Biomedical subjects
R Bruskewitz
Publications and source records attributed to R Bruskewitz.
Management dilemmas in prostate cancer.
Large numbers of men have an undetected prostate tumor, but in only a small proportion of cases do these lesions ever become clinically significant. That being so, it will take time to demonstrate the PSA screening or any given treatment strategy has benefit. Meanwhile, patients need help deciding whether to undergo screening and, if cancer is found whether to opt for aggressive treatment.
Trends in the surgical treatment of prostate cancer in Wisconsin, 1989-1991.
BACKGROUND: Radical prostatectomy (removal of the prostate gland and seminal vesicles) is usually considered a definitive treatment for localized prostate cancer. Although a sharp increase and wide geographic variation in radical prostatectomy rates have been recently documented, the reasons for this increase and the factors that make men diagnosed with the disease more likely to be treated surgically are not well known. PURPOSE: Our purpose was to examine trends in the use of surgical treatment for prostate cancer, as well as the factors associated with the choice of surgical treatment and how these factors changed in Wisconsin in the period 1989 through 1991. METHODS: We carried out a population-based cohort study. A cohort of Wisconsin men diagnosed from 1989 through 1991 with prostate cancer was identified through the Wisconsin cancer reporting system. To determine which men diagnosed with prostate cancer were treated with surgery, we linked prostate cancer records to the Wisconsin hospital discharge database. The outcome measured was radical prostatectomy within 6 months from the date of the diagnosis of prostate cancer. RESULTS: The yearly number of prostate cancer cases reported from 1989 through 1991 rose 33%, from 2468 to 3278. During the same period, the yearly number of radical prostatectomies rose 226%, from 283 to 922. Patients diagnosed in 1991 were twice as likely to have surgery as those diagnosed in 1989, the proportion of cases receiving surgical treatment rising from 12% to 25%. Patients who were white, less than 65 years of age, had a cancer reported to be at regional stage, and who were first reported by large hospitals were more likely to be treated surgically. CONCLUSIONS: The use of surgery to treat prostate cancer has increased dramatically in Wisconsin, doubling in a 3-year period, despite the fact that studies have not shown surgery to be more effective than other options for many patients. The increase observed in the rate of surgery was about the same across age, race, stage at diagnosis, and hospital size. The reasons for this increase are probably multifactorial. IMPLICATIONS: Risks, costs, and benefits of surgical treatment should be carefully compared with those of alternative management approaches. Patients should be enabled to make an informed decision, based on the current best evidence, on the treatment option they prefer.
New options in benign prostatic hyperplasia.
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Maximum urinary flow rate by uroflowmetry: automatic or visual interpretation.
We measured the maximum urinary flow rate monthly for 1 year by uroflowmetry in 1,645 patients in a double-blind, placebo-controlled study of finasteride therapy for benign prostatic hyperplasia. Patients were randomized to receive placebo (555) or finasteride (1,090). A total of 23,857 flow measurements was obtained. Because of the presence of artifacts on many uroflow curves, we read the maximum urinary flow rate values manually and compared them to the values provided electronically by the uroflowmeter. On average, the manually read values were 1.5 ml. per second lower than the machine read values. Artifacts causing a difference of 2 ml. per second or more between the 2 methods were found in 20% and of more than 3 ml. per second in 9% of the tracings. The difference between treatment groups in mean maximum urinary flow rate change at the end of the study was the same with both reading methods. However, confidence intervals were 15 to 25% larger for the machine read compared to the manually read values. This larger variability in machine read maximum urinary flow rate has a marked negative impact on the power of statistical tests to assess any given difference in maximum urinary flow rate between treatment groups. Furthermore, it increases sample size requirements by 50% to achieve any given statistical power. We conclude that maximum urinary flow rate artifacts contribute significantly to the variability of maximum urinary flow rate measurement by uroflowmetry. Manual reading of the maximum urinary flow rate eliminates an important fraction of such variability.
The treatment of localized prostate cancer: what are we doing, what do we know, and what should we be doing? The Prostate Patient Outcome Research Team.
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New therapies for benign prostatic hyperplasia.
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Symptom analysis of patients undergoing modified Pereyra bladder neck suspension for stress urinary incontinence. Pre- and postoperative findings.
The results of a physician-directed follow-up of 145 women undergoing the modified Pereyra bladder neck suspension from March 1980 to February 1986 are presented. Median follow-up was 3.5 years (2.0-7.7); 70 percent of patients had follow-up between three and four years postoperatively. All patients had preoperative demonstration of stress incontinence as well as urodynamic evaluation. Fifty-one percent of patients reported no stress incontinence and 76 percent reported that their sense of urinary control was better, or much better at the time of follow-up. Improvement was seen in all grades of stress incontinence. Age, weight, parity, and history of prior anti-incontinence surgery had no significant impact on success rates. Although preoperative urgency symptoms were more common among failure (28% vs 15%), this association was not statistically significant. However, persistent or de novo urgency symptoms postoperatively were highly associated with postoperative incontinence (p less than 0.005). The onset of recurrent incontinence was experienced more than two years postoperatively in 23 percent of the incontinent group.
Further study of the increased mortality following transurethral prostatectomy: a chart-based analysis.
Previous studies using large administrative databases found an elevated relative risk of reoperation and death after transurethral resection of the prostate compared to open prostatectomy. To investigate whether differences in case-mix unmeasured by administrative data explained this finding, we reviewed the charts of 485 patients who had undergone prostatectomy (236 open and 249 transurethral) at the Health Science Centre, Winnipeg, Manitoba, Canada between 1974 and 1980. Data from patient histories, physical examinations and laboratory evaluations were abstracted and used to control for case-mix in models comparing the rates of reoperation and mortality after transurethral versus open prostatectomy. Several models were specified. In all models the relative risk of dying after transurethral prostatectomy remained elevated (1.36 to 1.89), as did the risk for reoperation (3.62). A prospective trial is needed to establish the relative safety and effectiveness of transurethral and open prostatectomy.
Disorders of micturition in the aging patient.
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AMS malleable penile prosthesis.
The American Medical Systems (AMS) malleable penile prosthesis was implanted in 57 patients from January, 1983 to 1985. Fifty-one per cent of the procedures were performed under local anesthesia, and 28 per cent in ambulatory (day) surgery. The prosthesis was evaluated in terms of cosmetic result, patient satisfaction and function, and postoperative complications. Ninety-one per cent of patients were satisfied with their decision to select the malleable prosthesis, and 66 per cent reported no difficulty with concealment. A comparison is made with data available from the alternative Jonas malleable prosthesis.
Predictive value of low maximum flow rate in benign prostatic hyperplasia.
Among 84 patients with prostatism selected for transurethral resection of the prostate, 18 had a maximum flow at spontaneous uroflowmetry less than or equal to 7 ml/sec. Preoperatively there was no significant difference between patients with maximum flow less than or equal to 7 ml/sec (Group 1) and patients with maximum flow greater than 7 ml/sec (Group 2) in age, duration of symptoms, symptom scores, bladder volume, residual urine, and detrusor pressure at maximum flow. Patients in Group 1, however, had significantly lower urethral resistance and bladder volume independent maximum flow than patients in Group 2. Postoperatively, patients with preoperative maximum flow less than or equal to 7 ml/sec improved significantly in symptom scores and urodynamic findings apart from bladder volume and detrusor pressure at maximum flow. There were no significant differences between groups in postoperative symptom scores or urodynamic findings. We conclude that preoperative maximum flow rates less than or equal to 7 ml/sec at spontaneous uroflowmetry were related to high urethral resistance and not detrusor decompensation among patients with prostatism, and that patients with maximum flow rates less than or equal to 7 ml/sec fared as well postoperatively as patients with maximum flow greater than 7 ml/sec.
Long-term clean intermittent self-catheterization in renal transplant recipients.
Eight renal transplant recipients with neurogenic bladders or lower urinary tract dysfunction were managed with clean intermittent self-catheterization after transplantation instead of urinary diversion. A total of 85 treatment months was reviewed. Of the patients 5 continue to do well after 10 to 17 months of intermittent catheterization and 3 suffered immunological graft failures. In selected renal transplant recipients with lower urinary tract dysfunction clean intermittent catheterization is a reasonable alternative to urinary diversion.
Impact of an intermittent catheterization program on children with myelomeningocele.
Among 164 children being followed in a myelomeningocele clinic, 85 (52%) are on an intermittent catheterization program (ICP). Among 53 children on ICP for 5 years or more, a high percentage have achieved satisfactory dryness, decreased frequency of urinary tract infection, and improvement in renal status. The potential for improved well-being afforded by ICP is one factor that should be considered in decisions about "active" or "supportive" treatment in newborn infants with myelomeningocele.
Evaluation of obstructive uropathy with diuretic renography.
Diuretic renography has been recommended as a useful test to distinguish obstructed from dilated, but not obstructed, urinary systems. Twenty-four diuretic renograms were performed in 20 children, and a good correlation was found with other indicators of obstruction. The sensitivity for identifying obstruction was 83%, with a specificity of 94%. Severe hydroureteronephrosis may blunt or even mask the effect of diuresis on causing emptying of the tracer from the renal pelvis. Some kidneys did not drain well with the patient in a supine position but did empty with a change of position; these kidneys should be regarded as nonobstructed.
The relevance of minimum urethral resistance in prostatism.
To determine whether the minimum urethral resistance was useful to identify bladder outlet obstruction in prostatectomy candidates, 46 patients undergoing transurethral resection of the prostate were evaluated by means of detailed symptom analysis, cystoscopy, rectal examination and post-void residual urine determination. In addition, each patient underwent extensive urodynamic testing, the results of which were not made available to the operating urologist as patients were selected for surgery. This prospective, blind evaluation has been completed in 33 and 15 patients 3 and 12 months postoperatively, respectively. A correlation is noted between the minimum urethral resistance, and symptomatology and uroflowmetry but no correlation was identified with prostatic length and the resected prostatic weight. The minimum urethral resistance was not useful in predicting which patients would benefit from transurethral resection of the prostate. It is concluded that symptom analysis generally is a better predictor of the outcome of transurethral resection of the prostate than is minimum urethral resistance.
Autonomic dysreflexia: a cause of postoperative hemorrhage. Case report.
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Treatment of urinary incontinence with the artificial sphincter.
From December 1977 to November 1978, 21 American Medical System 742A artificial sphincters were implanted in 19 male and 2 female patients with a variety of etiologies for incontinence, including post-prostatectomy incontinence, female incontinence following unsuccessful bladder neck suspension and myelodysplasia. Urodynamic evaluation before sphincter placement is reviewed. Eight patients (38 per cent) had excellent or improved results, while 5 (24 per cent) remained unchanged and 5 (24 per cent) suffered urethral erosion. Between January and September 1979, 18 patients had placement of the 742B or 742C model of the sphincter. Again a variety of etiologies for incontinence was represented, including 11 patients with postoperative male incontinence (10 after prostatectomy). Over-all, 9 patients (50 per cent) had excellent or improved results, while 6 (33 per cent) suffered urethral erosion. Of the post-prostatectomy group 50 per cent had excellent or improved results, while 50 per cent had erosion. Failures occurred more frequently in women, in patients with recurrent urinary tract infections or neurogenic bladders, and after failure of previous anti-incontinence surgical procedures.