Need for upper urinary tract stenting in cases of ureteral orifice injury during laser enucleation of the prostate

Introduction

Benign prostatic hyperplasia (BPH) can be associated with marked intravesical protrusion, placing ureteral orifices at risk for injury during bladder outlet procedures.

Aim

To determine whether ureteral stenting is necessary in cases of ureteral orifice injury during laser enucleation.

Materials and methods

Retrospective study included 465 patients with bladder outlet obstruction (IPSS?>?20, Qmax?<?10) secondary to BPH who were managed with thulium fiber laser (ThuFLEP) or holmium laser enucleation of the prostate (HoLEP). In seven patients, the ureteral orifices were injured during surgery (3—HoLEP; 4—ThuFLEP). Three of the seven patients underwent intraoperative stenting of the upper urinary tract (1—HoLEP; 2—ThuFLEP). In four cases, stenting was not performed (2—HoLEP; 2—ThuFLEP). The follow-up period was 6 months.

Results

Postoperatively, none of the patients with a stent in the upper urinary tract exhibited signs of pelvicalyceal system (PCS) dilatation or inhibited urine flow from the kidney (assessed with abdominal ultrasound at 1, 3, 10, and 30 days after surgery). In two patients without stents, follow-up revealed no dilatation of the PCS. The other two patients without stents developed asymptomatic dilatation of the PCS (the pelvis—up to 1.5 cm; the calyx—up to 0.5 cm). At 1 month after surgery, no patients had dilatation of the PCS.

Conclusions

Upper urinary tract stenting in cases of intraoperative ureteral orifice injury during laser enucleation of the prostate for BPH may not be warranted.

     

Meta-analysis of metabolic syndrome and benign prostatic hyperplasia in Chinese patients

Purpose

To investigate the impact of metabolic syndrome (MetS) on benign prostatic hyperplasia (BPH), focusing on MetS and its relationship with prostate volume and prostate-specific antigen (PSA) in Chinese patients by performing a meta-analysis.

Methods

We systematically searched the PubMed, Embase, China National Knowledge Infrastructure, Wanfang, and VIP databases from inception to November 2014. All studies investigating the impact of MetS on prostate volume and PSA among BPH patients were included. Pooled mean difference (WMD) and 95 % confidence interval (CI) were used to analyze the difference between patients with MetS and those without MetS.

Results

Sixteen studies enrolled 1895 BPH patients, of whom 2224 had MetS. Compared with those without MetS, BHP patients with MetS had significantly higher total prostate volume (WMD 10.15 ml; 95 % CI 7.37–12.93) and serum PSA level (WMD 0.53 ng/ml; 95 % CI 0.17–0.88), respectively. In addition, annual prostate growth rate in patients with MetS was higher (WMD 0.49 ml/year; 95 % CI 0.24–0.73) than in those without MetS.

Conclusions

This meta-analysis supports that the presence of MetS increases total prostate volume and annual prostate growth rate in Chinese BPH patients. Future studies are needed to explain the detailed underlying mechanisms.

     

Evaluation of serum prolidase activity and oxidative stress markers in men with BPH and prostate cancer

Background

Prostate cancer (PCa) and benign prostatic hyperplasia (BPH) are diseases of elderly men and are related to increased oxidative stress (OS). Although prolidase has a role in collagen metabolism, it is also used to evaluate OS in many diseases. However, there is a lack of data about serum prolidase activity (SPA) in prostate cancer. The aim of this study was to evaluate and compare SPA levels in males with BPH and PCa.

Methods

Evaluation was made of a total of 81 men who underwent transrectal ultrasound guided prostate biopsy for a definitive diagnosis due to high PSA levels. Patients were separated into 2 groups as BPH and PCa patients. Pre-biopsy malondialdehyde (MDA), superoxide dismutase (SOD), PSA levels and serum prolidase activities (SPA) were compared between the groups and the correlations of SPA with the other parameters were also investigated in both groups.

Results

BPH was diagnosed in 51 patients and PCa in 30. The mean age of patients was similar in both groups as 63.25?±?5.81 years in the BPH group 65.30?±?7.35 years in the PCa group(p:0.081). The median MDA and SOD levels were insignificantly increased in the PCa patients. SPA values were similar in BPH and PCa patients. SPA did not correlate with age, PSA, MDA or SOD levels in either group.

Conclusions

Our study results revealed that serum prolidase activity is similar in BPH and PCa cases and is not correlated with MDA, SOD or PSA levels.

     

Effects of metformin on prostatic tissue of rats with metabolic syndrome and benign prostatic hyperplasia

Objectives

To investigate the efficacy of insulin sensitizer on prostatic tissue in animal model with benign prostatic hyperplasia (BPH) secondary to metabolic syndrome (MetS).

Methods

Models were established by providing Sprague–Dawley rats with high fat diet (HFD) combined with metformin or not. All objects were killed 40 days later with prostatic tissue being removed, weighed before stained, as well as the expression level of insulin-like growth factor I (IGF-1) and receptor (IGF-1R) being measured, and the level of insulin resistance (IR) has also been evaluated.

Results

Model has been successfully established. Level of prostatic hyperplasia and IR as well as IGF-1 and IGF-1R expressions in the blank and saline control subunits of HFD group was higher than that of normal diet group (P < 0.05). In the subunit of metformin, along with the suppression of IR, the level of prostatic hyperplasia and the expression of IGF-1 pathway have both decreased (P < 0.05).

Conclusion

MetS can promote the growth of prostate during the formation of central obesity and IR. IGF-1 pathway may have an important role in the induction of BPH following IR. The application of metformin can suppress the expression of IGF-1 and IGF-1R, thus preventing the promotive effect of IR on prostate tissue in animal model of MetS.

     

RANKL/RANK/OPG cytokine receptor system: mRNA expression pattern in BPH,primary and metastatic prostate cancer disease

Background

The cytokine system RANKL (receptor activator of NF-κB ligand), its receptor RANK and the antagonist OPG (osteoprotegerin) play a critical role in bone turnover. Our investigation was conducted to describe the gene expression at primary tumour site in prostate cancer patients and correlate the results with Gleason Score and PSA level.

Methods

Seventy-one samples were obtained from prostate cancer patients at the time of radical prostatectomy and palliative prostate resection (n = 71). Patients with benign prostate hyperplasia served as controls (n = 60). We performed real-time RT-PCR after microdissection of the samples.

Results

The mRNA expression of RANK was highest in tumour tissue from patients with bone metastases (p < 0.001) as compared to BPH or locally confined tumours, also shown in clinical subgroups distinguished by Gleason Score (< 7 or ≥ 7, p = 0.028) or PSA level (< 10 or ≥ 10 µg/l, p = 0.004). RANKL and OPG mRNA expression was higher in tumour tissue from patients with metastatic compared to local disease. The RANKL/OPG ratio was low in normal prostate tissue and high tumours with bone metastases (p < 0.05). Expression of all three cytokines was high in BPH tissue but did not exceed as much as in the tumour tissue.

Conclusion

We demonstrated that RANK, RANKL and OPG are directly expressed by prostate cancer cells at the primary tumour site and showed a clear correlation with Gleason Score, serum PSA level and advanced disease. In BPH, mRNA expression is also detectable, but RANK expression does not exceed as much as compared to tumour tissue.

     

Combined prostatic urethral lift and remodeling of the prostate and bladder neck: a modified transurethral approach in the treatment of symptomatic lower urinary tract obstruction

Purpose

The aim of the study was to evaluate the feasibility and safety of combining prostatic urethral lift (PUL) and a limited resection of the prostatic middle lobe or bladder neck incision in the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

Methods

Twenty-eight patients were treated at two tertiary centers and followed prospectively. Patient evaluations included patient characteristics, relief of LUTS symptoms, erectile and ejaculatory function, continence, operative time and adverse events. Patients were followed for a mean of 10.9 months.

Results

Patient characteristics were as follows: age 66 years (46–85), prostate volume 39.6 cc (22–66), preoperative IPSS/AUASI 20 (6–35)/QoL 3.9 (1–6)/peak flow 10.5 mL/s (4.0–19)/post-void residual volume (PVR) 123 mL (0–500). Mean operating time was 31 min (9–55). Postoperative complications were minor except for the surgical retreatment of one patient for blood clot retention (Clavien 3b). One patient required catheterization due to urinary retention. Reduction of symptoms (IPSS ? 59.6%), increase in QoL (+ 49.0%), increase in flow (+ 111.5%), and reduction of PVR (? 66.8%) were significant. Antegrade ejaculation was always maintained.

Conclusion

Our data suggest that a combination of PUL and transurethral surgical techniques is feasible, safe, and effective. This approach may be offered to patients with moderate size prostates including those with unfavorable anatomic conditions for PUL. This procedure is still ‘minimally invasive’ and preserves sexual function. In addition, it may add to a higher functional efficacy compared to PUL alone.

Study register number

DRKS00008970.

     

Multicenter international experience of 532 nm-laser photo-vaporization with Greenlight XPS in men with large prostates (prostate volume &gt; 100 cc)

Purpose

To evaluate the outcomes and durability of photoselective vaporization of the prostate (PVP) using the XPS-180 system in patients with a large prostate volume (PV)?>?100 cc at 4 years of follow-up in a large, multicenter experience.

Methods

438 men with pre-operative transrectal ultrasound (TRUS) PV?>?100 cc were treated in eight experienced centers in Canada, USA, and in France with the Greenlight XPS laser using PVP for the treatment of symptomatic BPH. IPSS, Qmax, postvoid residual (PVR), and prostate-specific antigen (PSA) were measured at 6, 12, 24, 36, and 48 months. Durability was evaluated using BPH retreatment rate at 12, 24, and 36 months.

Results

Median PV and PSA were 121 cc and 6.3 ng/dl. Indwelling catheter at the time of surgery was observed in 37% of men. Median operative, laser time, and energy applied were 90 min, 55 min, and 422 kJ, respectively. Median energy delivery was 3.4 kJ/cc of prostate per case. Outpatient surgery was feasible with median length of stay at 24 h. IPSS, Qmax and PVR were significantly improved at all endpoints including at 48 months. Moreover, surgical BPH retreatment rates were 5.4 and 9.3% at 24 and 36 months. Interestingly, characteristics of retreated men include: energy delivery 2.4 vs. 3.4 kJ/cc of prostate (p?=?0.02) and PSA reduction at 12 months 26 vs. 51% (p?=?0.02).

Conclusions

PVP using Greenlight XPS-180W can potentially provide durable improvements with regard to functional outcomes at 4 years. However, rising retreatment rates after 3 years is of concern. This highlights the imperative need of utilizing a standardized surgical technique (enucleation-like-defect) and an optimal energy density >3KJ/cc.

     

Fexapotide triflutate: results of long-term safety and efficacy trials of a novel injectable therapy for symptomatic prostate enlargement

Purpose

These studies were undertaken to determine if fexapotide triflutate 2.5 mg transrectal injectable (FT) has significant long-term (LT) safety and efficacy for the treatment of benign prostatic hyperplasia (BPH).

Methods

Two placebo controlled double-blind randomized parallel group trials with 995 BPH patients at 72 sites treated 3:2 FT:placebo, with open-label FT crossover (CO) re-injection in 2 trials n = 344 and long-term follow-up (LF) 2–6.75 years (mean 3.58 years, median 3.67 years; FT re-injection CO mean 4.27 years, median 4.42 years) were evaluated. 12 months post-treatment patients elected no further treatment, approved oral medications, FT, or interventional treatment. Primary endpoint variable was change in Symptom Score (IPSS) at 12 months and at LF. CO primary co-endpoints were 3-year incidence of (1) surgery for BPH in FT treated CO patients versus patients crossed over to oral BPH medications and (2) surgery or acute urinary retention in FT-treated CO placebo patients versus placebo patients crossed over to oral BPH medications. 28 CO secondary endpoints assessed surgical and symptomatic outcomes in FT reinjected patients versus conventional BPH medication CO and control subgroups at 2 and 3 years.

Results

FT injection had no significant safety differences from placebo. LF IPSS change from baseline was higher in FT treated patients compared to placebo (median FT group improvement ? 5.2 versus placebo ? 3.0, p < 0.0001). LF incidence of AUR (1.08% p = 0.0058) and prostate cancer (PCa) (1.1% p = 0.0116) were both reduced in FT treated patients. LF incidence of intervention for BPH was reduced in the FT group versus oral BPH medications (8.08% versus 27.85% at 3 years, p < 0.0001). LF incidence of intervention or AUR in placebo CO group with FT versus placebo CO group with oral medications was reduced (6.07% versus 33.3% at 3 years, p < 0.0001). 28/28 secondary efficacy endpoints were reached in LF CO re-injection studies.

Conclusions

FT 2.5 mg is a safe and effective transrectal injectable for LT treatment of BPH. FT treated patients also had reduced need for BPH intervention, and reduced incidence of PCa and AUR.

     

Current impact of age and comorbidity assessment on prostate cancer treatment choice and over/undertreatment risk

Purpose

We evaluated the influence of age and comorbidity (Charlson score assessment) on localized prostate cancer therapeutic management and the risk of prostate cancer over- and under-treatment.

Methods

Among the 2571 prostate cancer cases diagnosed in 2011, a subset of 633 patients was randomly selected from the prospectively accrued cohort of the Regional Cancer Registry, among the 17 participating institutions. Treatment distributions were examined for patients at each individual prostate cancer risk, age and comorbidity level and analyzed by multivariate logistic regression analysis.

Results

Treatments with curative intent were observed less often when age increased (p < 0.001). We found no impact of the Charlson score on the selection of a curative treatment [HR 0.89, 95 % CI (0.70–1.15)]. A 20 % overtreatment rate was reported in low-risk prostate cancer patients. For younger patients (65–75 years) with high comorbidity score, a 14 % overtreatment rate was observed. Conversely, a 16 % undertreatment rate was reported in older patients >75 years without any significant comorbidity.

Conclusion

A better consideration of comorbidities could significantly reduce overtreatment in patients <75 year and promote curative treatment in aggressive prostate cancer for older patients without any significant comorbidity.

     

Results of transurethral resection of the prostate in renal transplant recipients: a single center experience

Objectives

The aim of this study was to retrospectively evaluate the early and long-term results of renal transplantation (RT) patients undergoing transurethral resection of the prostate (TURP) due to benign prostate hyperplasia (BPH).

Materials and methods

Eighty-nine patients with RT performed in our hospital underwent TURP between November 2008 and March 2016. Results were evaluated along with early and long-term complications. Patients were followed up for a minimum of 12 months.

Results

The mean age of the patients was 61.4 ± 7.4 years. The median duration of dialysis was 28 (0–180) months. The median duration between transplantation and TURP was 13 (0–84) months. Before TURP, the mean serum creatinine (sCr) was 1.99 ± 0.83 mg/dL and the mean prostate volume was 33.3 ± 14.6 cm³. The mean Q _max, Q _ave and PVR values were 9.5 ± 3.7, 5.2 ± 2.2 ml/s and 85(5–480) mL, respectively. None of the patients developed perioperative and postoperative major complications. Twelve patients (13.4%) developed urinary tract infections in the postoperative period. The sCr, IPSS and PVR values significantly decreased, while Q _max and Q _ave significantly increased at the 1-month follow-up. At the 6-month follow-up, 63 (70.8%) patients had retrograde ejaculation. Patients were followed up for a median of 42 (12–96) months. Three patients (3.3%) were re-operated for bladder neck contracture and eight (8.9%) patients were re-operated for urethral stricture.

Conclusion

TURP can be safely and successfully applied for the treatment of BPH after RT. LUTS and renal functions significantly improve after the operation. Patients should be followed up for UTIs in the short term and for urethral stricture in the long term.

     

Prostatic artery embolization for the treatment of symptomatic benign prostatic hyperplasia in men ≥75 years: a prospective single-center study

Purpose

To compare the safety and efficacy of PAE for the treatment of benign prostatic hyperplasia (BPH) in men ≥75 years, who we defined as elderly, to those <75 years.

Methods

A total of 157 patients diagnosed with lower urinary tract symptoms (LUTS) due to BPH underwent PAE. Group A (n = 52) included patients ≥75 years, and group B (n = 105) included patients <75 years. Follow-up was performed using the International Prostate Symptoms Score (IPSS), quality of life (QoL), peak urinary flow rate (Q _max), post-void residual volume (PVR), the International Index of Erectile Function short form (IIEF-5), prostatic-specific antigen (PSA), and prostate volume (PV), at 1, 3, 6, and every 6 months thereafter.

Results

More coexistent systemic diseases were identified in group A than in group B (P < 0.05). Technical success rate of PAE was 90.4 % in group A and 95.2 % in group B (P = 0.06). A total of 147 patients had completed the follow-up with a mean of 20 months. Compared with the baseline, there were significant improvements in IPSS, QoL, Q _max, PV, PVR, and PSA in both groups after PAE. There were no significant differences in the changes of IPSS, Q _max, PVR, PSA, and IIEF-5 between groups after PAE. No major complications were noted.

Conclusion

PAE could be used as an effective, safe, and well tolerable method in the treatment of elderly symptomatic BPH patients, similarly to younger patients, and it may play an important role in patients in whom medical therapy has failed, who are at high surgical and anesthetic risk or who refuse the standard surgical therapy.

     

Vitamin D and prostate cancer prognosis: a Mendelian randomization study

Purpose

Decreased vitamin D levels have been associated with prostate cancer, but it is unclear whether this association is causal. A functional single-nucleotide polymorphism (SNP) in the group-specific component (GC) gene (T > G, rs2282679) has been associated with 25-hydroxy (25-OH) vitamin D and 1.25 dihydroxy (1.25-OH2) vitamin D levels.

Methods

To examine the hypothesized inverse relationship between vitamin D status and prostate cancer, we studied the association between this SNP and prostate cancer outcome in the prospective PROCAGENE study comprising 702 prostate cancer patients with a median follow-up of 82 months.

Results

GC rs2282679 genotypes were not associated with biochemical recurrence [hazard ratios (HR) 0.91, 95 % confidence interval (CI) 0.73–1.12; p = 0.36], development of metastases (HR 1.20, 95 % CI 0.88–1.63; p = 0.25) or overall survival (HR 1.10; 95 % CI 0.84–1.43; p = 0.50).

Conclusions

A causal role of vitamin D status, as reflected by GC rs2282679 genotype, in disease progression and mortality in prostate cancer patients is unlikely.

     

Prospective randomized study comparing monopolar with bipolar transurethral resection of prostate in benign prostatic obstruction: 36-month outcomes

Objectives

Monopolar transurethral resection of the prostate (TURP) is the gold standard surgical treatment for bothersome moderate to severe lower urinary tract symptoms (LUTS) secondary to benign prostate obstruction. The aim of the study is to compare monopolar versus bipolar TURP focusing on operative and functional outcomes, and evaluating complications with a long-term follow-up.

Methods

From January 2007 to July 2014, a total of 497 patients were randomized and prospectively scheduled to undergo bipolar (251) or monopolar (246) TURP. International prostate symptom score (IPSS), IPSS-Quality of life (QoL), post-void residual and maximum flow rate were assessed preoperatively and postoperatively at 3, 12, 24 and 36 months. Operative time, length of catheterization and hospitalization were all recorded. Complications were classified and reported.

Results

All patients completed the 36-month follow-up visit. Perioperative results showed no statistical significance between the two groups in terms of catheterization days, post-void residual, IPSS, IPSS-QoL score. The hospitalization length was found statistically significant in favor of the bipolar group. The 3-, 12-, 24- and 36-month follow-up showed significant and equal improvements in LUTS related to BPO in the two treatment groups. Regarding TURP complications, significant differences were observed in relation to urethral strictures, blood transfusion and TUR syndrome in favor of the bipolar group.

Conclusions

Monopolar and bipolar TURP are safe and effective techniques for BPH management. Bipolar TURP in our prospective study reported the same efficacy of monopolar prostate resection, with a significant reduction of related complications.

     

Early results and complications of prostatic arterial embolization for benign prostatic hyperplasia

Purpose

To review current knowledge on clinical outcomes and peri-operative complications of prostatic arterial embolization (PAE) in patients treated for lower urinary tract symptoms (LUTS) related to benign prostatic obstruction (BPO).

Methods

A systematic review of the literature published from January 2008 to January 2015 was performed on PubMed/MEDLINE.

Results

Fifty-seven articles were identified, and four were selected for inclusion in this review. Only one randomized clinical trial compared transurethral resection of the prostate (TURP) to PAE. At 3 months after the procedure, mean IPSS reduction from baseline ranged from 7.2 to 15.6 points. Mean urine peak-flow improvement ranged from +3.21 ml/s to +9.5 ml/s. When compared to TURP, PAE was associated with a significantly lower IPSS reduction 1 and 3 months after the procedure. A trend toward similar symptoms improvement was however reported without statistical significance from 6 to 24 months. Major complications were rare with one bladder partial necrosis due to non-selective embolization. Mild adverse events occurred in 10 % of the patients and included transient hyperthermia, hematuria, rectal bleeding, painful urination or acute urinary retention. Further comparative studies are mandatory to assess post-operative rates of complications, especially acute urinary retention, after PAE and standard procedures.

Conclusion

Early reports suggest that PAE may be a promising procedure for the treatment of patients with LUTS due to BPO. However, the low level of evidence and short follow-up of published reports preclude any firm conclusion on its mid-term efficiency. Further clinical trials are warranted before any use in clinical practice.

     

PHI and PCA3 improve the prognostic performance of PRIAS and Epstein criteria in predicting insignificant prostate cancer in men eligible for active surveillance

Purpose

To assess the performance of prostate health index (PHI) and prostate cancer antigen 3 (PCA3) when added to the PRIAS or Epstein criteria in predicting the presence of pathologically insignificant prostate cancer (IPCa) in patients who underwent radical prostatectomy (RP) but eligible for active surveillance (AS).

Methods

An observational retrospective study was performed in 188 PCa patients treated with laparoscopic or robot-assisted RP but eligible for AS according to Epstein or PRIAS criteria. Blood and urinary specimens were collected before initial prostate biopsy for PHI and PCA3 measurements. Multivariate logistic regression analyses and decision curve analysis were carried out to identify predictors of IPCa using the updated ERSPC definition.

Results

At the multivariate analyses, the inclusion of both PCA3 and PHI significantly increased the accuracy of the Epstein multivariate model in predicting IPCa with an increase of 17 % (AUC = 0.77) and of 32 % (AUC = 0.92), respectively. The inclusion of both PCA3 and PHI also increased the predictive accuracy of the PRIAS multivariate model with an increase of 29 % (AUC = 0.87) and of 39 % (AUC = 0.97), respectively. DCA revealed that the multivariable models with the addition of PHI or PCA3 showed a greater net benefit and performed better than the reference models. In a direct comparison, PHI outperformed PCA3 performance resulting in higher net benefit.

Conclusions

In a same cohort of patients eligible for AS, the addition of PHI and PCA3 to Epstein or PRIAS models improved their prognostic performance. PHI resulted in greater net benefit in predicting IPCa compared to PCA3.

     

Multiparametric ultrasound-targeted biopsy compares favorably to multiparametric MRI-transrectal ultrasound fusion-targeted biopsy on initial biopsy of men at risk for prostate cancer

Purpose

The purpose this study is to evaluate the efficacy of multiparametric ultrasound-targeted biopsies in patients undergoing initial biopsy of the prostate for the suspicion of prostate cancer.

Materials and methods

A total of 167 patients who are biopsy naïve underwent multiparametric ultrasound-targeted biopsy of the prostate. All patients had a transrectal ultrasound which included gray-scale evaluation and color Doppler evaluation. 12-core biopsies were performed on all patients, based on sextant anatomy; however, all cores were directed toward visually abnormal areas of the prostate as identified by multiparametric ultrasound, when such areas were present.

Results

Of 167 patients undergoing biopsy, a total of 111 (66.5%) were positive for cancer. Of these, 78 (70.3%) had a Gleason grade ≥ 7 and 33 (29.7%) had a Gleason grade ≤ 6. Of those undergoing radical prostatectomy 29 of 38 (76.3%) had biopsy Gleason grade ≥ 7, while nine of 38 (23.7%) had a Gleason grade ≤ 6. Only four of 38 (10.5%) patients who had final pathologic staging underwent surgical therapy for disease of low-malignant potential (Gleason ≤ 6).

Conclusion

On initial biopsy for prostate cancer, multiparametric ultrasound-targeted biopsy compares favorably to the published performance of multiparametric MRI-TRUS fusion-targeted biopsy in terms of positive biopsy rate and the detection of disease of low-malignant potential.

     

Postoperative urinary retention after inguinal hernia repair: a single institution experience

Purpose

Inguinal hernia repair is a common general surgery procedure with low morbidity. However, postoperative urinary retention (PUR) occurs in up to 22% of patients, resulting in further extraneous treatments.This single institution series investigates whether patient comorbidities, surgical approaches, and anesthesia methods are associated with developing PUR after inguinal hernia repairs.

Methods

This is a single institution retrospective review of inguinal hernia from 2012 to 2015. PUR was defined as patients without a postoperative urinary catheter who subsequently required bladder decompression due to an inability to void. Univariate and multivariate logistic regressions were performed to quantify the associations between patient, surgical, and anesthetic factors with PUR. Stratification analysis was conducted at age of 50 years.

Results

445 patients were included (42.9% laparoscopic and 57.1% open). Overall rate of PUR was 11.2% (12% laparoscopic, 10.6% open, and p = 0.64). In univariate analysis, PUR was significantly associated with patient age >50 and history of benign prostatic hyperplasia (BPH). Risk stratification for age >50 revealed in this cohort a 2.49 times increased PUR risk with lack of intraoperative bladder decompression (p = 0.013).

Conclusions

At our institution, we found that patient age, history of BPH, and bilateral repair were associated with PUR after inguinal hernia repair. No association was found with PUR and laparoscopic vs open approach. Older males may be at higher risk without intraoperative bladder decompression, and therefore, catheter placement should be considered in this population, regardless of surgical approach.

     

Timing of initiation of renal replacement therapy for acute kidney injury: a systematic review and meta-analysis of randomized-controlled trials

Background

The effects of early renal replacement therapy (RRT) on mortality and renal recovery in patients with acute kidney injury (AKI) remain controversial. A systematic review and meta-analysis of randomized-controlled trials (RCTs) was performed.

Methods

MEDLINE, EMBASE and the Cochrane Library database (Cochrane Central Register of Controlled Trials) were searched to identify RCTs, investigating the effects of early RRT on patients with AKI.

Results

Six studies with a total of 1257 participants were included in this meta-analysis. Compared to late RRT, early RRT did not reduce the risk of mortality (RR 0.93, 95 % CI 0.68–1.26) or affect renal recovery (RR 0.88, 95 % CI 0.48–1.62) or composite endpoint (death or dialysis dependence) (RR 0.91, 95 % CI 0.71–1.17). There was no significant difference in adverse events in the analysis, between the early RRT and late RRT arms.

Conclusions

Early initiation of RRT for patients with AKI is not associated with decreased overall mortality or a delayed renal recovery rate. The optimal time to initiate RRT remains uncertain. Large scale and adequately powered RCTs are needed to detect the effects of early initiation of RRT in AKI patients.

     

A national benchmark for the initial assessment of men with LUTS: data from the 2010 Royal College of Physicians National Audit of Continence Care

Objective

To assess the degree of adherence to the current National Institute for Health and Clinical Excellence (NICE) guidelines on the management of urinary incontinence (UI) in men.

Design

Retrospective survey of male patients with UI in primary and acute hospital (AH) care as part of a national audit.

Setting

NHS AH and primary care (PC) trusts.

Sample

Twenty-five men <65 years old and 25 men ≥65 years old from each participating site.

Methods

All NHS trusts in England, Wales Northern Ireland and Channel Islands were eligible to participate. A web-based data collection form aligned to the NICE guidelines was constructed for the study. All data submitted to the audit were anonymous, and access to the web tool was password protected for confidentiality.

Results

Data were returned by 80 % (128/161) of acute trusts and 52 % (75/144) of PC trusts in England, and 71 % (10/14) of combined trusts from Northern Ireland, Wales and the Channel Islands including data on 559 men <65 and 1271 65+ from 141 sites within acute hospitals and 445 men <65 and 826 men 65+ in PC, a total of 3101 participants.

Conclusion

The majority of men seen within the NHS with LUTS do not receive management according to evidence-informed NICE guidelines; in general, older men are less likely to receive care that meets guideline standards than younger men.