Flexible ureterorenoscopy versus extracorporeal shock wave lithotripsy for treatment of lower pole stones of 10-20 mm

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Shock wave lithotripsy and flexible ureterorenoscopy are acceptable treatment options for lower pole stones smaller than 10 mm, while percutaneous nephrolithotomy is the favoured treatment for stones larger than 20 mm. For treatment of lower pole stones of 10–20 mm, flexible ureterorenoscopy has a significantly higher stone‐free rate and lower retreatment rate than shock wave lithotripsy.

OBJECTIVE

• ? To compare the outcomes of flexible ureterorenoscopy (F‐URS) and extracorporeal shock wave lithotripsy (ESWL) for treatment of lower pole stones of 10–20 mm.

PATIENTS AND METHODS

• ? The database of patients with a single lower pole stone of 10–20 mm was examined to obtain two matched groups who were treated with F‐URS or ESWL. Matching criteria were stone length, side and patient gender.
• ? Stone‐free rates were evaluated 3 months after the last treatment session by non‐contrast computed tomography. Both groups were compared for retreatment rate, complications and stone‐free rate.

RESULTS

• ? The matched groups included 37 patients who underwent F‐URS and 62 patients who underwent ESWL. Retreatment rate was significantly higher for ESWL (60% vs 8%, P < 0.001).
• ? Complications were more after F‐URS (13.5% vs 4.8%), but the difference was not significant (P= 0.146). All complications were grade II or IIIa on modified Clavien classification.
• ? The stone‐free rate was significantly better after F‐URS (86.5% vs 67.7%, P= 0.038). One failure of F‐URS (2.7%) and five failures (8%) of ESWL were treated with percutaneous nephrolithotomy.
• ? Significant residual fragments in three patients (8%) after F‐URS were treated with ESWL, while significant residual fragments after ESWL in five patients (8%) were treated with F‐URS. Residual fragments (<4 mm) were followed every 3 months in one patient (2.7%) after F‐URS and in 10 patients (16%) after ESWL.

CONCLUSIONS

• ? For treatment of lower pole stones of 10–20 mm, F‐URS provided significantly higher stone‐free rate and lower retreatment rate compared with ESWL.
• ? The incidence of complications after F‐URS was not significantly more than after ESWL.

     

Comparison of percutaneous nephrolithotomy and retrograde flexible nephrolithotripsy for the management of 2-4 cm stones: a matched-pair analysis

Study Type – Therapy (case control) Level of Evidence 3b What's known on the subject? and What does the study add? Recently European Association of Urology 2011 guidelines on urolithiasis recommended retrograde intrarenal surgery as the second‐line therapy for the treatment of kidney stones <10 mm in diameter. This study shows that retrograde intrarenal surgery may be an alternative therapy to percutaneous nephrolithotomy, with acceptable efficacy and low morbidity for 2–4 cm stones.

OBJECTIVE

• ? Currently, the indications for retrograde intrarenal surgery (RIRS) have been extended due to recent improvements in endoscopic technology. In this study, we compare the outcomes of percutaneous nephrolithotomy (PCNL) and RIRS in the treatment of 2–4 cm kidney stones.

MATERIALS AND METHODS

• ? Between September 2008 and January 2011, 34 patients who had renal stones ranging from 2 to 4 cm in diameter were treated with RIRS. The outcomes of these patients were compared with patients who underwent PCNL using matched‐pair analysis (1:1 scenario).
• ? The matching parameters were the size, number and location of the stones as well as age, gender, body mass index, solitary kidney, degree of hydronephrosis, presence of previous shock wave lithotripsy and open surgery.
• ? Data were analysed using Fisher's exact test, Student's t test and the Mann–Whitney U test.

RESULTS

• ? Stone‐free rates after one session were 73.5% and 91.2% for RIRS and PCNL respectively (P= 0.05). Stone‐free rate in the RIRS group improved to 88.2% after the second procedure.
• ? Mean operation duration was 58.2 (±) 13.4 min in the RIRS group but 38.7 (±) 11.6 min in the PCNL group (P < 0.0001). Blood transfusions were required in two patients in the PCNL group.
• ? Overall complication rates in the PCNL group were higher, but the differences were not statistically significant. Hospitalization time was significantly shorter in the RIRS group (30.0 + 37.4 vs 61.4 + 34.0 h, respectively; P < 0.001).

CONCLUSION

• ? Satisfactory outcomes can be achieved with multi‐session RIRS in the treatment of 2–4 cm renal stones. RIRS can be used as an alternative treatment to PCNL in selected cases with larger renal stones.

     

Trends in urological stone disease

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add?

• ? Urolithiasis is a major clinical and economic burden for health care systems.
• ? International epidemiological data suggest that the incidence and prevalence of stone disease is increasing.
• This study demonstrates that the number of diagnoses and procedures relating to kidney stone disease has increased significantly in the last 10 years in the UK.
• Management of stone disease comprises a significant and increasing proportion of urological practice in the UK, which has implications for work force planning, training, service delivery and research in this field.

OBJECTIVE

• ? To summarize the changes in prevalence and treatment of upper urinary tract stone disease in the UK over the last 10 years.

METHODS

• ? Data from the Hospital Episode Statistics (HES) website ( http://www.hesonline.nhs.uk ) were extracted, summarized and presented.

RESULTS

• ? The number of upper urinary tract stone hospital episodes increased by 63% to 83 050 in the 10‐year period.
• ? The use of shock wave lithotripsy (SWL) for treating all upper tract stones increased from 14 491 cases in 2000–2001 to 22 402 cases in 2010 (a 55% increase) with a 69% increase in lithotripsy for renal stones.
• ? There was a 127% increase in the number of ureteroscopic stone treatments from 6 283 to 14 242 cases over the 10‐year period with a 49% increase from 2007/2008 to 2009/2010.
• ? There was a decline in open surgery for upper tract stones from 278 cases in 2000/2001 to 47 cases in 2009/2010 (an 83% reduction).
• ? Treatment for stone disease has increased substantially in comparison with other urological activity. In 2009/2010, SWL was performed almost as frequently as transurethral resection of the prostate or transurethral resection of bladder tumour, ureteroscopy for stones was performed more frequently than nephrectomy, radical prostatectomy and cystectomy combined, and percutaneous nephrolithotomy was performed more frequently than cystectomy.

CONCLUSIONS

• ? The present study highlights the increase in prevalence and treatment of stone disease in the UK over the last 10 years.
• ? If this trend continues it has important implications for workforce planning, training, service delivery and research in the field of urolithiasis.

     

A multicentre, prospective, randomized trial: comparative efficacy of tamsulosin and nifedipine in medical expulsive therapy for distal ureteric stones with renal colic

Study Type – Therapy (RCT) Level of Evidence 1b What’s known on the subject? and What does the study add? α‐blocker tamsulosin in medical expusion therapy was determined to be safe and effective for distal ureteric stones with renal colic. This trial further demonstrates that the tamsulosin in MET is more efficative and more safer than nifedipine for distal ureteric stones with renal colic.

OBJECTIVE

• ? To determine the comparative efficacy of tamsulosin and nifedipine in medical expulsive therapy (MET) for distal ureteric stones with renal colic.

PATIENTS AND METHODS

• ? We evaluated the comparative efficacy of tamsulosin and nifedipine in MET in a prospective randomized trial of 3189 outpatients from 10 centres in China.
• ? Eligible patients randomly received tamsulosin or nifedipine. Efficacies of the two agents in MET were compared at 4 weeks.
• ? The primary endpoint was overall stone‐expulsion rate.
• ? Secondary endpoints were stone‐expulsion time, rate of pain relief therapy, mean analgesic consumption for renal colic recurrence, and side‐effects incidence.

RESULTS

• ? Stone‐expulsion rates in the tamsulosin group (group 1) were greater than those in the nifedipine group (group 2; P < 0.01).
• ? There was a significant variation in stone‐expulsion rates and times between groups 1 and 2 (P < 0.01); with improvements in stone‐expulsion rate and time significantly better in group 1 than in group 2.
• ? There was a significant variation in the rate of pain relief therapy for renal colic recurrence between groups 1 and 2 (P < 0.01); patients in group 1 required significantly less analgesics than those in group 2 (P < 0.01).
• ? There were no statistically significant differences in side‐effects incidence between the groups.

CONCLUSIONS

• ? Administration of tamsulosin and nifedipine in MET was determined to be safe and effective for distal ureteric stones with renal colic.
• ? Tamsulosin was significantly better than nifedipine in relieving renal colic and facilitating ureteric stone expulsion.

     

Cost-effectiveness and efficiency of shockwave lithotripsy vs flexible ureteroscopic holmium:yttrium-aluminium-garnet laser lithotripsy in the treatment of lower pole renal calculi

Study Type – Therapy (cost effectiveness) Level of Evidence 2b What’s known on the subject? and What does the study add? Stone management economics is a complex issue. FURS and SWL are recognised treatment option for lower pole kidney stones. There are paucity of data comparing cost implication and effectiveness of both treatment options. Both treatment modalities are equally efficacious. FURS incurred greater cost burden compared to SWL in the UK setting. In the present economic circumstance, clinicians should also consider cost‐impact, patient’s preference and specific clinical indication when counselling patients for treatment.

OBJECTIVE

• ? To compare the cost‐effectiveness and outcome efficiency of extracorporeal shockwave lithotripsy (SWL) vs intracorporeal flexible ureteroscopic laser lithotripsy (FURS) for lower pole renal calculi ≤20 mm.

PATIENTS AND METHODS

• ? Patients who had treatment for their radio‐opaque lower pole renal calculi were categorized into SWL and FURS group.
• ? The primary outcomes compared were: clinical success, stone‐free, retreatment and additional procedure rate, and perceived and actual costs.
• ? Clinical success was defined as stone‐free status or asymptomatic insignificant residual fragments <3 mm.
• ? Perceived cost was defined as the cost of procedure alone, and the actual cost included the cost of additional procedures as well as the overhead costs to result in clinical success.

RESULTS

• ? The FURS (n= 37) and SWL (n= 51) group were comparable with respect to sex, age, stone size and the presence of ureteric stent.
• ? The final treatment success rate (100% vs 100%), stone‐free rate (64.9% vs 58.8%), retreatment rate (16.2% vs 21.6%) and auxillary procedure rate (21.6% vs 7.8%) did not differ significantly.
• ? The mean perceived cost of each FURS and SWL procedure was similar (£249 vs £292, respectively); however, when all other costs were considered, the FURS group was significantly more costly (£2602 vs £426, P= 0.000; Mann–Whitney U‐test).

CONCLUSION

• ? SWL was efficacious and cost‐effective for the treatment of lower pole renal calculi ≤20 mm.

     

Ureteroscopy assisted retrograde nephrostomy: a new technique for percutaneous nephrolithotomy (PCNL)

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Retrograde nephrostomy was first developed by Lawson et al. in 1983, and Hunter et al. reported 30 cases of retrograde nephrostomy in 1987. This procedure uses less radiation exposure and has a shorter duration compared with the previous percutaneous nephrostomy techniques. Retrograde nephrostomy using Lawson's procedure was reported in the late 1980s by several authors. But since then, few studies have been reported about this procedure due to the development of ultrasonography assisted percutaneous nephrostomy. With the arrival and development of the flexible ureteroscope (URS) both observation and manipulation in the renal pelvis are now easily achieved. The present procedure provides less radiation exposure, less bleeding, and a shorter procedure than previous percutaneous nephrostomy techniques. Using this procedure, after the needle has exited through the skin, no further steps are required in preparation for dilatation. In the present study, we continuously visualised from puncture to inserting the nephron‐access sheath with the URS.

OBJECTIVE

• ? To describe a technique for ureteroscopy assisted retrograde nephrostomy.

PATIENTS AND METHODS

• ? Under general and epidural anaesthesia, the patient is placed in a modified‐Valdivia position. Flexible ureteroscopy is carried out, and a Lawson retrograde nephrostomy puncture wire is placed in the ureteroscope (URS).
• ? After the needle has exited through the skin, no further steps are required in preparation for dilatation.

RESULTS

• ? After informed consent was obtained, two patients (a 43‐year‐old man with left renal stones and a 57‐year‐old woman with right renal stones) underwent this procedure.
• ? The URS was positioned in the middle posterior calyx and punctured toward the skin.

CONCLUSIONS

• ? This procedure involves less radiation exposure and shorter surgery than the previous percutaneous nephrostomy technique.
• ? Our technique represents another new option for percutaneous nephrolithotomy in patients with a non‐dilated intrarenal collecting system.

     

Prospective randomized trial of three different methods of nephrostomy tract closure after percutaneous nephrolithotripsy

Study Type – Therapy (RCT)
Level of Evidence 1b What's known on the subject? and What does the study add? Percutaneous nephrolithotripsy is a common procedure throughout the world, but the optimal technique for closure of the percutaneous tract is unknown. This is important for two reasons, the first is that the access tract may bleed after removal of the instruments and access sheath, the second is that several randomized studies have shown improved patient comfort by not having any nephrostomy tubes after the procedure. Our study is the first to compare three common methods of access tract closure in a randomized study.

OBJECTIVE

• ? To evaluate the safety and efficacy of ‘tubeless’ nephrostomy tract closure in reducing postoperative morbidity after percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

• ? In all, 31 patients undergoing PCNL were randomized into three groups, each with a different method of nephrostomy tract closure: using either a gelatin matrix haemostatic sealant (FloSeal), fascial stitch or Cope loop nephrostomy tube.
• ? We compared operative time, estimated blood loss (EBL), postoperative stay, analgaesics use, changes in creatinine and haemoglobin levels, and stone clearance rate, as well as postoperative short‐form (SF)‐36 quality‐of‐life and pain analogue scores at five different time points after surgery.
• ? All data were analysed using a one‐way anova test.
• ? A repeated measures anova test was used selectively to assess the progression of SF‐36 and pain analogue scores.

RESULTS

• ? The preoperative variables operative time, EBL, postoperative stay (P= 0.45), analgaesia use (P= 0.79), changes in creatinine (P= 0.28) and haemoglobin (P= 0.09) levels, and postoperative SF‐36 scores were not significantly different.
• ? In contrast, the differences in analogue pain scales at 1 week after surgery (P= 0.02) and the trends of analogue pain score progression (P= 0.03) were statistically significant.
• ? Three patients underwent second‐look procedures for residual stones and there was one case of postoperative pyelonephritis in a multiple sclerosis patient.

CONCLUSIONS

• ? The Cope loop closure patients recovered fastest, while FloSeal closure patients experienced initial increase in pain followed by resolution at 1 month.
• ? As a result of the small study group sizes, it is difficult to show any significant difference in postoperative pain, especially in long‐term follow‐up; further clinical evaluation is necessary.

     

The use of triclosan eluting stents effectively reduces ureteral stent symptoms: a prospective randomized trial

Study Type – Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Infection, encrustation and ureteral‐stent‐related symptoms (USRS) including pain, urgency and frequency are all major problems associated with stent use. No current ureteral stent or exogenously applied therapy adequately deals with these problems and antibiotic use is ineffective once a bacterial biofilm forms on the device. Triclosan is a broad spectrum antibacterial agent widely used in numerous healthcare products and has been previously shown to reduce inflammation on the skin and in the oral cavity. This study tested a triclosan‐impregnated ureteral stent for its ability to reduce infection, encrustation and USRS. This study shows that while a triclosan‐impregnated ureteral stent cannot reduce infection rates alone compared with antibiotic use, the stent can reduce several USRS including pain during indwelling. This study suggests that the triclosan eluting stent may have a role in treating patients, perhaps in combination with standard antibiotic therapy.

OBJECTIVE

• ? To evaluate the capacity of triclosan‐loaded ureteral stents to reduce stent‐associated bacterial attachment, biofilm formation and encrustation, thereby potentially reducing infection development and other device‐related sequelae.

PATIENTS AND METHODS

• ? Twenty subjects requiring short‐term stenting (7–15 days) were randomized to receive either a Percuflex Plus® non‐eluting stent (control) or a Triumph® triclosan eluting stent.
• ? Control‐stented subjects received 3 days of levofloxacin prophylaxis (500 mg once daily) while Triumph®‐stented subjects did not.
• ? All subjects were assessed for positive urine and stent cultures, stent biofilm development and encrustation.
• ? Following device removal, each subject completed an analogue‐scale symptom assessment questionnaire.

RESULTS

• ? Ureteral stenting was performed after nine ureteroscopic and one extracorporeal shock wave lithotripsy procedure in the control group and eight ureteroscopic and two shock wave lithotripsy procedures in the triclosan group.
• ? No significant differences were observed for culture, biofilm and encrustation between the two groups.
• ? Subjects in the triclosan group reported significant reductions in lower flank pain scores during activity (58.1% reduction, P= 0.017) and urination (42.6%, P= 0.041), abdominal pain during activity (42.1%, P= 0.042) and urethral pain during urination (31.7%, P= 0.049).

CONCLUSIONS

• ? In this study, the use of the Triumph® triclosan eluting stent had no marked impact on biofilm formation, encrustation or infection development in short‐term stented patients.
• ? The Triumph® device led to significant reductions in several common ureteral‐stent‐related symptoms, supporting its use in this patient population.

     

RADICAL CYSTECTOMY FOR BCG FAILURE: HAS THE TIMING IMPROVED IN RECENT YEARS?

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? High‐grade Ta‐T1‐carcinoma in situ bladder cancer is a heterogeneous group; long‐term studies have shown that intravesical BCG therapy can be inadequate in a substantial percentage. Despite concerns about delay in performing RC for patients failing one or more courses of BCG, in our study we have not observed a trend towards a lower pathological stage for patients undergoing RC after BCG.

OBJECTIVE

• ? To analyse if there is a trend in recent years towards performing radical cystectomy (RC) before muscle invasion or extravesical spread after failure of bacille Calmette–Guérin (BCG) for high grade Ta/T1 bladder cancer. Although BCG is indicated for prophylaxis after endoscopic tumour resection there is still a risk of progression.

PATIENTS AND METHODS

• ? A retrospective analysis of our RC database (1992–2008) was performed to identify patients who underwent RC after receiving BCG.
• ? Relevant clinical and pathological data for the patients with clinical stage Ta, T1 and/or Tis at initial transurethral resection of bladder tumour were analysed.
• ? Pathological stage and survival for patients undergoing RC from 2003 to 2007 (group 2) were compared with those for patients operated between 1992 and 2002 (group 1).

RESULTS

• ? A total of 152 patients were included (75 in group 2 and 77 in group 1). Both groups were similar in T‐stage before BCG initiation, number of BCG cycles received and time interval to RC.
• ? There was no change in the proportion of patients undergoing RC with ≥pT2 bladder cancer in recent years (P= 0.5).
• ? Fifty‐two percent of group 2 and 43% of group 1 had ≥pT2 BC. The 5‐year survival was similar.

CONCLUSIONS

• ? Despite concerns about delay in performing RC for patients failing one or more courses of BCG we have not observed a trend towards a lower pathological stage for patients undergoing RC after BCG.
• ? A high proportion of patients have muscle‐invasive bladder cancer; more than 10% have lymph node metastasis.

     

Complications after bladder augmentation or substitution in children: a prospective study of 86 patients

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? A lot of information has been gathered on the subject of complications following urinary bladder augmentation and/or substitution in the recent years. The present study, based on the analysis of 86 patients, gives a critical analysis of these complications (stone formation, bowel obstruction, hematuria‐dysuria syndrome, small bowel bacterial overgrowth, persistent vesico‐ureteral reflux, obstruction at the site of ureteral reimplantation, reservoir perforation, premalignant histological changes, decreased bladder capacity/compliance requiring reaugmentation, etc.). The study adds one more new complication (small bowel colonization following colocystoplasty performed with the cecum and ascending colon) and reports complications in a fairly big (by European standards) cohort of patients with a long follow‐up.

OBJECTIVE

• ? To evaluate complications after urinary bladder augmentation or substitution in a prospective study in children.

PATIENTS AND METHODS

• ? Data of 86 patients who underwent urinary bladder augmentation (80 patients) or substitution (6 patients) between 1988 and 2008 at the authors’ institute were analysed.
• ? Ileocystoplasty occurred in 32, colocystoplasty in 30 and gastrocystoplasty in 18. Urinary bladder substitution using the large bowel was performed in six patients.
• ? All patients empty their bladder by intermittent clean catheterization (ICC), 30 patients via their native urethra and 56 patients through continent abdominal stoma. Mean follow‐up was 8.6 years.
• ? Rate of complications and frequency of surgical interventions were statistically analysed (two samples t‐test for proportions) according to the type of gastrointestinal part used.

RESULTS

• ? In all, 30 patients had no complications. In 56 patients, there were a total of 105 complications (39 bladder stones, 16 stoma complications, 11 bowel obstructions, 5 reservoir perforations, 7 VUR recurrences, 1 ureteral obstruction, 4 vesico‐urethral fistulae, 4 orchido‐epididymitis, 4 haematuria‐dysuria syndrome, 3 decreased bladder capacity/compliance, 3 pre‐malignant histological changes, 1 small bowel bacterial overgrowth and 7 miscellaneous).
• ? In 25 patients, more than one complication occurred and required 91 subsequent surgical interventions. Patients with colocystoplasty had significantly more complications (P < 0.05), especially more stone formation rate (P < 0.001) and required more post‐ operative interventions (P < 0.05) than patients with gastrocystoplasty and ileocystoplasty.

CONCLUSIONS

• ? Urinary bladder augmentation or substitution is associated with a large number of complications, particularly after colocystoplasty.
• ? Careful patient selection, adequate preoperative information and life‐long follow‐up are essential for reduction, early detection and management of surgical and metabolic complications in patients with bladder augmentation or substitution.

     

Nerve growth factor level in the prostatic fluid of patients with chronic prostatitis/chronic pelvic pain syndrome is correlated with symptom severity and response to treatment

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To explore whether levels of nerve growth factor (NGF) in expressed prostatic secretions (EPS) are correlated with symptom severity in chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS).

PATIENTS AND METHODS

• ? All patients with CP/CPPS underwent a complete history and physical examination, and were scored according to the National Institutes of Health Chronic Prostatitis Symptom Index (NIH‐CPSI).
• ? Expressed prostatic secretion samples from 20 patients with CP/CPPS and from four asymptomatic control patients were collected and frozen, and NGF levels in EPS were measured by enzyme‐linked immunosorbent assay.
• ? Patients were asked to complete NIH‐CPSI questionnaires at baseline and 8 weeks after treatment and patients with at least a 25% decrease in total NIH‐CPSI score from the baseline values were classified as responders to treatment.

RESULTS

• ? The mean (±sd ) NGF levels in EPS of patients with CP/CPPS and asymptomatic control patients were 7409 (±3788) pg/mL and 4174 (±1349) pg/mL, respectively. The NGF level in patients with CP/CPPS correlated directly with pain severity (P= 0.014, r= 0.541).
• ? There were no significant differences between NGF levels in EPS before and after treatment. However, successful treatment significantly decreased NGF levels in responders (P= 0.001).

CONCLUSION

• ? Nerve growth factor might contribute to the pathophysiology of CP/CPPS as changes in NGF level in EPS occurred in proportion to pain severity. Therefore, these results suggest that NGF could be used as a new biomarker to evaluate the symptoms of CP/CPPS and the effects of treatment.

     

Is joint hypermobility associated with vesico‐ureteral reflux? An assessment of 50 patients

Study Type – Aetiology (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Recent studies have already shown associations between generalized joint hypermobility (GJH) and voiding and defecation dysfunction and/or slow transit constipation. Changes in extracellular matrix composition in vesico‐ureteric junction of vesico‐ureteral reflux (VUR) patients were also observed previously. This study is the first to assess joint mobility as a parameter for connective tissue composition in vesico‐ureteral reflux. We convincingly demonstrate that VUR patients have significantly more hypermobile joints compared to controls and this provides a new angle to the intriguing subjects of development of VUR and susceptibility to VUR.

OBJECTIVE

• ? To assess whether there is an increased prevalence of joint hypermobility in patients with vesico‐ureteric reflux (VUR).

MATERIALS AND METHODS

• ? We studied 50 patients with primary VUR and matched controls drawn from a reference population.
• ? Joint mobility was assessed using the Bulbena hypermobility score.

RESULTS

• ? We identified significantly more patients with VUR with generalized joint hypermobility than controls (24% vs 6.7%, P= 0.007).

CONCLUSION

• ? Our findings confirm our clinical observation of an increased rate of joint hypermobility in patients with VUR. We speculate that an altered composition of the connective tissue may contribute to the severity of the (pre‐existing) VUR phenotype.

     

Impact of comorbidity on complications after nephrectomy: use of the Clavien Classification of Surgical Complications

Study Type – Retrospective (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Tumour characteristics, physical status and comorbidities are considered important for surgical outcome and prognosis. The present study objectively evaluates the association between comorbidity and postoperative complications after nephrectomy for RCC, by using the modified Clavien Classification of Surgical Complications to grade complications after nephrectomy.

OBJECTIVE

• ? To present a single‐centre experience of open nephrectomy for lesions suspected for renal cell carcinoma (RCC), evaluating the association between comorbidity and postoperative complications using a standardized classification system for postoperative complications.

PATIENTS AND METHODS

• ? Clinicopathological data of 198 patients undergoing open radical or partial nephrectomy for lesions suspected of RCC were retrospectively analysed.
• ? Comorbidity scored by the Charlson comorbidity index (CCI), body mass index, age, gender, surgical procedure and surgical history were examined as predictive factors for postoperative complications, which were scored using the modified Clavien Classification of Surgical Complications (CCSC).

RESULTS

• ? The overall complication rate was 34%: 7% grade I, 15% grade II, 5% grade III, 3% grade IV and 4% grade V. Preoperative comorbidities were present in 51% of all patients.
• ? There were significantly more major complications (CCSC >2) in patients with major comorbidities (CCI >2), at 16% vs 7% (P= 0.018).
• ? Patients with high‐stage RCC had significantly more severe complications than low‐stage RCC (P= 0.018).
• ? In multivariable analysis, comorbidity (odds ratio [OR] 7.55, P= 0.004) and tumour stage 3–4 (OR 6.23, P= 0.007) were independent predictive factors for major complications.

CONCLUSIONS

• ? Major complications occur significantly more often when major comorbidities are present.
• ? Comorbidity scores can be used in risk stratification for complications and should be considered during decision‐making and counselling of patients before nephrectomy.

     

Clomiphene citrate is safe and effective for long‐term management of hypogonadism

Study Type – Therapy (population cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Clomiphene citrate (CC) has previously been documented to be efficacious in the treatment of hypogonadism. However little is known about the long term efficacy and safety of CC. Our study demonstrates that CC is efficacious after 3 years of therapy. Testosterone levels and bone mineral density measurement improved significantly and were sustained over this prolonged period. Subjective improvements were also demonstrated. No adverse events were reported.

OBJECTIVE

• ? To assess the efficacy and safety of long‐term clomiphene citrate (CC) therapy in symptomatic patients with hypogonadism (HG).

PATIENTS AND METHODS

• ? Serum T, oestradiol and luteinizing hormone (LH) were measured in patients who were treated with CC for over 12 months.
• ? Additionally, bone densitometry (BD) results were collected for all patients. Demographic, comorbidity, treatment and Androgen Deficiency in Aging Men (ADAM) score data were also recorded.
• ? Comparison was made between baseline and post‐treatment variables, and multivariable analysis was conducted to define predictors of successful response to CC.
• ? The main outcome measures were predictors of response and long‐term results with long‐term CC therapy in hypogonadal patients.

RESULTS

• ? The 46 patients (mean age 44 years) had baseline serum testosterone (T) levels of 228 ng/dL.
• ? Follow‐up T levels were 612 ng/dL at 1 year, 562 ng/dL at 2 years, and 582 ng/dL at 3 years (P < 0.001).
• ? Mean femoral neck and lumbar spine BD scores improved significantly.
• ? ADAM scores (and responses) fell from a baseline of 7 to a nadir of 3 after 1 year.
• ? No adverse events were reported by any patients.

CONCLUSIONS

• ? Clomiphene citrate is an effective long‐term therapy for HG in appropriate patients.
• ? The drug raises T levels substantially in addition to improving other manifestations of HG such as osteopenia/osteoporosis and ADAM symptoms.

     

Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk

Study Type – Prognosis (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? RENAL nephrometry is a quantitative, reproducible scoring system that characterizes RENAL masses and standardizes reporting. Previous work has suggested that the system may be useful in predicting outcomes after partial nephrectomy. This study is the first to correlate RENAL nephrometry score with operative approach or risk of complication in patients undergoing either partial or radical nephrectomy.

OBJECTIVE

• ? To evaluate the utility of the RENAL scoring system in predicting operative approach and risk of complications. The RENAL nephrometry scoring system is designed to allow comparison of renal masses based on the radiological features of (R)adius, (E)xophytic/endophytic, (N)earness to collecting system, (A)nterior/posterior and (L)ocation relative to polar lines.

METHODS

• ? A retrospective review of all patients at a single institution undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for a renal mass between July 2007 and May 2010 was carried out.
• ? Preoperative RENAL score was calculated for each patient. Surgical approach and operative outcomes were then compared with the RENAL score.

RESULTS

• ? In all, 249 patients underwent either RN (158) or PN (91) with average RENAL scores of 8.9 and 6.3, respectively (P < 0.001).
• ? Patients who underwent RN were more likely to have hilar tumours (64% vs 10%, P < 0.001) than patients who underwent PN, but were no more likely to have posteriorly located tumours (50% each).
• ? There were more complications among patients with RN (58%) vs patients with PN (42%, P= 0.02).
• ? RENAL scores were higher in patients with PN who developed complications than in patients with PN who did not develop complications (6.9 vs 6.0, P= 0.02), with no difference noted among patients with RN developing complications (8.9 vs 8.9, P= 0.99).

CONCLUSION

• ? The RENAL system accurately predicted surgeon operative preference and risk of complications for patients undergoing PN.

     

Among potent men post radical prostatectomy,does the need for phosphodiesterase inhibitors have an impact on sexual bother scores?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although phosphodiesterase inhibitor use post radical prostatectomy improves potency, little is known about its affects on sexual bother. We found no difference in sexual bother scores between patients who use and do not use phosphodiesterase inhibitors. This suggests that the current definition of potency, inclusive of medication use, is valid with respect to sexual bother.

OBJECTIVE

• ? To determine whether the current definition of potency, inclusive of phosphodiesterase inhibitor (PDEi) use, is valid with respect to sexual bother (SB). This will be assessed by characterizing the effect of PDEi use on SB scores in men who are potent post radical prostatectomy.

PATIENTS AND METHODS

• ? The study population consisted of patients who were potent both before and after radical prostatectomy, with at least 2 years of follow‐up.
• ? Disease‐specific quality of life data were evaluated by the University of California, Los Angeles, Prostate Cancer Index (PCI) survey.
• ? The relationships between changes in sexual function (SF) and SB and use of PDEi over time were evaluated by mixed model analysis controlling for age, clinical risk group, marital status, and time of PCI assessment.

RESULTS

• ? Of the 246 patients who met the study criteria, 39% reported PDEi use at some point after treatment.
• ? PDEi use was not associated with improved SF (P= 0.81).
• ? Furthermore, PDEi use was not associated with a change in SB (P= 0.36).
• ? Both SF and SB were significantly associated with time of assessment and age, and SF and SB each improved over time.
• ? In addition, SB was significantly associated with marital status.

CONCLUSIONS

• ? In this analysis, there was no difference in SF scores between men who were potent with or without the use of PDEi.
• ? Furthermore, there was no difference in SB scores between men who were potent with or without the use of PDEi.
• ? This suggests that the current, inclusive, definition of potency is valid with respect to SB.

     

Incidence and clinical significance of arterial injury in varicocele repair

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

• ? This study was performed to histologically determine the rate of arterial injury in varicocele ligation surgery and to determine the clinical significance of these arterial injuries.

MATERIALS AND METHODS

• ? 41 men who underwent varicocele ligation surgery, and had segments of each ligated vessel examined histologically.
• ? The patients were followed prospectively to determine the effect of arterial injury on surgical results and clinical complications.

RESULTS

• ? Arterial ligation was identified in 6 of 41 patients (12%), and in 7 of 132 specimens (5%), which is higher than previous reports.
• ? Arterial injury was not associated with testicular atrophy and there was no apparent effect of arterial injury on surgical outcome.

CONCLUSION

• ? The rate of arterial injury during varicocele repair is higher than previously reported, but the clinical significance of these injuries appears to be limited.

     

EXTENDING THE INDICATIONS AND ANATOMICAL LIMITS OF PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: IMPROVED STAGING OR INCREASED MORBIDITY?

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To assess, in a risk/benefit analysis, the additional risk for complications and benefits of extending the indications and anatomical limits of pelvic lymph node dissection (PLND).

PATIENTS AND METHODS

• ? In total, 971 consecutive patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy from 2003–2007.
• ? Before 1 February 2005, patients with a nomogram probability of lymph node invasion (LNI) <2% did not undergo PLND (No PLND group), whereas those with a LNI ≥2% had a PLND limited to the external iliac nodal group (limited PLND group).
• ? After 1 February 2005, all patients underwent a standard PLND including the external iliac, hypogastric and obturator fossa nodal groups (standard PLND group).
• ? The risk parameters were PLND‐related complications and operating time. Complications were graded using a modified Clavien classification. The benefit was the detection of nodal metastases.

RESULTS

• ? In the subgroup of patients with a LNI ≥2%, standard PLND was a superior operation than the limited PLND in detecting nodal metastases (14.3% vs 4.5%, respectively; P = 0.003).
• ? The risk/benefit of standard vs limited PLND would be one additional grade 3 complication per 20 additional patients with nodal metastases. In the subgroup of patients with LNI <2%, three patients (1.0%) had positive nodes after a standard PLND.
• ? The risk/benefit of standard PLND vs no PLND would be one additional grade 3 complication per three or four additional patients with nodal metastasis. The no PLND group was associated with the lowest risk of grade 1, 2 and 3 complications compared to either the limited or standard PLND groups (P < 0.001).

CONCLUSIONS

• ? In patients with LNI ≥2%, standard PLND detects more nodal metastasis. PLND is associated with higher but non‐prohibitive complications rate.
• ? The present study found no evidence that the incidence of complications would be reduced by a limited PLND.

     

Stage-specific impact of pelvic lymph node dissection on survival in patients with non-metastatic bladder cancer treated with radical cystectomy

Study Type – Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? In patients treated with radical cystectomy, pelvic lymph node dissection may have a beneficial effect on cancer control outcomes. We examined the effect of pelvic lymph node dissection on stage‐specific cancer control outcomes.

OBJECTIVE

• ? To examine the effect of stage‐specific pelvic lymph node dissection (PLND) on cancer‐specific (CSM) and overall mortality (OM) rates at radical cystectomy (RC) for bladder cancer.

METHODS

• ? Overall, 11 183 patients were treated with RC within the Surveillance, Epidemiology, and End Results database.
• ? Univariable and multivariable Cox regression analyses tested the effect of PLND on CSM and OM rates, after stratifying according to pathological tumour stage.

RESULTS

• ? Overall, PLND was omitted in 25% of patients, and in 50, 35, 27, 16 and 23% of patients with respectively pTa/is, pT1, pT2, pT3 and pT4 disease (P < 0.001).
• ? For the same stages, the 10‐year CSM‐free rates for patients undergoing PLND compared with those with no PLND were, respectively, 80 vs 71.9% (P = 0.02), 81.7 vs 70.0% (P < 0.001), 71.5 vs 56.1% (P = 0.001), 43.7 vs 38.8% (P = 0.006), and 35.1 vs 32.0% (P = 0.1).
• ? In multivariable analyses, PLND omission was associated with a higher CSM in patients with pTa/is, pT1 and pT2 disease (all P ≤ 0.01), but failed to achieve independent predictor status in patients with pT3 and pT4 disease (both P ≥ 0.05).
• ? Omitting PLND predisposed to a higher OM across all tumour stages (all P ≤ 0.03).

CONCLUSIONS

• ? Our results indicate that PLND was more frequently omitted in patients with organ‐confined disease.
• ? The beneficial effect of PLND on cancer control outcomes was more evident in these patients than in those with pT3 or pT4 disease.
• ? PLND at RC should always be considered, regardless of tumour stage.

     

Early infectious complications with transponder placement for external beam radiation therapy for prostate cancer

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Little has been published related to transponders per se, but a number of studies relating to prostate biopsy‐related infections and the increased incidence of quinolone‐resistant Escherichia coli have been published. The study alerts the practising urologist to the risk of quinolone‐resistant E. coli in the setting of transrectally placed transponders. Furthermore, it proposes an antibiotic regimen that should reduce this risk.

OBJECTIVE

• ? To report our series of early infectious complications after placement of Calypso® transponders (Calypso Medical, Seattle, WA, USA) into the prostate.

PATIENTS AND METHODS

• ? Between February 2008 and October 2010, 50 consecutive patients underwent placement of Calypso® transponders into the prostate.
• ? Patients were administered ciprofloxacin 500 mg every 12 h, starting the night before the procedure and for 2 days after the procedure.
• ? Data were collected via chart review, and complications were classified according to the Clavien classification system.

RESULTS

• ? Of the 50 patients undergoing the procedure, five (10%) developed infectious complications, and three (6%) developed a grade II complication with a UTI requiring antibiotic therapy. One patient (2%) developed a grade IIIb complication with an epidural abscess and osteomyelitis of the lumbar vertebrae requiring open debridement and a lumbar fusion. One patient (2%) developed a prostatic abscess with methicillin‐resistant Staphylococcus aureus and subsequently died of an unrelated lower GI bleed.
• ? In 4/50 patients (8%), a culture confirmed the responsible bacteria, of which three cases were quinolone‐resistant Escherichia coli.

CONCLUSION

• ? As with prostate biopsy, the emergence of quinolone‐resistant E. coli remains a challenging infectious complication with transrectal prostate procedures. We propose an alternative strategy of double antibiotic coverage with one dose of oral ciprofloxacin 500 mg and gentamicin 80 mg i.m. before this procedure.