The PINNACLE Study: A Double-blind, Randomized, Sham-controlled Study Evaluating the Optilume BPH Catheter System for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

PURPOSE

The Optilume BPH Catheter System is a novel drug/device combination minimally invasive surgical therapy for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. The PINNACLE study is a prospective, randomized, double-blind, sham-controlled clinical trial evaluating the safety and efficacy of Optilume BPH against a sham surgical procedure.

MATERIALS AND METHODS

Eligible patients were men 50 years or older with symptomatic benign prostatic hyperplasia and a prostate size between 20 and 80 g. Subjects were randomized 2:1 to receive treatment with Optilume BPH or a sham surgical procedure. Blinding was maintained for subjects in both arms and evaluating personnel through 1 year postprocedure. Follow-up assessments included the International Prostate Symptom Score, uroflowmetry, and other quality-of-life and sexual function assessments.

RESULTS

A total of 148 men were randomized (100 active, 48 sham) at 18 centers in the U.S. and Canada. Subjects randomized to receive Optilume BPH saw a reduction in International Prostate Symptom Score of 11.5±7.8 points at 1 year posttreatment, as compared to a reduction of 8.0±8.3 points at 3 months in the sham arm. Flow rate was dramatically improved after treatment with Optilume BPH, with an improvement of +10.3 mL/s from baseline to 1 year (+125%).

CONCLUSIONS

Treatment with Optilume BPH provides immediate and sustained improvements in obstructive symptoms and flow rate while preserving erectile and ejaculatory function. Treatment is well tolerated and can be done in an office or ambulatory setting.

How I Do It: The Optilume drug-coated balloon for urethral strictures

Urethral stricture disease can be difficult to treat and stricture recurrence is common. The management of stricture disease has evolved and urethroplasty can achieve a high rate of lasting urethral patency. Nevertheless, endoscopic treatments still seem to have sub-optimal outcomes with high stricture recurrence rates. The Optilume drug-coated balloon represents a step forward in the endoscopic management of urethral strictures. The drug-coated balloon may offer an intermediate step prior to repeated dilations, urethrostomies, or urethroplasty. This treatment modality is a promising alternative to current endoscopic management and an option for patients that are poor surgical candidates or decline urethroplasty.

Up and Away: Five Decades of Urologic Investigation in Microgravity

A renewed global interest in manned space exploration has emerged, propelled by the challenge of reaching a new frontier: travel to the Red Planet, Mars. As the physiological changes induced by microgravity bear direct relevance to the safety and viability of these goals, we provide a historical narrative of the urologic investigations in space. We review the significant contributions to the understanding of the urologic consequences associated with exposure to microgravity, considerations for prolonged missions, and forward-looking efforts to manage emergent conditions remotely. Historical insights gleaned are poised to inform interplanetary travel, where urologic pathology will remain an important practical consideration.

Membrane negative curvature induced by a hybrid peptide from pediocin PA-1 and plantaricin 149 as revealed by atomistic molecular dynamics simulations

Antimicrobial peptides (AMPs) are cationic peptides that kill bacteria with a broad spectrum of action, low toxicity to mammalian cells and exceptionally low rates of bacterial resistance. These features have led to considerable efforts in developing AMPs as an alternative antibacterial therapy. In vitro studies have shown that AMPs interfere with membrane bilayer integrity via several possible mechanisms, which are not entirely understood. We have performed the synthesis, membrane lysis measurements, and biophysical characterization of a novel hybrid peptide. These measurements show that PA-Pln149 does not form nanopores, but instead promotes membrane rupture. It causes fast rupture of the bacterial model membrane (POPG-rich) at concentrations 100-fold lower than that required for the disruption of mammalian model membranes (POPC-rich). Atomistic molecular dynamics (MD) simulations were performed for single and multiple copies of PA-Pln149 in the presence of mixed and pure POPC/POPG bilayers to investigate the concentration-dependent membrane disruption by the hybrid peptide. These simulations reproduced the experimental trend and provided a potential mechanism of action for PA-Pln149. It shows that the PA-Pln149 does not form nanopores, but instead promotes membrane destabilization through peptide aggregation and induction of membrane negative curvature with the collapse of the lamellar arrangement. The sequence of events depicted for PA-Pln149 may offer insights into the mechanism of action of AMPs previously shown to induce negative deformation of membrane curvature and often associated with peptide translocation via non-bilayer intermediate structures.

Are magnetic resonance imaging undetectable prostate tumours clinically significant? Results of histopathological analyses

OBJECTIVE

To investigate whether tumours at threshold values for detection on magnetic resonance imaging (MRI) represent clinically significant tumours or not, and therefore the utility of MRI in active surveillance (AS) protocols.

PATIENTS AND METHODS

A retrospective analysis of a single institution database was performed after Institutional Review Board approval. Between 2010 and 2013, 1633 patients underwent robot-assisted laparoscopic prostatectomy (RALP) at a single institution by a single surgeon. Of these, 1361 had complete clinical data and were included in analysis. Multivariate logistic regression was used to assess histopathological grade compared to tumour size whilst controlling for biopsy Gleason score, prostate-specific antigen level, body mass index, race, and age.

RESULTS

Of 120 tumours <5 mm in size, four were Gleason score 4 + 3. Of 276 tumours of 5-10 mm, 22 (8.1%) were Gleason score 4 + 3 and one (0.2%) was Gleason score 8. On multivariate regression analyses, tumours of <5 mm were much less likely to be high grade (Gleason score >3 + 4) at RALP compared to larger tumours (3.3% vs 25.1%, P < 0.001), or Gleason score ⩾8 (0.0% vs 7.6%, P < 0.001). Size was further shown to significantly correlate with grade on multivariate regression (P < 0.001).

CONCLUSIONS

Prostate tumours below the detection threshold for MRI (5 mm) most probably represent clinically insignificant tumours, which alone would not necessitate leaving AS in favour of more aggressive therapy. These findings point to a possible role of MRI in modern AS protocols.

Characteristics and outcomes of men who fail to leak on intubated urodynamics prior to artificial urinary sphincter placement

INTRODUCTION

To report the characteristics and anti-incontinence outcomes of men who fail to demonstrate incontinence on intubated urodynamics (UDS).

MATERIALS AND METHODS

From 2005 to 2013, the records of men who underwent UDS prior to artificial urinary sphincter (AUS) were reviewed. The histories, UDS, endoscopies, and anti-incontinence outcomes of men who failed to demonstrate incontinence on intubated UDS were recorded. In our UDS protocol, the urodynamic urethral catheter was removed and the UDS was repeated to elicit incontinence without the urethral catheter. The valsalva leak point pressure (VLPP) was obtained via the rectal catheter in these men.

RESULTS

All men were status post radical prostatectomy for prostate cancer. Nineteen percent (32) of the study population (169) had non-demonstrable incontinence on intubated UDS. Mean age at the time of UDS was 62 (range 48-81). All patients demonstrated incontinence on UDS upon removal of the urethral catheter. Their mean VLPP was 79.3 (SD 36.7). Fifty-six percent (18) of these men had an anastomotic stricture (AS) and 37.5% (12) had a history of radiotherapy treatment, of which six also had an AS. Mean pads per day at the time of UDS was 4.6 (SD 2.9). At a mean follow up of 40.7 months (SD 24.7) from AUS placement, mean pads per day was 0.87 (SD 1.2).

CONCLUSIONS

Men who fail to demonstrate incontinence on intubated UDS have a high rate of AS and history of radiotherapy treatment, which is a known cause for urethra fibrosis and scarring. Regardless, these men can achieve excellent anti-incontinence outcomes.

Pediatrician noncompliance with the American Academy of Pediatrics guidelines for the workup of UTI in infants

BACKGROUND

The American Academy of Pediatrics (AAP) guidelines on the workup for urinary tract infections (UTIs) in infants discourages the use of bagged urine specimens for urine culture. We report the results of a survey to assess urine collection preferences and adherence to AAP guidelines in clinical practice.

METHODS

A 29-question survey was e-mailed to pediatrician AAP members to determine their preferred method of urine collection in hypothetical infant patients.

RESULTS

Data from 155 respondents were analyzed. In febrile, circumcised boys, up to 18% preferred bagged specimens for urine culture, against AAP recommendations. In febrile girls, 13% of respondents preferred bagged specimens. There was no significant relationship between adherence to AAP guidelines and respondent's age, gender, years in practice, fellowship training, academic affiliation, or other demographic factors.

CONCLUSIONS

Up to 18% of practitioners prefer bagged specimens over more sterile ones in the workup of febrile UTIs in infants, against AAP guidelines.

Circumcision on the web: a comparison of quality, content, and bias online

OBJECTIVE

In 2012, the American Academy of Pediatrics (AAP) newborn circumcision policy statement expressed that although benefits outweigh risks, final decisions lie with parents. Although health information on the Internet is plentiful, the quality and availability of information on circumcision, including dissemination of AAP and AUA policy statements, is unknown. We analyzed English and Spanish circumcision websites to evaluate their overall quality, detail, accuracy, and bias.

METHODS

In April 2013, three search engines were queried for English and Spanish circumcision websites, which were analyzed utilizing the DISCERN Plus scale for content quality as well as additional study-specific criteria.

RESULTS

We analyzed 214 websites (141 English, 73 Spanish). Most websites in both languages had very good content quality and were neutral regarding circumcision. Regardless of language, only 21% of sites mentioned the updated AAP guidelines. Surprisingly, the AUA circumcision policy statement did not appear in the top results. Spanish sites were more likely to give good descriptions of circumcision procedures than English sites (p < 0.04), less likely to cite sources (p < 0.01), and more likely to describe benefits (p = 0.02)..

CONCLUSIONS

Newborn circumcision information on the Internet is of very good quality, but different English and Spanish characteristics possibly reflect cultural bias, which may explain the disparate rates of circumcision between different groups in the USA. The AAP's circumcision policy statement was referenced by a minority (20%) of websites, and AUA's policy statement was not even part of the top results. The AUA should have a more active role in providing accurate and comprehensive online information to parents regarding circumcision.

Variations in the management of asymptomatic adolescent grade 2 or 3 left varicoceles: a survey of practitioners

OBJECTIVE

Our study aims to evaluate variations in management of asymptomatic adolescent grade 2 and 3 varicoceles by pediatric urologists.

SUBJECTS AND METHODS

Electronic survey of all 267 current members of AAP Urology with 74 (28%) responding.

RESULTS

When managing patients with positive examination findings, 49% of surveyed practitioners use scrotal sonography as initial screening, while 38% use only manual orchidometry and 11% observation with serial examinations. If significant testicular size discrepancy is identified, 32% immediately intervene surgically, while 59% repeat measurements in 6-12 months. When no discrepancy is identified, 36.6% of practitioners discharge their patients with no follow-up, 22.5% refer to an infertility specialist, and 31% evaluate with semen analysis. Fifty-seven percent of practitioners have never sent patients for semen analysis; only 4% send >50% of patients. Of these, 52% and 27% analyzed semen at 17-18 years and 19-20 years, respectively, and 10% send for semen analysis at <17 years.

CONCLUSIONS

Our survey demonstrates that there does not appear to be a consensus among pediatric urologists managing asymptomatic grade 2 and 3 varicoceles. Better understanding of which adolescent patients with varicoceles will go on to develop male infertility is necessary to identify pediatric patients who could benefit from early intervention.

One- and two-photon absorption of fluorescein dianion in water: a study using S-QM/MM methodology and ZINDO method

One- and two-photon absorption (1PA and 2PA) of fluorescein dianion (FSD) in water were studied using a combined and sequential Quantum Mechanics/Molecular Dynamics methodology. Different sets of 250 statistically relevant (uncorrelated) configurations composed by the solute and several solvent molecules were sampled from the classical simulation. On these configurations, the electronic properties were calculated a posteriori using the Zerner's intermediate neglect of differential overlap (ZINDO) method. The linear and nonlinear absorption of FSD in water were calculated using discrete and explicit solvent models. In the largest case, the relevant configurations are composed by FSD and 47 explicit water molecules embedded in the electrostatic field of all remaining water molecules. Both INDO/CIS and INDO/CISD calculations were performed to study the absorption processes of FSD and the Sum-Over-States (SOS) model was used to describe the 2PA process. A semi-classical method for spectrum simulations was employed to simulate the 1PA and 2PA cross-section spectra of FSD in water. For comparison purposes, in the case of the 2PA process two approaches, the "full expression" and "resonant expression" methods, were employed to simulate the nonlinear spectrum. The last method assumes resonant conditions and on the computation point of view it represents an interesting option to study the 2PA process. The INDO/CI calculations give a satisfactory description of the 1PA spectrum of FSD and properly describe the unusual blue-shift of its first π→π(*) transition in water. In the case of 2PA, the introduction of doubly excited configuration interactions (INDO/CISD) has proven to be essential for an appropriate description of the process at the higher energy spectral region. It was observed that the solvent effects do not drastically change the cross-sections of both processes. The simulated 2PA cross-section spectrum provided by the "full expression" method presents a better definition of the bands which appear along the experimental spectrum than the one provided by the "resonant expression" method. However, both approaches provide similar description for the effect of the solvent environment on the 2PA process of FSD in water.

Isotropic magnetic shielding constants of retinal derivatives in aprotic and protic solvents

We investigate the nuclear isotropic shielding constants σ((13)C) and σ((17)O) of isomers of retinoic acid and retinal in gas-phase and in chloroform, acetonitrile, methanol, and water solutions via Monte Carlo simulation and quantum mechanics calculations using the GIAO-B3LYP∕6-311++G(2d,2p) approach. Electronic solute polarization effects due to protic and aprotic solvents are included iteratively and play an important role in the quantitative determination of oxygen shielding constants. Our MP2∕6-31G+(d) results show substantial increases of the dipole moment of both retinal derivatives in solution as compared with the gas-phase results (between 22% and 26% in chloroform and between 55% and 99% in water). For the oxygen atoms the influence of the solute polarization is mild for σ((17)O) of hydroxyl group, even in protic solvents, but it is particularly important for σ((17)O) of carbonyl group. For the latter, there is a sizable increase in the magnitude with increasing solvent polarity. For the carbon atoms, the solvent effects on the σ((13)C) values are in general small, being more appreciable in carbon atoms of the polyene chain than in the carbon atoms of the β-ionone ring and methyl groups. The results also show that isomeric changes on the backbones of the polyene chains have marked influence on the (13)C chemical shifts of carbon atoms near to the structural distortions, in good agreement with the experimental results measured in solution.

Treatment of recurrent Rapunzel syndrome and trichotillomania: case report and literature review

BACKGROUND

Trichotillomania (obsession with one's hair) was first described in the literature over 100 years ago and was recognized by the American Psychiatric Association as a distinct disorder in 1987.

OBJECTIVE

The authors discuss a rare presentation of a case of recurrent Rapunzel syndrome in a 37-year-old woman.

METHOD

The authors present a biopsychosocial treatment plan for a therapeutic approach.

RESULTS

This patient was unique for her relatively advanced age at onset, the recurrent nature, association with pancreatitis, and the consumption of artificial hair extensions, rather than her own hair. This patient presented with small-bowel obstruction requiring laparotomy. After surgery, she was evaluated by the psychiatric service; after discharge, she removed her hair extensions, continued to take her prescribed medication, attended a psychiatric program, and was monitored by family and friends.

CONCLUSION

There are no definitive guidelines for treating trichotillomania. In this case, quetiapine, hair-extension removal, family involvement, and regular follow-up helped with the initial cessation of her hair consumption. Antidepressant treatment helped control the obsession while behavioral therapy and family involvement provided the means for habit-reversal training.

[Linkage of environmental and health data: health risk analysis of the Rio de Janeiro water supply by using geographical information systems]

Exposure assessment of population groups is based on linkage of environmental and health data. This relationship can be hard to establish due to spatial and temporal lags in data sets. Environmental data generally refer to scattered sampling points, while epidemiological data integrate periods of time within administrative territories. GIS can be used as a basis for organizing health-related and environmental data sets. We examined potential health risk in the Rio de Janeiro city water supply based on the overlay of information layers containing data on the presence and quality of water supply services. We used census tracts as the primary georeferenced data, since they contain information on how households are supplied, water supply pipes, sources, and reservoirs, and water quality according to the monitoring program. Population groups exposed to risks were located and quantified using spatial operations among these layers and adopting different risk criteria. The main problems related to water supply are located on the northern slope of the Tijuca Mountain Range (involving the absence or poor quality of water) and in the western area of the city of Rio, where the population relies on alternative water supply sources. The different origins, objectives, and structures of data have to be analyzed critically, and GIS can be used as a data validation tool as well as an instrument for detailed identification of inconsistencies.