, this issue is of equal importance to private practitioners and to academicians.