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Open Access Publications from the University of California

Scholarly Works (8 results)

  • Thesis
  • Peer Reviewed
UC Irvine Electronic Theses and Dissertations (2023)

Importance: Prostate cancer remains as one of the most common malignancies in men in the United States. Testosterone Replacement Therapy (TRT) is known to improve functional and sexual outcomes in hypogonadal men. TRT historically has been contraindicated for the management of hypogonadism in men with prostate cancer (PC). In 2020, our team demonstrated in a cohort of 850 men that TRT reduced biochemical recurrence (BCR) by 53% (median follow-up 3.5 yrs.). The present study extends the median follow-up time up to 5.84 years [4.18; 7.24].

Objective: This study mainly aims to investigate the utility of TRT to reduce BCR.

Methods: A retrospective review of prospectively collected data between December 2009 and June 2018 undergoing robotic radical prostatectomy by a single surgeon was conducted. 152 patients who had TRT post-RP with a cFT (below 25%) were frequency-matched to 420 patients not receiving TRT with respect to pathological stage (p-stage) and Gleason Grade Group (GGG). Furthermore, the TRT group was propensity-score matched to 304 patients. Propensity scores were calculated using a multivariable logistic model that incorporated the following variables: age, BMI, Gleason group, PSA, SHIM, prostate size, pathological stage, total testosterone (TT), sex hormone-binding globulin (SHBG), and free testosterone (FT). Biochemical recurrence (BCR) was defined as two consecutive prostate specific antigen (PSA) blood tests >0.2 ng/mL. A cox regression model and Kaplan-Meier (KM) graphs were used to analyze rate and time to BCR. We also used our cox regression model of the time to BCR with truncated time of 10.32 to calculate restricted mean survival time (RMST) for the TRT vs no-TRT groups.

Results: With propensity-score matching, there were no baseline differences in demographics observed except in TT (p-value= <0.001), cFT (p-value <0.001), and follow-up time (p-value = 0.004). In the cox regression multivariate analysis of the propensity- scored matched control, patients with a higher calculated free testosterone were less likely to have a BCR (p-value= 0.013). In the same analysis, patients with a higher GGG, p-stage, and preoperative PSA (p-value= <0.001) were more likely to have a BCR. Patients receiving TRT had 47% reduction in BCR rates (p-value = 0.011) after a median follow-up time of 5.84 [4.18;7.24] years. Furthermore, our 10-year cox regression model for the time to BCR showed RMST difference between the TRT and no-TRT groups: in patients who did recur, patients on TRT had an increased latency of 0.44 years.

Conclusion and Relevance: With the long-term follow-up, TRT was observed to have a continuing protective effect in preventing and delaying BCR in patients post-RARP when compared to patients who did not receive TRT.

    Cover page: Testosterone Replacement Therapy Reduces Biochemical Recurrence Post-Radical Prostatectomy: Long-term OutcomesCreative Commons 'BY' version 4.0 license
    • Article
    • Peer Reviewed
    UC Irvine Previously Published Works (2023)
    Inflatable Penile Prostheses (IPP) implantation is a surgical treatment for patients desiring definitive treatment for erectile dysfunction. While this procedure has proven to be effective, it also carries its own set of unique risks that need to be carefully considered. The article reviews the current understanding of complications associated with penile prosthetic surgery and provides strategies to mitigate these adverse events. This article covers various aspects of IPP implantation, including the risks of infection, bleeding, injury to nearby structures, glans ischemia, and device malfunction. It also discusses the importance of careful preoperative screening to identify risk factors and the implementation of infection reduction strategies such as antimicrobial prophylaxis, skin prep, and operative techniques. In addition, it emphasizes the need for postoperative vigilance and prompt management of any complications that may arise. Overall, the article provides a comprehensive overview of the risks and strategies for mitigating complications associated with IPP implantation. Our recommendations are given based on the current consensus in the field and highlight the importance of careful planning, attention to detail, and effective communication between healthcare providers and patients. Despite the potential risks, this review underscores the fact that complications following penile prosthesis implantation are relatively rare.
      Cover page: Maximizing outcomes in penile prosthetic surgery: exploring strategies to prevent and manage infectious and non-infectious complications.
      • Article
      • Peer Reviewed
      UC Irvine Previously Published Works (2023)

      Background

      Nephroureterectomy remains the gold standard treatment for upper tract urothelial carcinoma (UTUC). Considering the high risk of developing renal function impairment after surgery, the rationale for nephron sparing approaches in treatment of UTUC has been raised. In this case, renal cryoablation was able to achieve successful oncologic control while preserving renal function during 5 years of follow up without intraoperative or post operative complications.

      Case presentation

      A 79 year old male presents after three months of macroscopic hematuria. Imaging revealed a 3.6 × 3.1 × 2.7 cm endophytic mass in the interpolar region of the left kidney and an atrophic right kidney. After weighing the lesion's location with the patient's of complex medical history, he was counselled to undergo a minimally invasive percutaneous cryoablation as treatment for his solitary renal mass. A diagnostic dilemma was encountered as imaging suggested a diagnosis of renal cell carcinoma. However, the pre-ablation biopsy established an alternative diagnosis, revealing UTUC. Percutaneous cryoablation became an unorthodox treatment modality for the endophytic component of his UTUC followed by retrograde ureteroscopic laser fulguration. The patient was followed in 3 months, 6 months, then annually with cross sectional imaging by MRI, cystoscopy, urine cytology and renal function testing. After five years of follow-up, the patient did not encountered recurrence of UTUC or deterioration in renal function, thereby maintaining a stable eGFR.

      Conclusion

      Although evidence for nephron-sparing modalities for UTUC is mounting in recent literature, limited data still exists on cryotherapy as a line of treatment for urothelial carcinoma. We report successful management of a low-grade UTUC using cryoablation with the crucial aid of an initial renal biopsy and long-term follow-up. Our results provide insight into the role of cryoablation as a nephron-sparing approach for UTUC.
        Cover page: Endophytic upper tract urothelial carcinoma in a solitary kidney treated by cryotherapy: an unorthodox case for successful management.
        • Article
        • Peer Reviewed
        UC Irvine Previously Published Works (2024)
        High-grade (HG) urothelial carcinoma (UC) with variant histology has historically been managed conservatively. The presented case details a solitary lesion of muscle-invasive bladder cancer (MIBC) with sarcomatoid variant (SV) histology treated by partial cystectomy (PC) and adjuvant chemotherapy. A 71-year-old male with a 15-pack year smoking history presented after outside transurethral resection of bladder tumor (TURBT). Computerized tomography imaging was negative for pelvic lymphadenopathy, a 2 cm broad-based papillary tumor at the bladder dome was identified on office cystoscopy. Complete staging TURBT noted a final pathology of invasive HG UC with areas of spindle cell differentiation consistent with sarcomatous changes and no evidence of lymphovascular invasion. The patient was inclined toward bladder-preserving options. PC with a 2 cm margin and bilateral pelvic lymphadenectomy was performed. Final pathology revealed HG UC with sarcomatoid differentiation and invasion into the deep muscularis propria, consistent with pathologic T2bN0 disease, a negative margin, and no lymphovascular invasion. Subsequently, the patient pursued four doses of adjuvant doxorubicin though his treatment was complicated by hand-foot syndrome. At 21 months postoperatively, the patient developed a small (<1 cm) papillary lesion near but uninvolved with the left ureteral orifice. Blue light cystoscopy and TURBT revealed noninvasive low-grade Ta UC. To date, the patient has no evidence of HG UC recurrence; 8 years after PC. Patient maintains good bladder function and voiding every 3-4 h with a bladder capacity of around 350 ml. Surgical extirpation with PC followed by adjuvant chemotherapy may represent a durable solution for muscle invasive (pT2) UC with SV histology if tumor size and location are amenable. Due to the sparse nature of sarcomatous features within UC, large multicenter studies are required to further understand the clinical significance and optimal management options for this variant histology.
          Cover page: Successful bladder-sparing partial cystectomy for muscle-invasive domal urothelial carcinoma with sarcomatoid differentiation: a case report.
          • Article
          • Peer Reviewed
          UC Irvine Previously Published Works (2024)
          PURPOSE: To assess the diagnostic performance and utility of the ExoDx IntelliScore and an OPKO4K score to predict prostate cancer in men presenting with elevated PSA-both as independent predictors and in combination with clinical/MRI characteristics. METHODS: Patients with elevated PSA were retrospectively reviewed. Abnormal tests were defined as an OPKO4K score ≥ 7.5% and an ExoDx IntelliScore ≥ 15.6. Four regression models and ROC curves were generated based on: (1) age, PSA, and DRE, (2) model 1 + OPKO4K 4Kscore ≥ 7.5%, (3) model 2 + ExoDx IntelliScore ≥ 15.6, and (4) model 3 + MRI PIRADS 4-5. RESULTS: 359 men received an OPKO4K test, 307 had MRI and 113 had ExoDx tests. 163 men proceeded to prostate biopsy and 196 (55%) were saved from biopsy. Mean age was 65.0 ± 8.7 years and mean PSA was 7.1 ± 6.1 ng/mL. Positive biopsies were found in 84 (51.5%) men. The sensitivity and negative predictive value of an OPKO4K score were 86.7% and 72.3%; values for an ExoDx test were 76.5% and 77.1%, respectively. On regression analysis, clinical markers (Age, PSA, DRE) generated an AUC of 0.559. The addition of an OPKO4K score raised the AUC to 0.653. The stepwise addition of an ExoDx score raised the AUC to 0.766. The combined use of both biomarkers, patient characteristics, and MRI yielded an AUC of 0.825. CONCLUSION: This analysis demonstrates the high negative predictive value of both the OPKO4K score and ExoDX IntelliScore independently while demonstrating that the combination of an OPKO4K score, an ExoDX IntelliScore, and MRI increases predictive capability for biopsy confirmed prostate cancer.
            Cover page: Utility of noninvasive biomarker testing and MRI to predict a prostate cancer diagnosis.
            • Article
            • Peer Reviewed
            UC Irvine Previously Published Works (2024)
              Cover page: Successful management of high urogenital sinus in an adult female: Case reportCreative Commons 'BY-ND' version 4.0 license
              • Article
              • Peer Reviewed
              UC Irvine Previously Published Works (2023)

              Background

              Information regarding the Medicaid coverage of artificial urinary sphincter (AUS) and male suburethral slings (MS) placement in the United States (US) is not readily available. In this manuscript, we seek to elucidate the state-by-state Medicaid coverage of these two procedures in the US.

              Methods

              State Medicaid websites were utilized to access publicly available physician fee schedules for the calendar year 2020. Fee schedules were searched for current procedural terminology (CPT) codes. CPT codes representing insertion of tandem cuff, insertion of AUS, removal of AUS, removal and replacement AUS, sling operation for correction of male stress urinary incontinence (SUI), and removal or revision of sling for male SUI were utilized. Data were recorded by the procedure for each device, including the coverage status and physician fees.

              Results

              Of the 50 US states analyzed, 49 publish publicly accessible physician fee schedules. All 49 of these states reported coverage for removal with and without revision of the AUS, and 48 states reported coverage for insertion of an AUS, and insertion of a tandem cuff. The median reimbursement for each AUS related procedure was $624.00 ($181.84-$10,960.90) for tandem cuff, $665.54 ($199.89-$11,949.86) for AUS insertion, $528.03 ($146.90-$1,893.12) for AUS removal, and $630.29 ($208.55-$11,586.74) for AUS revision. All 49 states reported coverage for placement of MS, and 48 states reported coverage for removal or revision of MS. The median reimbursement was $652.57 ($198.00-$5,237.35) for MS placement and $554.47 ($104.27-$2,288.93) for MS revision.

              Conclusions

              AUS and MS procedures in the Medicaid population are covered by nearly all states. Therefore, surgical treatment of SUI may be offered to Medicaid patients in most states without reimbursement concerns.
                Cover page: Does Medicaid cover artificial urinary sphincter and male urethral sling surgery?—a state-by-state analysis
                • Article
                • Peer Reviewed
                UC Irvine Previously Published Works (2023)

                Background

                In 2017, a prospective multicenter, multinational, investigational pilot study was conducted examining outcomes using a novel surgical technique, the Mini-Jupette sling, for the management of erectile dysfunction (ED) patients with climacturia and/or minimal stress urinary incontinence (SUI) after prostate procedures. Climacturia has been reported in up to 64% of patients following radical prostatectomy (RP). We sought to report the 5-year outcomes from this original cohort to assess long-term safety and effectivity of the mini-jupette sling in the treatment of ED and concomitant mild SUI and/or climacturia.

                Methods

                This is a single-arm, multicenter, retrospective, observational study. We identified patients who were enrolled in the previous multicenter study with post-RP ED and climacturia and/or mild SUI- 2 PADS PER DAY (PPD) and underwent inflatable penile prosthesis (IPP) insertion with simultaneous placement of a mini-jupette sling. Data were collected including current PPD, subjective improvement in climacturia/SUI, complications, need for revision of IPP or additional urinary incontinence surgery, and date of most recent follow-up. SPSS was used for statistical analysis.

                Results

                Of the original 38 patients, 5 have since died and 10 were lost to follow-up with 23/38 (61%) patients available for evaluation of long-term outcomes. The average follow-up time was 59 months (SD =8.8) with a mean age of 69 years (SD =6.8). Most patients (n=21, 91%) had subjective improvement of SUI and climacturia. One patient with persistent bothersome incontinence underwent artificial urinary sphincter (AUS) placement in 2018 with no complications, while the other is still considering a repeat procedure due to minor but persistent SUI. The mean PPD decreased from 1.4 preoperatively to 0.4 at a mean of 5 years of follow-up. Most patients reported satisfaction in their urinary symptoms with 91% and 73% reporting improvement in SUI and climacturia respectively, compared to 86% and 93% respectively in the original series. One (4.3%) patient had an IPP revision for pump malfunction. There were no device infections reported.

                Conclusions

                The mini-jupette sling appears to be a safe and effective procedure with durable improvements in SUI and climacturia at 5 years of follow-up.
                  Cover page: Long-term assessment of the safety and effectivity of the mini-jupette sling: 5-year follow-up of the original series
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