Does Male Circumcision Protect against Sexually Transmitted Infections? Arguments and Meta-Analyses to the Contrary Fail to Withstand Scrutiny

We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, contrary to current evidence, that male circumcision increases the risk of various common sexually transmitted infections (STIs). Our detailed scrutiny reveals that these meta-analyses (1) failed to include results of all relevant studies, especially data from randomized controlled trials, (2) introduced bias through use of inappropriate control groups, (3) altered original data, in the case of human papillomavirus (HPV), by questionable adjustments for “sampling bias,” (4) failed to control for confounders through use of crude odds ratios, and (5) used unnecessarily complicated methods without adequate explanation, so impeding replication by others. Interventions that can reduce the prevalence of STIs are important to international health. Of major concern is the global epidemic of oncogenic types of HPV that contribute to the burden of genital cancers. Meta-analyses, when well conducted, can better inform public health policy and medical practice, but when seriously flawed can have detrimental consequences. Our critical evaluation leads us to reject the findings and conclusions of Van Howe on multiple grounds. Our timely analysis thus reaffirms the medical evidence supporting male circumcision as a desirable intervention for STI prevention.

Comparative Study of Snodgrass and Mathieu’s Procedure for Primary Hypospadias Repair

Objective. Present study was undertaken to compare the results of two single stage hypospadias repairs, namely, Tubularized Incised Plate (TIP) repair and Mathieu’s repair. Methods. The study included 100 patients of distal penile hypospadias, from January, 2008 to January, 2013. After a detailed history, local examination was performed with reference to the site of meatus, shape of glans, and presence of chordee. TIP repair was performed in 52 patients and Mathieu’s repair in 48 patients. On follow-up, the patients were examined for the position of meatus, shape of meatus, urinary stream, urethrocutaneous fistula, and stricture formation. Results. The mean age of presentation was 6.2 ± 3.2 years (range 1.5–15years). The mean operative time was 63.7 ± 14.3 (45–90) minutes and 95.0 ± 19.1 (70–125) minutes in TIP and Mathieu’s repair, respectively.Complications after surgery were urethero cutaneous fistula in 3(5.76%) and 7 (14.5%), meatal stenosis in 3(5.33%) and 4(8.33%), wound infection in 19.2% and 8.3% cases in TIP repair and Mathieu repair, respectively. The shape of meatus was slit-like and vertically oriented in 48(92.3%) patients who had undergone TIP repair. Conclusion. The Snodgrass repair is significantly faster, with more natural cosmetic appearance of the meatus than the Mathieu’s repair.

Outcomes of Dorsal and Ventral Buccal Graft Urethroplasty at a Tertiary Hospital in Uganda

Purpose. Although the use of buccal mucosa in substitution urethroplasty has been practiced for some years, it has not been free of controversy over which surgical technique is the most appropriate to use. There is paucity of data in Sub-Saharan Africa about its success; this study presents the outcomes of dorsal and ventral buccal graft urethroplasty at a sub-Saharan tertiary hospital. Methods. This is a prospective study in which buccal mucosa was used for ventral and dorsal grafts; followup was up to two years. All patients provided informed written consent for the procedures. Results. Seventy-two patients with bulbar urethral strictures underwent buccal graft one-stage urethroplasty. Mean age was 55 years; etiology of the strictures was postinflammatory due to urethritis from sexually transmitted infections 97% (70/72) and trauma 3% (2/72). Buccal mucosa grafts were harvested from the cheek using a two-team approach. Grafts were placed on the ventral and dorsal urethral surfaces in 32 and 40 cases, respectively; the success rate was 84 and 80%, respectively. Repeated urethroplasty was successfully done among 10% (7/72) and patients reported resolution of symptoms in the follow-up period. Conclusion. There was no difference between dorsal and ventral onlay buccal graft outcomes for bulbar urethral strictures. The success rate was 80 to 84%.

Alpha 1-Adrenoceptor Blocker May Improve Not Only Voiding But Also Storage Lower Urinary Tract Symptoms Caused by 125I Brachytherapy for Prostate Cancer

Purpose. To assess changes in lower urinary tract symptoms (LUTS) within 1 year after brachytherapy in patients receiving alpha 1-adrenoceptor antagonists. Methods. We retrospectively evaluated 116 patients who underwent 125I prostate brachytherapy in our institute. Seventy-one patients were treated with a combination of external beam radiation therapy and brachytherapy. Alpha 1-adrenoceptor antagonists were prescribed to all patients after brachytherapy. International Prostate Symptom Score (IPSS) forms and postvoid residual urine volume were recorded at all follow-up visits. Results. Forty-nine patients were given tamsulosin hydrochloride, 32 were given silodosin hydrochloride, and 35 were given naftopidil for up to 6 months after seed implantation. Patients given tamsulosin or naftopidil tended to show a higher peak IPSS and slower recovery to baseline values than those given silodosin. The patients given naftopidil showed an insufficient recovery in storage symptoms in naftopidil group in comparison with tamsulosin group at 3 months and with silodosin group at 6 and 9 months. Conclusions. In the management of LUT after brachytherapy, silodosin may provide a more favorable improvement. Silodosin and tamsulosin may have an advantage in improving not only voiding but also storage lower urinary tract symptoms after brachytherapy.

Neutrophil-Lymphocyte Ratio in Small Renal Masses

Introduction. To evaluate the association between preoperative neutrophil-lymphocyte ratio (NLR) and clinicopathologic characteristics in patients with small renal masses (SRM). Methods. Retrospective chart reviews of patients with renal masses ≤4 cm who underwent nephrectomy from January 2007 to July 2012 were conducted. Multivariable linear regression was used to examine the association between preoperative NLR and clinicopathologic variables. Results. In 1001 patients, we noted higher mean preoperative NLR in men (3.0±1.4 versus 2.6±1.3 in women, P<0.01) and Caucasians (2.9±1.4 versus 1.9±0.9 in African Americans, P<0.01) but no significant differences in patients with low (I-II) versus high (III-IV) American Society of Anesthesiologists (ASA) scores (2.8±1.4 versus 2.9±1.5, P=0.18) or benign versus malignant pathology (2.9±1.4 versus 2.8±1.3, P=0.75). Spearman correlation analysis (ρ) showed preoperative NLR significantly correlated with age (ρ=0.15, P<0.01) and preoperative serum creatinine (Crea) [ρ=0.13, P<0.01]. On multivariable linear regression analysis older age, male gender, Caucasian race, and preoperative Crea were predictive of higher preoperative NLR, but ASA score and tumor pathology were not. Conclusions. In patients with SRM, we found no association between preoperative NLR and tumor pathology.

Novel Closing Method Using Subcutaneous Continuous Drain for Preventing Surgical Site Infections in Radical Cystectomy

To reduce the incidence of surgical site infection (SSI) after radical cystectomy, a new closing method using subcutaneous continuous aspiration drain was developed and compared to the conventional closing method. The new method involved (a) closed aspiration with an indwelling aspiration drain without suture of the subcutaneous fat and (b) covering with hydrocolloid wound dressing after suture of the dermis with 4-0 absorbable thread and reinforcement using strips. The incidence of SSI was significantly improved by using the new method. Furthermore, univariate and multivariate analysis associated with SSI revealed that the new closing method was statistically correlated with 85% reduction of SSI (odds ratio: 0.15, 95% confidence interval: 0.03–0.69).Our new method using continuous aspiration with subcutaneous drain is useful for preventing SSI through removal of effusions and reduction of dead space by apposition of the subcutaneous fat.

Retrograde Robotic Radical Prostatectomy: Description of a New Technique and Early Perioperative Outcomes

Objectives. This research was conducted to describe a novel technique for performing robotic-assisted laparoscopic prostatectomy (RALP) using a retrograde approach that mimics the classic open surgical technique. Methods. From June 2009 to March 2011, we performed 18 nonconsecutive RALPs using a novel retrograde approach. Patients were initially selected with D’Amico low to intermediate risk disease. Pre-, intra-, and postoperative data were analyzed in all patients. Results. All 18 patients had successful surgery without any intraoperative complications. Mean preoperative PSA was 6.0 ng/mL. Nine patients had biopsy Gleason score (GS) 6, seven patients had GS 7, and two patients had GS 8. Fourteen patients had clinical stage T1c and four patients had stage T2a. Mean operative time was 198 minutes, with a mean robotic console time of 168 minutes. Fifteen patients had T2 disease on the final pathology and three had T3 disease. With a median follow-up of 11 months, 10 patients had an undetectable PSA. Conclusions. Our early experience with retrograde robotic-assisted laparoscopic prostatectomy demonstrates the feasibility of this approach with early outcomes comparable to the contemporary antegrade approach. Long-term study with a greater number of patients will be necessary to fully evaluate the oncologic and functional outcomes using this technique.

Colicin E2 Expression in Lactobacillus brevis DT24, A Vaginal Probiotic Isolate, against Uropathogenic Escherichia coli

Novel therapeutic approaches are needed to combat the urinary tract infection in women. During menstruation elevated protein concentration and increase in oxygen and carbon dioxide concentrations with decrease in vaginal Lactobacilli all together contribute to urinary tract infections. Lactobacillus species are a predominant member of the vaginal microflora and are critical in the prevention of a number of urogenital diseases. In order to increase antimicrobial potential of vaginal Lactobacilli, bacteriocin colicin E2 which has specific activity against uropathogenic Escherichia coli has been overexpressed in vaginal probiotic Lactobacillus brevis DT24. Recombinant Lactobacillus brevis DT24 expressing colicin E2 showed much higher inhibitory activity against uropathogenic Escherichia coli than wild type L. brevis DT24 in vitro. Efficacy of probiotic Lactobacillus brevis DT24 expressing colicin E2 protein is required for further in vivo evaluation.

Can Tumor Necrosis Factor-α and Interleukin-6 Be Used as Prognostic Markers of Infection following Ureteroscopic Lithotripsy?

Introduction. Ureteroscopic lithotripsy (URS) although highly effective for the treatment of ureteral stones is associated with certain complications, the more common of which are postoperative fever and infection. In the present study we aimed to evaluate the levels of serum cytokines in patients undergoing ureteroscopic lithotripsy and investigate any possible correlation between levels of cytokines and infectious complications after URS. Materials and Methods. Thirty patients (19 males, 11 females), with a mean age of 47 (range: 26–68) that underwent URS lithotripsy for ureteral stones, and 10 healthy volunteers serving as the control group were enrolled in this study. Serum samples for TNF-α and IL-6 were obtained before surgical intervention and after 1, 24, and 48 hours and 2 , 24, and 48 hours, respectively. The preoperative and postoperative levels were compared and correlated with the possible complications after URS. Results. Serum TNF-α levels were statistically significant, increased 1 hour (P=0.0083) and 48 hours (P<0.001) after operation. IL-6 levels were found statistically significant, elevated after 2 and 24 hours from the URS (P<0.001). In 2 patients we observed postoperative fever (>38.5°C). These two patients had high preoperative values of TNF-α and IL-6 ( 30 and 50 pg/mL, resp.) and these values increased postoperatively. Conclusion. High preoperative levels of serum TNF-α and IL-6 may indicate a predisposition for postoperative inflammation and infection following URS lithotripsy.

Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma: A Review of the Historical Literature and Its Role in the Era of Targeted Molecular Therapy

Renal cell carcinoma presents with metastatic disease in approximately 30% cases. While surgical intervention remains the standard of care for organ confined disease, its role is limited in the management of metastatic disease. Over the last decade, cytoreductive nephrectomy prior to immunotherapy has demonstrated significant improvement in overall survival for appropriately selected patients. This review summarizes the evidence for the role of cytoreductive nephrectomy in combination with immunotherapy and discusses its potential role in the current era of targeted molecular therapy.