Upper urinary tract: when is obstruction obstruction?

PURPOSE OF REVIEW: Obstruction can either be defined as a condition that hampers optimal renal development, or, more conservatively, as a restriction to urinary outflow that, when left untreated, will cause progressive renal deterioration. Currently, management is mostly based on the latter definition, but still remains controversial. Relevant work published before 2002 is considered because of a lack of recent literature. RECENT FINDINGS: Almost all reports comparing the primary conservative treatment of suspected obstruction versus early surgical intervention show comparable results, but there are different interpretations. The approach of 'watch and wait' for a unilateral hydronephrotic kidney with normal function is usually quite safe, with a very low risk of the permanent loss of renal function when accompanied by close monitoring, but it is certainly not without risk. At this time, the main underlying problems are that all currently applied diagnostic methods only detect effects secondary to obstruction, and the currently used definition of obstruction is based on a longitudinal observation period. The most relevant publication in the observation period was an in-depth report on a workshop in which the need for valid prospective markers for renal maldevelopment and 'significant' obstruction was expressed. SUMMARY: The optimal management of infants with congenital hydronephrosis and suspected obstruction will remain controversial until new diagnostic methods are able to discriminate between 'harmful' and 'harmless' obstruction. Most experts currently advocate primary conservative management, with close follow-up and surgical intervention only if there are signs of reduced function of the obstructed kidney.     

Upper urinary tract damage caused by ketamine snorting—A report of nine cases

ObjectiveThe toxicity of ketamine to genitourinary system not only involved in lower urinary tract, which include urinary frequency, urgency, suprapubic pain, dysuria and hematuria, but also upper urinary tracts. However, the reports of ketmaine-induced upper urinary tract damage were rare.Materials and methodsHerein, we reported nine ketamine abusers presented with moderate flank pain with hydronephrosis and lower urinary tract symptoms from three medical centers located around Taiwan.ResultsAll patients were diagnosed of hydronephrosis by sonography or abdominal computed tomography scans and 7 cases combined with acute kidney injury. They all receive ureteroscopy exam and double-J stenting. All of their flank pain and renal function impairment improved during follow up.ConclusionTo the best of our knowledge, currently there is no standard therapy for ketamine-induced nephropathy, we therefore supplied a therapeutic choice for those ketamine abuser combined with hydronephrosis and/or acute kidney injury.     

What are the oncological risks of minimal access surgery for the treatment of urinary tract cancer?

OBJECTIVES: A review of the oncological safety of minimal access surgery for the treatment of urinary tract cancers. The particular areas reviewed were port-site metastases, local tumour recurrence and long-term survival. METHODS: Review of the literature using Medline. RESULTS: There is a low rate of port-site metastases following laparoscopic surgery for urological malignancies, these are usually related to the stage and grade of the tumour. So far follow-up data shows that laparoscopic surgery for urological malignancy does not result in higher levels of local recurrence or shorter survival than open surgery. Percutaneous (PCN) and ureteroscopic (URS) resection of TCC of the upper urinary tract are acceptable forms of treatment for grade 1 and 2 TCCs even in patients with normal contralateral kidneys. However, for grade 3 TCC nephroureterectomy should be utilised because of increased risk of local recurrence (URS) and track seeding (PCN). CONCLUSIONS: Provided the principles of cancer surgery, combined with proper case selection are followed, minimal access surgery for urological cancer is safe and is rapidly emerging as the standard of care for many upper tract tumours.     

What is the efficacy of circumcision in boys with complex urinary tract abnormalities?

The risk of urinary tract infection (UTI) in normal boys is 1%. This risk is significantly increased in boys with congenital abnormalities of the urinary tract, which includes such abnormalities as vesico-ureteric reflux, obstructive megaureter (VUJO) and posterior urethral valves. UTI in these boys can lead to urosepsis, a potentially life-threatening complication, and in the longer term renal scarring complicating pyelonephritis can lead to chronic renal impairment or even end-stage renal disease. Circumcision has been shown in normal boys to reduce the risk of UTI by 90%, and potentially could be a simple intervention to reduce the risk of urosepsis and renal scarring. In order to make this decision a clinician really needs to have the answers to two questions: 1) What is the risk of UTI in this particular boy? 2) What is the evidence of efficacy of circumcision in this particular condition? This article reviews what evidence exists to make a calculation of the risk/benefit ratio for circumcision in boys with abnormalities of the urinary tract.     

Lower urinary tract symptoms suggestive of benign prostatic obstruction--what's the long-term effectiveness of medical therapies?

The primary treatment goal in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO) is symptom relief. However, it is also important to assess the effects of medical treatments on disease progression because this can lead to complications such as acute urinary retention or can ultimately require surgical treatment. In a placebo-controlled study finasteride was shown to reduce the incidence of acute urinary retention and the need for surgery in patients with LUTS suggestive of BPO. While alpha(1)-adrenoceptor antagonists are superior to finasteride with regard to LUTS relief, systematic studies on their effects on BPO complications and progression to surgery are not available. However, we reviewed a number of smaller studies which consistently indicate that alpha(1)-adrenoceptor antagonists may be at least as effective as finasteride in the prevention of acute urinary retention or the need for surgery in patients with LUTS suggestive of BPO. While this needs to be confirmed in adequately designed and powered studies, such evidence should be taken into consideration when choosing between alpha(1)-adrenoceptor antagonists and finasteride treatment.     

The destruction of the lower urinary tract by ketamine abuse: a new syndrome?

OBJECTIVE

To report the clinical spectrum seen in young abusers of street‐ketamine (regular recreational abusers of street‐ketamine, for its hallucinogenic effects) in Hong Kong, presenting with significant lower urinary tract symptoms (LUTS) but with no evidence of bacterial infection.

PATIENTS AND METHODS

We retrospectively analysed the clinical presentations, pelvic pain and urgency/frequency scores, video‐urodynamic studies, cystoscopy findings, histological features of bladder biopsies and radiological findings of 59 ketamine abusers who were referred to the urology units of Princess Margaret and Tuen Mun Hospital, Hong Kong, from March 2000 to December 2007.

RESULTS

Of the 59 patients, all had moderate to severe LUTS, i.e. frequency, urgency, dysuria, urge incontinence and occasionally painful haematuria. Forty‐two (71%) patients had a cystoscopy that showed various degrees of epithelial inflammation similar to that seen in chronic interstitial cystitis. All of 12 available bladder biopsies had histological features resembling those of interstitial cystitis. Urodynamically, either detrusor overactivity or decreased bladder compliance with or without vesico‐ureteric reflux was detected to some degree in all of 47 patients. Thirty patients (51%) had unilateral or bilateral hydronephrosis on renal ultrasonography, and four (7%) showed features suggestive of papillary necrosis on radiological imaging. Eight patients had a raised serum creatinine level.

CONCLUSION

A syndrome of cystitis and contracted bladder can be associated with street‐ketamine abuse. Secondary renal damage can occur in severe cases which might be irreversible, rendering patients dependent on dialysis. The present data do not establish the precise cause nor the incidence. Street‐ketamine abuse is not only a drug problem, but might be associated with a serious urological condition causing a significant burden to healthcare resources.     

Is radiotherapy helpful for the prognosis of upper urinary tract urothelial carcinoma? A meta-analysis

BackgroundAt present, the guidelines of the European Society of Urology regarding the use of adjuvant radiotherapy for patients with upper tract urothelial carcinoma (UTUC) are not clear, and there are many contradictions in previous research. In addition, several studies on the effect of radiotherapy alone on UTUC patients have been published in recent years, but their results are still inconsistent. To address these problems, we conducted the current meta-analysis.MethodArticles were searched in 3 electronic databases: PubMed, Embase and the Cochrane Library. Studies were filtered according to a selection strategy, and data were extracted. Finally, Stata software was used for sensitivity analysis, and Egger's test was used to calculate the stability of the results and determine whether there was publication bias.ResultIn total, 17 studies involving and 25906 patients were included, adjuvant radiotherapy had no significant effect on patients with UTUC (OS: HR = 1.38 [0.94, 2.03], = P 0.10; CSS: HR = 1.43 [0.92, 2.25], P = 0.11; LRFS: HR = 1.40 [0.99, 1.98], P = 0.06; RFS: HR = 1.19 [0.52, 2.73], P = 0.68; MFS: HR = 1.37 [0.35, 5.31], P = 0.65). Radiotherapy alone had adverse effects on patients with UTUC (OS: HR = 1.25 [1.09, 1.43], P = 0.001, CSS: HR = 1.47 [1.37, 1.59], P < 0.00001).ConclusionOur results show that adjuvant radiotherapy has no significant effect on the prognosis of patients with UTUC, while radiotherapy alone will have an adverse effect on patients with UTUC. In the future, the determination of the tumor stage of patients receiving adjuvant radiotherapy may be an important research direction.     

Do we know everything about alpha-blockade in the management of lower urinary tract symptoms?

alpha(1)-Adrenoceptor antagonists such as tamsulosin relieve voiding and filling LUTS. Improvement of the voiding ('obstructive') symptoms is related to alpha(1A)-related desobstruction. Improvement of the filling ('irritative') symptoms may be related to reduction of alpha(1D) (and alpha(1A))-related obstruction. Blockade of alpha(1A)-adrenoceptors in the human prostate may be required for reduction of obstruction and improvement of related voiding symptoms and urinary flow. Blockade of alpha(1D) (and alpha(1A))-adrenoceptors in the human bladder may, in addition, be required to relieve filling LUTS. These concepts should be evaluated further before definitive conclusions can be drawn. If definitely proven, this could mean that alpha-blockers have to be considered to not only act on BPH (the causative disease) but also (and perhaps more) on the target organ, the bladder. Early treatment could have a protective effect on the bladder and chronic treatment could prevent hypertrophic bladder modification.