Publications by authors named "David S Aaronson"

39 Publications

Catheter Balloon-trauma: Design, Development, and Ex-vivo Studies Using Intact Human Penis Specimens.

Urology 2020 Dec 1;146:287-292. Epub 2020 Sep 1.

Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Urology, University of California San Francisco; San Francisco, CA; Department of Anatomy, University of California San Francisco; San Francisco, CA. Electronic address:

Objective: To present a novel urethral catheter design with a pilot balloon to reduce intraurethral retention balloon inflation pressures and to provide a visual alert during catheter placement.

Methods: We manufactured our pilot balloon prototype from both molded and extruded silicone components. Various pilot balloon thicknesses were tested in order to determine the ideal compliance. We studied the filling pressures of the retention balloon of our prototype in a mechanical urethral model. The prototype catheter was then tested in ex-vivo human penis specimens obtained from gender affirming surgery and changes in the size of the retention balloon were measured under fluoroscopy.

Results: The thickness of the pilot balloon was directly related to the inflation pressure of the retention balloon in the mechanical urethral model. The thickness chosen for the pilot balloon in our prototype was based on a retention balloon pressure of 70 kPa. In the ex-vivo human penis model, the presence of the pilot balloon resulted in a 40% reduction in the cross-sectional area of the retention balloon compared to a standard urinary catheter.

Conclusion: The prototype urinary catheter appears to decrease the filling pressure and size of an improperly positioned retention balloon inside a urethra. This can potentially reduce the risk of iatrogenic urethral catheter injuries. In addition, the prototype urinary catheter may act as a visual warning sign for the healthcare practitioner.
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http://dx.doi.org/10.1016/j.urology.2020.08.035DOI Listing
December 2020

Tighter Blood Pressure Control Is Associated with Lower Incidence of Erectile Dysfunction in Hypertensive Men.

J Sex Med 2019 03;16(3):410-417

Department of Urology, Kaiser Permanente, Oakland Medical Center, Oakland, CA, USA.

Introduction: Tighter blood pressure control is widely thought to be associated with better erectile function, although the preponderance of data is limited to dichotomous representations of hypertension without an attempt to look at degree of blood pressure control.

Aim: To determine the association between optimal blood pressure control over time and the development of erectile dysfunction (ED) in a cohort of potent men.

Methods: We performed a retrospective cohort study of newly diagnosed hypertensive men without major medical comorbidities in an integrated healthcare system. Patients were stratified by exposure to hypertension, with varying levels of blood pressure control, as measured by ordinal categories of systolic blood pressure and deviation from the mean systolic pressure.

Main Outcome Measures: Incidence of ED was defined by at least 2 primary care or urology diagnoses of ED in our electronic health records within 2 years, at least 2 filled prescriptions for ED medications within 2 years, or 1 diagnosis of ED and 2 filled prescriptions for ED medications.

Results: We identified 39,320 newly diagnosed hypertensive men. The overall incidence for ED was 13.9%, with a mean follow-up of 55.1 ± 28.7 months. Higher average systolic blood pressure was associated with a higher risk of ED in a dose-dependent manner (trend test, P < .001). Wide variation in blood pressure control was associated with a higher incidence of ED (OR [95% CI]; 1.359 [1.258-1.469]) and a shorter time to the development of ED (log rank, P < .0001).

Clinical Implications: We believe these data may serve as a motivator for hypertensive men to better adhere to their hypertension treatment regimen.

Strength & Limitations: The retrospective nature of our study precludes us from drawing more than an association between tighter blood pressure control and ED. Strengths of our study include the large sample size, community cohort, and completeness of follow-up.

Conclusion: Among adults diagnosed with hypertension, tighter blood pressure control, as measured by average systolic blood pressure and deviation from the average, is associated with a lower incidence and a longer time to the development of ED. Hsiao W, Bertsch RA, Hung Y-Y, et al. Tighter Blood Pressure Control Is Associated with Lower Incidence of Erectile Dysfunction in Hypertensive Men. J Sex Med 2019;16:410-417.
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http://dx.doi.org/10.1016/j.jsxm.2019.01.011DOI Listing
March 2019

AUTHOR REPLY.

Urology 2019 03;125:229

Kaiser Permanente Center for Health Research, Portland, OR.

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http://dx.doi.org/10.1016/j.urology.2018.11.023DOI Listing
March 2019

The Be-Well Study: a prospective cohort study of lifestyle and genetic factors to reduce the risk of recurrence and progression of non-muscle-invasive bladder cancer.

Cancer Causes Control 2019 Feb 17;30(2):187-193. Epub 2019 Jan 17.

Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA.

Purpose: Bladder cancer is one of the top five cancers diagnosed in the U.S. with a high recurrence rate, and also one of the most expensive cancers to treat over the life-course. However, there are few observational, prospective studies of bladder cancer survivors.

Methods: The Bladder Cancer Epidemiology, Wellness, and Lifestyle Study (Be-Well Study) is a National Cancer Institute-funded, multi-center prospective cohort study of non-muscle-invasive bladder cancer (NMIBC) patients (Stage Ta, T1, Tis) enrolled from the Kaiser Permanente Northern California (KPNC) and Southern California (KPSC) health care systems, with genotyping and biomarker assays performed at Roswell Park Comprehensive Cancer Center. The goal is to investigate diet and lifestyle factors in recurrence and progression of NMIBC, with genetic profiles considered, and to build a resource for future NMIBC studies.

Results: Recruitment began in February 2015. As of 30 June 2018, 1,281 patients completed the baseline interview (774 KPNC, 511 KPSC) with a recruitment rate of 54%, of whom 77% were male and 23% female, and 80% White, 6% Black, 8% Hispanic, 5% Asian, and 2% other race/ethnicity. Most patients were diagnosed with Ta (69%) or T1 (27%) tumors. Urine and blood specimens were collected from 67% and 73% of consented patients at baseline, respectively. To date, 599 and 261 patients have completed the 12- and 24-month follow-up questionnaires, respectively, with additional urine and saliva collection.

Conclusions: The Be-Well Study will be able to answer novel questions related to diet, other lifestyle, and genetic factors and their relationship to recurrence and progression among early-stage bladder cancer patients.
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http://dx.doi.org/10.1007/s10552-019-1130-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422041PMC
February 2019

Factors That Influence Selectionof Urinary Diversion Among Bladder Cancer Patients in 3 Community-based Integrated Health Care Systems.

Urology 2019 03 22;125:222-229. Epub 2018 Nov 22.

Kaiser Permanente Center for Health Research, Portland, OR.

Objective: To assess the relative contributions of patient and surgeon factors for predicting selection of ileal conduit (IC), neobladder (NB), or continent pouch (CP) urinary diversions (UD) for patients diagnosed with muscle-invasive/high-risk nonmuscle invasive bladder cancer. This information is needed to enhance research comparing cancer survivors' outcomes across different surgical treatment options.

Methods: Bladder cancer patients' age ≥21 years with cystectomy/UD performed from January 2010 to June 2015 in 3 Kaiser Permanente regions were included. All patient and surgeon data were obtained from electronic health records. A mixed effects logistic regression model was used treating surgeon as a random effect and region as a fixed effect.

Results: Of 991 eligible patients, 794 (80%) received IC. One hundred sixty-nine surgeons performed the surgeries and accounted for a sizeable proportion of the variability in patient receipt of UD (intraclass correlation coefficient = 0.26). The multilevel model with only patient factors showed good fit (area under the curve = 0.93, Hosmer-Lemeshow test P = .44), and older age, female sex, estimated glomerular filtration rate <45, 4+ comorbidity index score, and stage III/IV tumors were associated with higher odds of receiving an IC vs neobladder/continent pouch. However, including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) had no association (P = .29).

Conclusion: In this community setting, patient factors were major predictors of UD received. Surgeons also played a substantial role, yet clinical training and experience were not major predictors. Surgeon factors such as beliefs about UD options and outcomes should be explored.
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http://dx.doi.org/10.1016/j.urology.2018.09.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6389399PMC
March 2019

Perioperative Intravesical Chemotherapy for Patients WithNon-Muscle-invasive Bladder Cancer: Understanding the Extent of and Sources of Variation in Guideline-recommended Use.

Urology 2019 02 23;124:107-112. Epub 2018 Oct 23.

Kaiser Permanente Northern California Division of Research, Oakland, CA.

Objective: To examine intravesical chemotherapy (IVC) use according to non-muscle-invasive bladder cancer patient disease risk, and the contributions of multilevel factors to variation in proficient use among patients with low-intermediate disease.

Methods: This study included 988 patients diagnosed with non-muscle-invasive bladder cancer in an integrated health system in Northern California from 2015-2017. We calculated IVC receipt by disease risk, and among patients with low-intermediate risk disease, assessed the relationship between multilevel factors and IVC receipt using a logistic regression model with random intercepts for provider and service area, and patient-, provider-, and service area-level fixed effects. We further assessed the association of provider- and service area-level factors with IVC use by examining intraclass correlation coefficients.

Results: Similar proportions of low-intermediate (36%) and high-risk (34%) patients received IVC. In the multivariate analysis, including low-intermediate risk patients, service area volume was strongly and statistically significantly associated with IVC use (adjusted odds ratio, high- vs low-volume: 0.08, 95% Confidence Interval: 0.01-0.58). Provider- and service area-level intraclass correlation coefficients were large, (38%, P = .0009 and 39% P = .03, respectively) indicating that much of the variance in IVC use was explained by factors at these levels.

Conclusion: Our findings highlight opportunities to improve proficient use of IVC. Future research should assess provider- and practice-level barriers to IVC use among low-intermediate risk patients.
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http://dx.doi.org/10.1016/j.urology.2018.10.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202079PMC
February 2019

The Use of 5-Alpha Reductase Inhibitors to Manage Benign Prostatic Hyperplasia and the Risk of All-cause Mortality.

Urology 2018 Sep 12;119:70-78. Epub 2018 Jun 12.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA, CA.

Objective: To compare the risk of mortality among men treated for benign prostatic hyperplasia (BPH) with 5 alpha-reductase inhibitors (5ARI) to those treated with alpha-blockers (AB) in community practice settings.

Methods: We employed a retrospective matched cohort study in 4 regions of an integrated healthcare system. Men aged 50 years and older who initiated pharmaceutical treatment for BPH and/or lower urinary tract symptoms between 1992 and 2008 and had at least 3 consecutive prescriptions that were eligible and followed through 2010 (N = 174,895). Adjusted hazard ratios were used to estimate the risk of mortality due to all-causes associated with 5ARI use (with or without concomitant ABs) as compared to AB use.

Results: In this large and diverse sample with 543,523 person-years of follow-up, 35,266 men died during the study period, 18.9% of the 5ARI users and 20.4% of the AB users. After adjustment for age, medication initiation year, race, region, prior AB history, Charlson score, and comorbidities, 5ARI use was not associated with an increased risk of mortality when compared to AB use (Adjusted hazard ratios: 0.64, 95% confidence interval: 0.62, 0.66).

Conclusion: Among men receiving medications for BPH in community practice settings, 5ARI use was not associated with an increased risk of mortality when compared to AB use. These data provide reassurance about the safety of using 5ARIs in general practice to manage BPH and/or lower urinary tract symptoms.
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http://dx.doi.org/10.1016/j.urology.2018.05.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080272PMC
September 2018

Quality of life among men with low-risk prostate cancer during the first year following diagnosis: the PREPARE prospective cohort study.

Transl Behav Med 2018 03;8(2):156-165

Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.

As many as 40% of men diagnosed with prostate cancer have low-risk disease, which results in the need to decide whether to undergo active treatment (AT) or active surveillance (AS). The treatment decision can have a significant effect on general and prostate-specific quality of life (QOL). The purpose of this study was to assess the QOL among men with low-risk prostate cancer during the first year following diagnosis. In a prospective cohort study, we conducted pretreatment telephone interviews (N = 1,139; 69.3% response rate) with low-risk PCa patients (PSA ≤ 10, Gleason ≤ 6) and a follow-up assessment 6-10 months postdiagnosis (N = 1057; 93%). We assessed general depression, anxiety, and physical functioning, prostate-specific anxiety, and prostate-specific QOL at both interviews. Clinical variables were obtained from the medical record. Men were 61.7 (SD = 7.2) years old, 82% white, 39% had undergone AT (surgery or radiation), and 61.0% had begun AS. Linear regression analyses revealed that at follow-up, the AS group reported significantly better sexual, bowel, urinary, and general physical function (compared to AT), and no difference in depression. However, the AS group did report greater general anxiety and prostate-specific anxiety at follow-up, compared to AT. Among men with low-risk PCa, adjusting for pretreatment functioning, the AS group reported better prostate-related QOL, but were worse off on general and prostate-specific anxiety compared to men on AT. These results suggest that, within the first year postdiagnosis, men who did not undergo AT may require additional support in order to remain comfortable with this decision and to continue with AS when it is clinically indicated.
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http://dx.doi.org/10.1093/tbm/ibx005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6256951PMC
March 2018

Physicians' perspectives on the informational needs of low-risk prostate cancer patients.

Health Educ Res 2017 04;32(2):134-152

Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA.

Despite the evidence indicating that decision aids (DA) improve informed treatment decision making for prostate cancer (PCa), physicians do not routinely recommend DAs to their patients. We conducted semi-structured interviews with urologists (n = 11), radiation oncologists (n = 12) and primary care physicians (n = 10) about their methods of educating low-risk PCa patients regarding the treatment decision, their concerns about recommending DAs, and the essential content and format considerations that need to be addressed. Physicians stressed the need for providing comprehensive patient education before the treatment decision is made and expressed concern about the current unevaluated information available on the Internet. They made recommendations for a DA that is brief, applicable to diverse populations, and that fully discloses all treatment options (including active surveillance) and their potential side effects. Echoing previous studies showing that low-risk PCa patients are making rapid and potentially uninformed treatment decisions, these results highlight the importance of providing patient education early in the decision-making process. This need may be fulfilled by a treatment DA, should physicians systematically recommend DAs to their patients. Physicians' recommendations for the inclusion of particular content and presentation methods will be important for designing a high quality DA that will be used in clinical practice.
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http://dx.doi.org/10.1093/her/cyx035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914350PMC
April 2017

5-Alpha Reductase Inhibitors and the Risk of Prostate Cancer Mortality in Men Treated for Benign Prostatic Hyperplasia.

Mayo Clin Proc 2016 Dec 27;91(12):1717-1726. Epub 2016 Oct 27.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.

Objective: To compare the risk of prostate cancer mortality among men treated with 5- alpha reductase inhibitors (5-ARIs) with those treated with alpha-adrenergic blockers (ABs) in community practice settings.

Patients And Methods: A retrospective matched cohort (N=174,895) and nested case-control study (N=18,311) were conducted in 4 regions of an integrated health care system. Men 50 years and older who initiated pharmaceutical treatment for benign prostatic hyperplasia between January 1, 1992, and December 31, 2007, and had at least 3 consecutive prescriptions were followed through December 31, 2010. Adjusted subdistribution hazard ratios, accounting for competing risks of death, and matched odds ratios were used to estimate prostate cancer mortality associated with 5-ARI use (with or without concomitant ABs) as compared with AB use.

Results: In the cohort study, 1,053 men died of prostate cancer (mean follow-up, 3 years), 15% among 5-ARI users (N= 25,388) and 85% among AB users (N=149,507) (unadjusted mortality rate ratio, 0.80). After accounting for competing risks, it was found that 5-ARI use was not associated with prostate cancer mortality when compared with AB use (adjusted subdistribution hazard ratio, 0.85; 95% CI, 0.72-1.01). Similar results were observed in the case-control study (adjusted matched odds ratio, 0.95; 95% CI, 0.78-1.17).

Conclusion: Among men being pharmaceutically treated for benign prostatic hyperplasia, 5-ARI use was not associated with an increased risk of prostate cancer-specific mortality when compared with AB use. The increased prevalence of high-grade lesions at the time of diagnosis noted in our study and the chemoprevention trials may not result in increased prostate cancer mortality.
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http://dx.doi.org/10.1016/j.mayocp.2016.07.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080281PMC
December 2016

Mortality and Androgen Deprivation Therapy as Salvage Treatment for Biochemical Recurrence after Primary Therapy for Clinically Localized Prostate Cancer.

J Urol 2017 06 19;197(6):1448-1454. Epub 2016 Dec 19.

Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, D.C.

Purpose: Androgen deprivation therapy is often used as salvage treatment in men with rising prostate specific antigen after initial radical prostatectomy or radiotherapy for clinically localized prostate cancer. Given the lack of evidence from general practice, we examined the association of salvage androgen deprivation therapy with mortality in an observational cohort study.

Materials And Methods: From 3 managed care organizations we assembled a retrospective cohort of all 5,804 men with newly diagnosed localized prostate cancer from 1995 to 2009 who had a prostate specific antigen increase (biochemical recurrence) after primary radical prostatectomy or radiotherapy. The main outcomes were all-cause and prostate cancer specific mortality. We used Cox proportional hazards models to estimate mortality with salvage androgen deprivation therapy as a time dependent predictor.

Results: Overall salvage androgen deprivation therapy was not associated with all-cause or prostate cancer specific mortality in the prostatectomy cohort (HR 0.97, 95% CI 0.70-1.35 or HR 1.18, 95% CI 0.68-2.07) or in the radiotherapy cohort (HR 0.84, 95% CI 0.70-1.01 or HR 1.06, 95% CI 0.80-1.40, respectively). Among men with prostate specific antigen doubling time less than 9 months after the prostate specific antigen rise, salvage androgen deprivation therapy was statistically significantly associated with a decreased risk of all-cause and prostate cancer specific mortality in the prostatectomy cohort (HR 0.35, 95% CI 0.20-0.63 and HR 0.43, 95% CI 0.21-0.91) and in the radiotherapy cohort (HR 0.62, 95% CI 0.48-0.80 and HR 0.65, 95% CI 0.47-0.90, respectively).

Conclusions: We found no association of salvage androgen deprivation therapy with all-cause or cause specific mortality in most men with biochemical recurrence after primary radical prostatectomy or radiotherapy for clinically localized prostate cancer. Men with quickly progressed disease may derive a clinical benefit from salvage androgen deprivation therapy.
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http://dx.doi.org/10.1016/j.juro.2016.12.086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5433922PMC
June 2017

Sociodemographic and Clinical Predictors of Switching to Active Treatment among a Large, Ethnically Diverse Cohort of Men with Low Risk Prostate Cancer on Observational Management.

J Urol 2016 Sep 14;196(3):734-40. Epub 2016 Apr 14.

Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, D.C.

Purpose: We determined the clinical and sociodemographic predictors of beginning active treatment in an ethnically diverse population of men with low risk prostate cancer initially on observational treatment.

Materials And Methods: We retrospectively studied men diagnosed with low risk prostate cancer between 2004 and 2012 at Kaiser Permanente Northern California who did not receive any treatment within the first year of diagnosis and had at least 2 years of followup. We used Cox proportional hazards regression models to determine factors associated with time from diagnosis to active treatment.

Results: We identified 2,228 eligible men who were initially on observation, of whom 27% began active treatment during followup at a median of 2.9 years. NonHispanic black men were marginally more likely to begin active treatment than nonHispanic white men independent of baseline and followup clinical measures (HR 1.3, 95% CI 1.0-1.7). Among men who remained on observation nonHispanic black men were rebiopsied within 24 months of diagnosis at a slightly lower rate than nonHispanic white men (HR 0.70, 95% CI 0.6-1.0). Gleason grade progression (HR 3.3, 95% CI 2.7-4.1) and PSA doubling time less than 48 months (HR 2.9, 95% CI 2.3-3.7) were associated with initiation of active treatment independent of race.

Conclusions: Sociodemographic factors such as ethnicity and education may independently influence the patient decision to pursue active treatment and serial biopsies during active surveillance. These factors are important for further studies of prostate cancer treatment decision making.
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http://dx.doi.org/10.1016/j.juro.2016.04.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5094279PMC
September 2016

Use of androgen deprivation therapy as salvage treatment after primary therapy for clinically localized prostate cancer.

World J Urol 2016 Dec 15;34(12):1611-1619. Epub 2016 Apr 15.

Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA.

Purpose: The optimal use of androgen deprivation therapy as salvage treatment (sADT) for men after initial prostatectomy or radiotherapy for clinically localized prostate cancer is undefined. We describe patterns of sADT use and investigate clinical and sociodemographic characteristics of insured men who received sADT versus surveillance in managed care settings.

Methods: Using comprehensive electronic health records and cancer registry data from three integrated health plans, we identified all men with newly diagnosed clinically localized prostate cancer between 1995 and 2009 who received either prostatectomy (n = 16,445) or radiotherapy (n = 19,531) as their primary therapy. We defined sADT based on the timing of ADT following primary therapy and stage of cancer. We fit Cox proportional hazard models to identify sociodemographic characteristics and clinical factors associated with sADT.

Results: With a median follow-up of 6 years (range 2-15 years), 13 % of men who underwent primary prostatectomy or radiotherapy received sADT. After adjusting for selected covariates, sADT was more likely to be used in men who were older (e.g., HR 1.70, 95 % CI 1.48-1.96 or HR 1.33, 95 % CI 1.17-1.52 for age 70+ relative to age 35-59 for primary prostatectomy or radiotherapy, respectively), were African-American, had a short PSA doubling time, had a higher pre-treatment risk of progression, had more comorbidities, and received adjuvant ADT for initial disease.

Conclusions: In men with localized prostate cancer in community practice initially treated with prostatectomy or radiotherapy, sADT after primary treatment was more frequent for men at greater risk of death from prostate cancer, consistent with practice guidelines.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5065786PMC
http://dx.doi.org/10.1007/s00345-016-1823-5DOI Listing
December 2016

National incidence and outcomes of postoperative urinary retention in the Surgical Care Improvement Project.

Am J Surg 2012 Aug 3;204(2):167-71. Epub 2012 May 3.

Department of Urology, University of California San Francisco, San Francisco, CA, USA.

Background: The national incidence of postoperative urinary retention (POUR), its risk factors, and associated outcomes are not well understood.

Methods: We identified patients undergoing one of the Surgical Care Improvement Project surgeries using the National Inpatient Sample. By using International Classification of Diseases, 9th revision, Clinical Modification codes (ICD-9-CM), we identified POUR and the outcomes urinary tract infection, noninfectious catheter-related complications, length of stay, and posthospitalization care. Multivariable analysis identified predictors of POUR and its associated outcomes.

Results: A total of 415,409 patients, representing 2,077,045 nationally, underwent one of the Surgical Care Improvement Project procedures with 43,030 (2.1%) developing POUR. Age, sex, type of surgery, and medical comorbidities were predictive of POUR with a .71 area under the curve. Patients with POUR had greater odds of having urinary tract infections (odds ratio [OR], 2.3; 95% confidence interval [CI], 2.2-2.5), suffering catheter-related complications (OR, 5.2; 95% CI, 3.8-7.0), and needing additional posthospitalization care (OR, 1.3; 95% CI, 1.25-1.4), and they had a greater length of stay (.24 extra days).

Conclusions: Patients at risk for POUR can be identified, and they may benefit from interventions to prevent POUR.
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http://dx.doi.org/10.1016/j.amjsurg.2011.11.012DOI Listing
August 2012

Prediction of hospital acute myocardial infarction and heart failure 30-day mortality rates using publicly reported performance measures.

J Healthc Qual 2013 Mar-Apr;35(2):15-23. Epub 2011 Nov 11.

University of California, San Francisco, CA, USA.

Objective: To identify an approach to summarizing publicly reported hospital performance data for acute myocardial infarction (AMI) or heart failure (HF) that best predicts current year hospital mortality rates.

Setting: A total of 1,868 U.S. hospitals reporting process and outcome measures for AMI and HF to the Centers for Medicare and Medicaid Services (CMS) from July 2005 to June 2006 (Year 0) and July 2006 to June 2007 (Year 1).

Design: Observational cohort study measuring the percentage variation in Year 1 hospital 30-day risk-adjusted mortality rate explained by denominator-based weighted composite scores summarizing hospital Year 0 performance.

Data Collection: Data were prospectively collected from hospitalcompare.gov.

Results: Percentage variation in Year 1 mortality was best explained by mortality rate alone in Year 0 over other composites including process performance. If only Year 0 mortality rates were reported, and consumers using hospitals in the highest decile of mortality instead chose hospitals in the lowest decile of mortality rate, the number of deaths at 30 days that potentially could have been avoided was 1.31 per 100 patients for AMI and 2.12 for HF (p < .001).

Conclusion: Public reports focused on 30-day risk-adjusted mortality rate may more directly address policymakers' goals of facilitating consumer identification of hospitals with better outcomes.
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http://dx.doi.org/10.1111/j.1945-1474.2011.00173.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4096998PMC
January 2014

Safer urethral catheters: how study of catheter balloon pressure and force can guide design.

BJU Int 2012 Apr 22;109(7):1110-4. Epub 2011 Aug 22.

Department of Urology, University of California, San Francisco, CA 94143-0320, USA.

Objectives: To better define urethral catheter balloon pressures and extraction forces during traumatic placement and removal of urethral catheters. To help guide design for safer urethral catheters.

Materials And Methods: Measurements of balloon pressure were made upon filling within the urethra vs the bladder. Extraction forces were measured upon removal of a catheter with a filled balloon from the bladder. Models for the bladder and urethra included an ex vivo model (funnel, 'bladder', attached to a 30 F tube, 'urethra') and fresh human male cadavers. The mean (SEM) balloon pressures and extraction forces were calculated.

Results: In the ex vivo model, the mean (SEM) pressures upon filling the balloon with 10 mL were on average three-times higher within the ex vivo'urethra' (177 [6] kPa) vs 'bladder' (59 [2] kPa) across multiple catheter types. In the human cadaver, the mean balloon pressure was 1.9-times higher within the urethra (139 [11] kPa) vs bladder (68 [4] kPa). Balloon pressure increased non-linearly during intraurethral filling of both models, resulting in either balloon rupture (silicone catheters) or 'ballooning' of the neck of the balloon filling port (latex catheters). Removal of a filled balloon per the ex vivo model 'urethra' and cadaveric urethra, similarly required increasing force with greater balloon fill volumes (e.g. 9.34 [0.44] N for 5 mL vs 41.37 [8.01] N for 10 mL balloon volume).

Conclusions: Iatrogenic complications from improper urethral catheter use is common. Catheter balloon pressures and manual extraction forces associated with urethral injury are significantly greater than those found with normal use. The differences in pressure and force may be incorporated into a safer urethral catheter design, which may significantly reduce iatrogenic urethral injury associated with catheterization.
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http://dx.doi.org/10.1111/j.1464-410X.2011.10510.xDOI Listing
April 2012

Use of Google Insights for Search to track seasonal and geographic kidney stone incidence in the United States.

Urology 2011 Aug 3;78(2):267-71. Epub 2011 Apr 3.

Department of Urology, University of California, San Francisco, CA 94143, USA.

Objective: To determine whether Internet search volume for kidney stones has seasonal and geographic distributions similar to known kidney stone incidence.

Material And Methods: Google Insights for Search analyzes a portion of Google web searches from all Google domains to compute how many searches are performed for a given term relative to the total number of searches done over a specific time interval and geographic region. Selected terms related to kidney stones were examined to determine which most closely tracked kidney stone incidence. Google Insights for Search data were correlated with hospital admissions for the emergent treatment of nephrolithiasis found through the Nationwide Inpatient Sample. Ambient temperature in Seattle and New York were compared with search volume for these regions to display qualitative relationships.

Results: The term "kidney stones" had the highest seasonal correlation of terms examined (r = .81, P = .0014). Google Insights for Search output and national Inpatient Sample admissions also correlated when regions were compared (r = .90, P = .005). Qualitative relationships between ambient temperatures and kidney stone search volume do exist.

Conclusions: Internet search volume activity for kidney stones correlates with temporal and regional kidney stone insurance claims data. In the future, with improved modeling of search detection algorithms and increased Internet usage, search volume has the potential to serve as a surrogate for kidney stone incidence.
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http://dx.doi.org/10.1016/j.urology.2011.01.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4551459PMC
August 2011

National incidence and impact of noninfectious urethral catheter related complications on the Surgical Care Improvement Project.

J Urol 2011 May 21;185(5):1756-60. Epub 2011 Mar 21.

Department of Urology, University of California San Francisco, San Francisco, California, USA.

Purpose: We defined the incidence and health outcomes related impact of noninfectious urethral catheter related complications for the 7 surgical procedures monitored by the Joint Commission as part of the Surgical Care Improvement Project.

Materials And Methods: We performed a cross-sectional analysis of the 2007 National Inpatient Sample (a 20% stratified sampling of nonfederal United States hospitals) using ICD-9-CM procedure and diagnostic codes to identify the incidence of catheter related complications for coronary artery bypass graft, and noncoronary artery bypass graft cardiac surgery, hysterectomy, colon, hip, knee and major vascular surgery. Univariate and multivariate analysis (with a significance level of less than 0.05) was performed to determine if these complications were associated with length of stay, urinary tract infections and/or deaths.

Results: A total of 1,420 cases of catheter related complications were identified nationally. The incidence of catheter related complications varied by surgical procedure (average 1 in 528 men and 1 in 5,217 women for all procedures). Univariate analysis revealed that in the presence of catheter related complications, mean length of stay (6 of 7 procedures, range 1.5 to 3.0 days, p <0.05) and urinary tract infection (5 of 7 procedures, absolute range 6.9% to 11.8%, p <0.05) were statistically increased for most procedures. Multivariate analysis demonstrated a significant association between catheter related complications, and increased length of stay (range 1.5 to 3.5 days, p <0.05) and urinary tract infection (OR 2.4-6.8, p <0.05) for 5 and 6 of 7 procedure types, respectively, but not mortality rate (0 of 7 procedures).

Conclusions: Catheter related complications are reported rarely, but are associated with increased length of stay and urinary tract infection rates for patients in the Surgical Care Improvement Project.
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http://dx.doi.org/10.1016/j.juro.2010.12.041DOI Listing
May 2011

Complications rates of non-oncologic urologic procedures in population-based data: a comparison to published series.

Int Braz J Urol 2010 Sep-Oct;36(5):548-56

Department of Urology, University of California San Francisco, San Francisco, CA 94117 , USA.

Purpose: Published single institutional case series are often performed by one or more surgeons with considerable expertise in specific procedures. The reported incidence of complications in these series may not accurately reflect community-based practice. We sought to compare complication and mortality rates following urologic procedures derived from population-based data to those of published single-institutional case series.

Materials And Methods: In-hospital mortality and complications of common urologic procedures (percutaneous nephrostomy, ureteropelvic junction obstruction repair, ureteroneocystostomy, urethral repair, artificial urethral sphincter implantation, urethral suspension, transurethral resection of the prostate, and penile prosthesis implantation) reported in the U.S.'s National Inpatient Sample of the Healthcare Cost and Utilization Project were identified. Rates were then compared to those of published single-institution series using statistical analysis.

Results: For 7 of the 8 procedures examined, there was no significant difference in rates of complication or mortality between published studies and our population-based data. However, for percutaneous nephrostomy, two published single-center series had significantly lower mortality rates (p < 0.001). The overall rate of complications in the population-based data was higher than published single or select multi-institutional data for percutaneous nephrostomy performed for urinary obstruction (p < 0.001).

Conclusions: If one assumes that administrative data does not suffer from under reporting of complications then for some common urological procedures, complication rates between population-based data and published case series seem comparable. Endorsement of mandatory collection of clinical outcomes is likely the best way to appropriately counsel patients about the risks of these common urologic procedures.
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http://dx.doi.org/10.1590/s1677-55382010000500004DOI Listing
August 2011

Selective arterial embolization of angiomyolipoma leading to pulmonary hypertension.

Can J Urol 2010 Jun;17(3):5232-5

Department of Urology, University of California, San Francisco, California 94110, USA.

Objectives: To report two cases of secondary pulmonary hypertension resulting from microsphere extravasation following selective arterial embolization of renal angiomyolipoma, its diagnosis, and management.

Methods: We reviewed the cases of two patients at the University of California, San Francisco, treated with selective arterial embolization for management of their angiomyolipoma (AML) using Tris-Acryl Gelatin Microspheres.

Results: Both patients were women, ages 51 and 77. Indications for treatment were the following: Patient 1 was treated for a large asymptomatic AML. Patient 2 was treated for a symptomatic, bleeding AML. Both patients developed progressive hypoxia following selective arterial embolization using Tris-Acryl Gelatin Microspheres. Each patient underwent a subsequent work up including a CT chest, echocardiogram, and chest x-ray. Both demonstrated significant pulmonary hypertension following their procedure and were discharged with supplemental oxygen.

Conclusions: Selective arterial embolization of AML with microsphere extravasation into the pulmonary vasculature can lead to pulmonary hypertension and hypoxemia.
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June 2010

Squamous cell carcinoma at the site of a Prince Albert's piercing.

J Sex Med 2010 Jun 19;7(6):2280-2283. Epub 2010 Apr 19.

Urology, University of California School of Medicine, San Francisco, CA, USA.

Introduction: Medical practitioners should be aware of genital piercing and its potential complications. General piercings are associate with complications common to all piercings as well as some unique to urethral piercings. Specifically, the association between carcinoma and genital piercing is not well recognized.

Aim: The present study is a report of two cases describing squamous cell carcinoma associated with genital piercing.

Methods: Case reports of two men admitted to an academic medical center.

Results: A 60-year-old man with a history of HIV and hepatitis C as well as a Prince Albert piercing presented for treatment of a urethrocutaneous fistula. A biopsy of indurated granulation tissue surrounding the fistula revealed invasive, moderately-differentiated squamous cell carcinoma. A 56-year-old man with a history of HIV, hepatitis C, and a Prince Albert piercing presented following a single episode of gross hematuria. He also reported splitting of his urinary stream. On physical examination, areas of necrosis were noted on the glans penis; biopsy revealed invasive, poorly-differentiated squamous cell carcinoma.

Conclusions: The present study is the first to suggest a possible association between squamous cell carcinoma of the penis/urethra and genital piercing. Patients with genital piercings, especially those with concurrent risk factors such as HIV and HCV, should be counselled about this rare complication.
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http://dx.doi.org/10.1111/j.1743-6109.2010.01818.xDOI Listing
June 2010

Advocating for safer use of sexual enhancement products.

J Sex Med 2010 Jun 26;7(6):2285-2287. Epub 2010 Mar 26.

Department of Urology, University of California, San Francisco, CA, USA.

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http://dx.doi.org/10.1111/j.1743-6109.2010.01770.xDOI Listing
June 2010

A novel application of 1H magnetic resonance spectroscopy: non-invasive identification of spermatogenesis in men with non-obstructive azoospermia.

Hum Reprod 2010 Apr 2;25(4):847-52. Epub 2010 Feb 2.

Department of Urology, University of California San Francisco, Ambulatory Care Center, Suite A633, San Francisco, CA 94117, USA.

Background: About 10% of infertile men have no sperm in their ejaculate due to poor or absent spermatogenesis, also known as non-obstructive azoospermia (NOA). Testis (1)H magnetic resonance spectroscopy ((1)H-MRS) is a non-invasive imaging tool that can potentially identify and localize spermatogenesis in the testis. This study sought to identify metabolic signatures associated with various histological states of spermatogenesis in infertile men.

Methods: Quantitative high resolution magic angle spinning spectroscopy was performed on snap frozen testicular tissue from 27 men with three classic histological patterns: (i) normal spermatogenesis (men with prior paternity undergoing vasectomy reversal), (ii) maturation arrest (early or late, MA) or (iii) Sertoli-cell only (SCO). Concentrations of 19 tissue metabolites were acquired from each biopsy specimen. One-way ANOVA analysis was used to determine inter-group differences in metabolite concentrations among the three histologic groups.

Results: Phosphocholine (PC) and taurine tissue concentrations were significantly different between normal and SCO tissue. Mean PC concentrations were three times higher in normal testes compared with SCO (5.4 +/- 1.4 versus 1.5 +/- 0.3 mmol/kg; P = 0.01). No differences in metabolite concentrations were observed between normal and MA testes or between SCO and MA testes. Further histologic stratification of MA testes into subsets of those with (early) and without (late) spermatids or mature sperm, identified differences in PC concentrations. A predictive model for sperm presence with (1)H-MRS was developed based upon PC tissue concentrations.

Conclusions: PC concentrations are significantly higher in testes with spermatogenesis. This suggests that a unique metabolic signature for spermatogenesis is possible using (1)H-MRS which could aid in the non-invasive diagnosis of sperm in men with NOA.
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http://dx.doi.org/10.1093/humrep/dep475DOI Listing
April 2010

Evaluation of renal function after major renal injury: correlation with the American Association for the Surgery of Trauma Injury Scale.

J Urol 2010 Jan;183(1):196-200

Department of Urology, University of California, San Francisco and San Francisco General Hospital, San Francisco, California 94110, USA.

Purpose: In this study we evaluated the effect of major kidney injury on renal function.

Materials And Methods: A retrospective cross-sectional analysis was conducted of all patients who sustained renal trauma between 1977 and 2008 at San Francisco General Hospital, and underwent post-injury dimercapto-succinic acid renal scan (67). Decrease in renal function was defined as the absolute percentage difference between the affected and unaffected kidney on dimercapto-succinic acid scan. Univariate (Spearman rank correlation) and multivariate (linear regression) analyses of the American Association for the Surgery of Trauma renal injury grade, patient age, mechanism of injury (blunt vs penetrating), side of injury, treatment used (nonoperative vs surgery), shock, gender, presence of gross hematuria, serum creatinine on hospital admission, postoperative complications and associated injuries were performed.

Results: Of the 67 renal injuries 23 (34%) were managed nonoperatively. There were 43 (64%) injuries due to penetrating trauma and 24 (36%) due to blunt injury. Mean decrease in renal function for grade III, IV and V injuries was 15%, 30% and 65%, respectively. Univariate analysis demonstrated a significant association between decrease in renal function and injury grade (rho 0.43, p <0.005). There was no difference in the decrease in kidney function between parenchymal and vascular causes for grade IV and V injuries. Although the right kidney demonstrated a greater decrease in function (rho 0.26, p = 0.033) on univariate analysis, multivariate analysis showed that only American Association for the Surgery of Trauma injury grade correlated with decreased function (correlation coefficient 14.3, 95% CI 4.7-24.8, p <0.005).

Conclusions: Decrease in kidney function is directly correlated with American Association for the Surgery of Trauma renal injury grade.
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http://dx.doi.org/10.1016/j.juro.2009.08.149DOI Listing
January 2010

Patient decision aids for prostate cancer treatment: a systematic review of the literature.

CA Cancer J Clin 2009 Nov-Dec;59(6):379-90. Epub 2009 Oct 19.

Division of General Internal Medicine, University of California at San Francisco, 400 Parnassus Avenue, 4th Floor, Box 0320, San Francisco, CA 94143-0320, USA.

Treatment decision-making can be difficult and complex for patients with low-risk prostate cancer. To the authors' knowledge, there is no consensus regarding an optimal treatment strategy and the choice of therapy involves tradeoffs between differing harms and benefits that are sensitive to patient values. In such situations, patients are often asked to participate actively in the decision-making process, and high-quality decisions require a well-informed patient whose values and preferences have been taken into consideration. Prior studies have indicated that patients have poor knowledge and unrealistic expectations regarding treatment, and physician judgments concerning patient preferences are often inaccurate. Decision aids (DAs) have been developed to help inform patients with low-risk prostate cancer about treatment options and assist in the decision-making process; however, little is currently known regarding the effects of such programs in this population. Thirteen studies of DAs for patients with prostate cancer were reviewed and it was found that the use of DAs can improve knowledge, encourage more active patient involvement in decision-making, and decrease levels of anxiety and distress. The effect of DAs on treatment choice was less clear, although fewer patients chose surgery compared with historical controls, particularly in Europe. Further studies are needed to determine how best to implement DAs into practice, and whether they improve the consistency between patient preferences and treatment choice.
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http://dx.doi.org/10.3322/caac.20039DOI Listing
November 2009

Salvage permanent perineal radioactive-seed implantation for treating recurrence of localized prostate adenocarcinoma after external beam radiotherapy.

BJU Int 2009 Sep 23;104(5):600-4. Epub 2009 Feb 23.

Department of Urology, University of California, San Francisco, CA 94117, USA.

Objective: To assess our experience with salvage permanent perineal radioactive-seed implantation (SPPI) as a possible therapeutic option for recurrent prostate adenocarcinoma, as salvage therapies for recurrences after definitive external beam radiotherapy (EBRT) for localized adenocarcinoma of the prostate are associated with significant morbidity and biochemical failure.

Patients And Methods: We retrospectively analysed on patients who had SPPI for localized recurrent prostate adenocarcinoma from 1996 to 2007 after primary treatment with EBRT. Excluded were patients who had other primary treatment or had no follow-up. Primary outcomes were time to biochemical relapse-free survival, using the Phoenix definition of a prostate-specific antigen (PSA) nadir +2 ng/mL, and cancer-specific survival. Secondary outcomes were the International Prostate Symptom Score (IPSS), the International Index of Erectile Function-5 score (IIEF-5), and complications based on Common Terminology Criteria for Adverse Events (version 3).

Results: In all, 37 patients had SPPI during this period; after applying inclusion and exclusion criteria, 24 remained for analysis. At the time of salvage therapy, the median time to the diagnosis of local recurrence was 49 months, the median PSA level was 3.36 ng/mL, the median PSA doubling time was 20 months, and all patients were clinically re-staged at or=8 in three (not recorded in two). The median follow-up after SPPI was 30 months; the cancer-free survival was 96% (one death) and biochemical relapse-free survival was 88% (three patients). The PSA level was higher than the levels before SPPI at 3 months in all three failures, but lower in all 21 patients considered relapse-free. Complications included one urethral stricture, one grade 3 rectal haemorrhage and five grade 2 gross haematuria that resolved with conservative management. Insufficient data were available to assess the IPSS or IIEF-5 scores.

Conclusion: With a short-term follow-up SPPI appears to provide excellent prostate cancer control with an acceptable rate of complications for patients with local recurrence of prostate cancer after EBRT. An extended follow-up is necessary to determine the long-term durability and safety of SPPI.
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http://dx.doi.org/10.1111/j.1464-410X.2009.08445.xDOI Listing
September 2009
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