Does the type of TRUS probe matter?
Reviewed by: Mark Harris
May/Jun 12 (Vol 16 No 4)
With a plethora of biopsy equipment available to the urologist to improve the standard and ease of biopsy, the crucial issue is whether cancer detection rates vary between devices. Using a large retrospective cohort of 2592 patients scheduled for prostate biopsy, the authors used either an end-firing probe or a side-firing version to take 14 or 18 cores, depending on whether it was an initial (1705 patients) or repeat biopsy (487 patients). Biopsies were performed by three experienced operators, using local anaesthetic block, with patients asked to complete a visual analogue scale after the procedure. A standardised 14-core template was used for initial biopsy, with three peripheral, two apical and two basal biopsies bilaterally. The extended regime was not specified. The patients were well-matched by probe type and operator. The authors found no significant difference in cancer detection (37.2% and 10.1% for initial and repeat biopsy) between the probes. The detection rate of apical, basal and peripheral tumours was similar, despite perceived variations in the ability to sample parts of the gland with each probe. There was also no difference in tumour detection with respect to gland volume. However, the end-firing probe was associated with more pain, principally due to the larger probe size. Whilst one has to be wary to extrapolate results from three experienced operators to everyday practice, this paper suggests that the probe type makes no difference to cancer detection. However, these results may only apply to these specific manufacturers’ probes and may reflect the extended core protocol used. Unfortunately the incidence of complications, such as bleeding and infection, was not analysed and this would have been of particular interest.
Radical prostatectomy in the UK: analysis of the BAUS database
Reviewed by: Mark Harris
May/Jun 12 (Vol 16 No 4)
This is the first analysis of five and a half years’ worth of data since the inception of the database; 8032 cases were entered but only 4026 had complete follow-up data. The majority were performed open (5429) rather than laparoscopic (2219), although the proportion of laparoscopic cases increased rapidly from 0% in 2003 to 59% by 2009. The overall positive margin rate was 38% (24% for pT2), with statistically higher positive surgical margin (PSM) rates in smaller glands. Other significant predictors of a PSM were the pathological and clinical (TNM) stages, surgeon volume and specimen grade. Of note were the findings that 45% of Gleason 8-10 grade biopsies were downgraded to 7 or less on prostatectomy analysis and of 2499 cases classified as ‘low-risk’ by the National Institute for Health & Clinical Excellence (NICE), 36% were upgraded to Gleason 7 or worse, with a 29.4% PSM and biochemical recurrence rate of 7.7%. When lymphadenectomy was performed, there were no positive nodes in any Gleason 6 cases. When outcome by surgeon volume was analysed, the authors suggested that results clearly improved when a minimum of 20 cases were performed per annum by an individual. In total, this series is felt to represent about 58% of the national data, after cross-referencing with Hospital Episode Statistics (HES) data. As a reasonably accurate reflection of ‘real-life’ practice in the UK, possibly the most striking result is the poor correlation between biopsy and pathological specimen grade and pre versus postoperative stage. Whilst this is not a new phenomenon, it does illustrate the current flaws in risk stratification with inaccurate variables used to determine treatment options. The link between surgeon volume and outcome suggests that higher volume surgeons achieve better results. However, the implementation of the Improving Outcome Guidance policy may have already caused a significant shift in this regard, with low volume surgeons ceasing to perform radical prostatectomy, a trend that was not discernible from the paper. Improvements in technique with time may also have helped to improve results, which will also affect the volume relationship. The role of extended biopsy schemes requires clarification and the paper also rightly questions the rationale for lymphadenectomy in Gleason 6 disease. Lastly, perhaps there may be justification for mandatory data collection to avoid a postcode lottery of outcome.
Cystoscopic surveillance in patients treated with BCG
Reviewed by: Kate Linton
May/Jun (Vol 16 No 4)
It is unclear at the present time how long patients treated with Bacillus Calmette-Guerin (BCG) should continue having cystoscopic surveillance, particularly when they have been clear of tumour for some years. Holmäng and Ströck have performed a retrospective analysis of all 542 patients treated with BCG over an 18-year period in the Goteborg area. Two hundred and four patients were tumour free for a continuous period of at least five years at some time since their first BCG instillation. Twenty-two of these patients (10.8%) had recurrences following a five-year tumour-free period. Seventeen recurrences were in the bladder alone. There was also one urethral recurrence, three ureteric tumours and one renal pelvis tumour. Of the bladder recurrences, 11 were small G1pTa tumours, five patients had carcinoma in situ (CIS) following five clear years after BCG, and two of these subsequently underwent cystectomy for BCG failure. One patient had a T2 tumour, underwent cystectomy and chemotherapy but died of his disease. Those patients who had recurrent tumours before BCG treatment were significantly more likely to have a late recurrence than those with primary tumours treated with BCG. Of the 22 patients with recurrences, seven had tumour-free periods of 10 years and longer, and then developed recurrences within the bladder, two of which were CIS and 4/5 of the others G1pTa. The risk of recurrence at 15 years was 21%. What is clear from this study is that patients who undergo BCG treatment can develop significant recurrences after five tumour-free years and even after 10 tumour-free years. The authors suggest that cystoscopic surveillance needs to be considered in patients who have BCG treatment for 10-15 years after their last recurrence.
Narrow band imaging reduces the risk of NMIBC recurrence at one year
Reviewed by: Kate Linton
May/Jun 12 (Vol 16 No 4)
There is great interest in the use of technologies to aid detection of lesions within the bladder at transurethral resection (TUR). Narrow band imaging (NBI) is a relatively new addition to the armamentarium to aid bladder tumour detection. NBI has previously been shown in small studies to improve tumour detection but there has never before been a prospective randomised study. Naselli et al. have performed a prospective randomised study assessing the impact of NBI on the one-year recurrence risk of non-muscle invasive bladder cancer (NMIBC). One hundred and eighty-eight patients were randomised; following exclusions, 76 NBI TUR and 72 white light (WL) TUR were included in the final analysis. TUR was performed completely in WL or NBI mode with no switch between the modalities during the procedure. Primary endpoint was the one-year intravesical recurrence risk; the secondary endpoints were three-month recurrence risk and detection rate. The three-month recurrence risk was 3.9% in the NBI group and 16.7% in the WL group. The one-year recurrence risk was 31.6% in the NBI group and 51.4% in the WL group. The detection rate of bladder cancer was increased in the NBI group compared to WL although did not reach significance, and there was a slight increase in the incidence of false positive findings in the NBI group, however not significant. TUR performed with NBI significantly reduces the one-year risk of recurrence of NMIBC. NBI has the advantage over fluorescence cystoscopy that there is no need for administration of a photo-sensitiser. Further randomised studies and longer follow-up in this field are awaited.
Can we choose between α-blockers and antimuscarinics in male LUTS based on the IPSS subscore ratio?
Reviewed by: Ananda Kumar Dhanasekaran
May/Jun 12 (Vol 16 No 4)
Lower urinary tract symptoms (LUTS) are mostly treated initially by alpha blockers. Antimuscarinics alone are used only if the patient has predominantly storage symptoms and if the post void residue (PVR) is not elevated. This article attempted to use the International Prostate Symptom Score (IPSS) voiding to storage subscore ratio (V/S) to decide first-line alpha blockers or anti-muscarinic monotherapy regardless of total prostate volume (TPV), serum prostate specific antigen (PSA) levels, PVR or Q max. Doxazosin (4mg per day) and tolterodine (4mg per day) were administered to patients with IPSS V/S >1 and IPSS V/S ≤1, respectively. At one and three months’ follow-up more than 75% of patients in both groups had an improved outcome. Mean IPSS-T, IPSS-S and quality of life improved significantly in both groups. Most importantly there was no significant rise of PVR - but six patients complained of inability or difficulty in voiding after tolterodine monotherapy. No patient developed urinary retention in either group. There were no significant differences in the reported adverse effects in both groups. Patients aged more than 70 years had significant association with increased PVR after tolterodine monotherapy. Thus this study attempted to answer the indications for tolterodine monotherapy. They have demonstrated a new approach for deciding initial drug treatment in LUTS with IPSS V/S ratio. A disadvantage of this study is the absence of a placebo group.
Oxybutynin ER prescription pattern – is there any scope for improvement?
Reviewed by: Ananda Kumar Dhanasekaran
May/Jun 12 (Vol 16 No 4)
Treatment of overactive bladder (OAB) is multimodal including antimuscarinic agents and lifestyle modifications. Of available antimuscarinic agents oxybutynin extended release (ER) has convenience of once daily dosing and has proven similar efficacy and improved tolerability when compared to immediate release formulations. Oxybutynin ER can be prescribed in six doses from 5 to 30mg/day in multiples of five depending on the individual requirement and side-effects. But we don’t know the actual prescription pattern and the common doses used in practice. This was a multicentre, open-label, prospective, observational, flexible dosing study examining oxybutynin ER prescription pattern. They recruited 809 patients of which 73% continued medications for the whole 12-week study period. The predictive factors for discontinuation of the treatment were female, younger age (<65 years), obesity (>25 body mass index), severe symptoms and large number of other co-medications. Most patients had starting (68.8%) and final (67.4%) dose of 10mg/day. Dose escalation rate was 14.9%. Dose reduction and dose maintenance rates were 3.5% and 81.6%, respectively. Clinically significant improvements in all the symptom scores were noted at the end of the study. Almost 20% of patients reported adverse effects, of which dry mouth was the commonest (60.2%). Only 4% discontinued treatment because of adverse effects. Thus this study mainly addresses the difference in oxybutynin ER dosing between clinical trials and real life practice. In real life dose escalation is mostly avoided to prevent adverse effects. Even though fewer than 50% of patients had reported considerable benefit from treatment they maintained a passive attitude towards dose adjustments or escalation. Thus this study stresses the need for both goal oriented treatment of OAB and active participation by patients in tailoring the dose to provide for an optimal outcome.
Ileal bladder augmentation and vitamin B12
Reviewed by: Henrik Steinbrecher
May/Jun 12 (Vol 16 No 4)
This retrospective study looked at 105 children under 16 years (mean age at surgery 7.7 years; 61 males, 44 females) who had undergone ileocystoplasty over a 14.5 year period. Patients had had their B12 measured annually since the procedure. Exclusions included revisional surgery and cloacal exstrophy patients. A subgroup of ileal sparing (60cm from ileocaecal valve; 19 patients) cases were sub-analysed. The mean interval from surgery to most recent B12 measure was 50 months (range 2-183 months). B12<150pg/ml was taken to be low. Two patients had low B12, both measured more than seven years post surgery. There was a significant correlation between length of follow-up and reduction of B12. The ileal sparing group had higher B12 at follow-up but postoperative interval was shorter (30-50 months).The authors recommend continual monitoring of B12 levels post surgery into adulthood and concurrent monitoring of neurological symptoms.
Polymorphism of MAMLD1Gene in hypospadias
Reviewed by: Henrik Steinbrecher
May/Jun 12 (Vol 16 No 4)
Mastermind-like domain containing 1 (MAMLD1) is a causative gene for the foetal development of male external genitalia – who thinks up these names?? It is expressed in foetal Sertoli and Leydig cells around the critical period for sex development. It is co-expressed with steroidogenic factor (SF-1), a regulator of the transcription genes involved in testicular differentiation. Almost 10% of patients with both severe and non-severe hypospadias exhibit mutations of MAMLD1. This study investigated the incidence of exonic polymorphism and haplotypes of MAMLD1 using 300 Caucasian children (150 controls, 150 with hypospadias), extracting DNA from blood or preputial skin and sequencing coding exons of MAMLD1. Online software tools were used to predict the potential functional consequences of the mutation based on amino acid position and other factors. The results showed that polymorphism of MAMLD1 gene (p.P386S, p.N5895S) is frequent in patients with hypospadias. The double polymorphisms (S-S haplotype) had a significant increased incidence and the prediction studies strengthened the hypothesis that these variants confer a particular susceptibility to hypospadias. However, none of the haplotypes induced any noted change in transactivating activity in a promoter. So the elusive cause of hypospadias continues and the overwhelming majority of hypospadias cases remain unexplained.
Relationship among VUR, UTI and renal injury in children with lower urinary tract dysfunction
Reviewed by: Henrik Steinbrecher
May/Jun 12 (Vol 16 No 4)
It is well recognised that primary and secondary VUR should have different management strategies. This paper retrospectively looked at 96 children with lower urinary tract dysfunction over a six-year period to assess risk factors for possible renal damage. They assessed patients clinically, with ultrasound scan (USS), DMSA and urodynamics. Overactive bladders (OAB) and overactivity with dysfunctional voiding (DV) were major risk factors for vesicoureteric reflux (VUR), urinary tract infection (UTI) and renal damage. Renal scarring was detected in 25/96 patients of whom 78% had OAB+DV and 75% had DV. In addition 24/96 patients had constipation at their first visit, and 11 also had encopresis. This paper highlights and complements current thinking that VUR alone is not sufficient to cause UTI or renal damage and that constipation is a significant factor in children with OAB and DV.
The Swedish reflux trial
Reviewed by: Henrik Steinbrecher
May/Jun 12 (Vol 16 No 4)
This paper is worth reading a few times. It summarises the latest thoughts on vesicoureteric reflux (VUR) in children aged one to two years. In the 1960s it became usual to operate on children with VUR to prevent renal damage progression because a string relationship was demonstrated between VUR and chronic pyelonephritis. In the 1970s prophylactic antibiotics became more common as it was recognised that in significant numbers of children primary reflux resolved with time. The mechanism of intrarenal reflux was studied by Ransley and Risdon in 1975 and was thought to be crucial to renal damage. In the 1980s the Birmingham reflux study demonstrated that long-term outcomes were no different between surgery and prophylaxis in terms of renal outcome and the enthusiasm for surgical intervention for VUR waned. In the 1990s, with the development of minimally invasive treatment for surgery (STING and other subureteric injection procedures) the surgical pathway was reignited. In the early 2000s the International Reflux Study emphasised continued supervision of children with treated reflux because of ongoing renal damage. It became clear that more randomised studies are needed. The RIVUR multicentre study is one such ongoing study. The Swedish study randomly allocated three treatment alternatives – antibiotic prophylaxis, endoscopic sub-ureteric injection and a control group on close surveillance – to 203 patients from 23 paediatric centres. The patients were between one and two years of age, had a micturating cystourethrogram (MCUG) showing grade 3 or 4 VUR. The study looked at rates of febrile urinary tract infections (UTI), new kidney damage and reflux status after two years. The results were published in full in 2011 but this paper was written to summarise them. In girls of this age, both active medical and surgical treatment reduced the risk of UTI recurrence rate. Medical treatment also reduced the risk of new renal damage (as shown on DMSA) in girls. Boys of this age, on the other hand, showed no benefit in either reduction of UTI or reduction of risk of renal damage with either medical or surgical treatment so the current management strategy is surveillance only for boys above one year.
Tubularised incised plate urethroplasty with and without dorsal inlay graft
Reviewed by: Stephen Griffin
May/Jun 12 (Vol 16 No 4)
Functional studies assessing urinary flow post hypospadias repairs are conflicting. However, there is a suggestion by some that the long-term functional outcome after hypospadias repair may be suboptimal leading some to consider whether urethral reconstruction is justified for distal hypospadias in all cases. Tubularised incised plate (TIP) urethroplasty has become one of the most widely used techniques because of the satisfactory cosmetic results it yields. However, some have concern that this leads to decreased flow possibly due to increased flow resistance in the tubularised incised urethra. This novel animal study describes a rabbit model for assessing passive flow through the rabbit urethra in vitro using gravity and an intravenous line. Four different experimental groups are described – primary urethroplasty, TIP, dorsal inlay graft urethroplasty – using inner preputial skin, and sham – surgical exposure of the urethra. Animals were sacrificed at four and eight weeks, respectively. The penis was harvested at the pubic level and trimmed to a standard 6cm length. Before fixation, the distal end of the penis, including the glans, was resected to ensure sections only included the operated area. Passive average flow rates were then compared between the four groups. Flow rates in the primary urethroplasty group were significantly lower than the sham controls, the TIP and dorsal inlay graft groups. There was no significant difference in flow when comparing the TIP and dorsal inlay groups. These were, however, significantly lower than the sham controls also. Histological analysis revealed adequate graft take and integration in all animals in the dorsal inlay group. The preputial graft displayed a stratified squamous epithelium in all specimens. However, in the TIP group the defect was lined by urothelium. This novel study demonstrates in vitro similar decreased flow in both the dorsal inlay and TIP groups compared with the sham control group. There is at least one 10-year follow-up paper (Journal of Urology 2009;182:1730) reporting good results with the dorsal inlay technique. However, my senior colleague who first described this technique (BJU International 1999;83:508) for salvage repairs no longer performs this operation as he is concerned it causes a functional obstruction (personal communication). A limitation of this study, I believe, is removal of the glans. A significant amount of resistance can be created by glanuloplasty which impacts overall flow. However, this model will allow for further study of the healing process post hypospadias repair.
Association of depression and urolithiasis
Reviewed by: Ashley Ridout
May/Jun 12 (Vol 16 No 4)
This prospective cohort study, from a US tertiary referral centre for stone disease, aimed to assess the prevalence of depression in their patients with urolithiasis. Three hundred and eighty-six non-consecutive patients were asked to complete two questionnaires, either at the outpatient clinic or via mail – the Emory Urology Stone Questionnaire and the validated Centre for Epidemiologic Studies Depression Scale (CES-D). Response rate was 29.7% (n=115); 30.4% of patients described a ‘significant level of psychological distress’, as compared with the US lifetime prevalence of depression (reported as 16.5%). With univariate analysis, significant factors for depression were at least one visit to the emergency department as a result of stone disease, a stone episode within the last 12 months, at least one complication after surgery and a Charlson co-morbidity Index of ≤1. There was no significant association with age, gender, or other demographic factors. This study has revealed a significantly increased prevalence of depression in these patients as compared to the general US population, and highlights an interesting aspect of chronic disease. However, limitations include the patient group from this tertiary referral centre, which may not be absolutely representative of all patients with stone disease, and the relatively low response rate, which may certainly introduce a selection bias (although history of depression was documented in 10% of responders and 14% of non-responders). They also speculate as to whether stone disease may not just predispose patients to depression, but rather whether depressed patients are more prone to urolithiasis. The psychological effects of disease, particularly chronic or recurrent disease, must not be underestimated.
Clinical predictors of testicular torsion in children
Reviewed by: Ashley Ridout
May/Ju 12 (Vol 16 No 4)
This retrospective study analysed all patients presenting with ‘acute scrotum’ (clinical symptoms and suspicion of testicular torsion) between January 2008 and December 2009 (n=138, mean age nine years eight months). All patients underwent scrotal exploration after initial assessment by a paediatric surgical resident. Noted features from the patient history included duration of pain, associated symptoms (including nausea and / or vomiting), previous episodes of pain or history of scrotal trauma, medical co-morbidities, medications, and, if appropriate, sexual history. Documented physical examination findings included side of pain, erythema or swelling, tenderness over the testis or epididymis, presence of the ‘blue dot sign’, urethral discharge and nature of the cremasteric reflex. At surgical exploration, 19 patients (13.8%) had testicular torsion – 92 (66.7%) had torsion of the appendix testis and 27 (19.6%) had epididymo-orchitis. A number of features were found to correlate with increased likelihood of testicular torsion – pain lasting less than 24 hours, presence of nausea and / or vomiting, abnormal cremasteric reflex and high position of the testis. Of those patients with at least two of these findings, all had testicular torsion, with no false positives. In addition, patients with testicular torsion were significantly older than those with other diagnoses (eleven years one month, vs. nine years one month). However, this study had not been able to identify a single, 100% sensitive, clinical finding for testicular torsion, and, therefore, surgical exploration remains the only absolute means of diagnosis. The authors plan to suggest a scoring system in attempt to predict the diagnosis prior to surgical exploration, in combination with doppler ultrasonography.
Symptomatic ureteric stones during pregnancy
Reviewed by: Ashley Ridout
May/Jun 12 (Vol 16 No 4)
This retrospective study reviewed 36 pregnant women (mean age 28.6 years; range 19-42 years; and mean gestation 23.8 weeks; range 10-34 weeks) who presented with symptomatic ureteric stones between September 2002 and May 2011. Initial assessment included history and physical examination, blood tests, urinalysis and ultrasound. Ultrasound successfully identified a ureteric stone in 25 patients (69.4%) – mean stone size was 8.8mm (range 6-10mm). For the remainder of patients (n=11, 30.6%), the suspected diagnosis of ureteric colic was based on history and examination findings. Six of these passed a stone spontaneously and five were confirmed with ureteroscopy. In the first instance, all patients were managed conservatively with analgesia, antiemetics and antibiotics. This was successful in 24 patients (66.6%). Of the remainder, three were successfully stented (procedure attempted in six patients) – percutaneous nephrostomy was required in one patient due to persistent pain and sepsis. Nine patients (including the patient who was initially treated with nephrostomy) underwent ureteroscopy and stone fragmentation, with no significant complications. All pregnancies were carried to term, with no apparent adverse foetal effects. This study reiterates the theory that, in the absence of sepsis or severe pain, initial management of ureteric stones in pregnancy should be conservative. Intermediate management with ureteric stenting or nephrostomy remain appropriate alternatives, as is ureteroscopy, which was carried out in these patients without significant complications.
Ablation of the prostate: holmium laser (HoLEP) or TU-P?
Reviewed by: Christian Bach
Mar/Apr 12 (Vol 16 No 3)
Transurethral resection of the prostate (TURP) and holmium laser enucleation of the prostate (HoLEP) are both widely used for treatment of benign prostatic obstruction (BPO) but, so far, comparative long-term data is missing. After initially presenting their two-year results in 2006, Peter Gilling and his group from New Zealand have now published their seven-year results in the BJUI. After median follow-up of 6.7 years, the data of 31 from the original 61 patients have been available, and one year after surgery, there was no significant difference in any of the relevant parameters apart from the re-treatment rate. The mean values (HoLEP vs. TURP) were as follows: Qmax 22.09 vs. 17.83mL/s; American Urological Association symptom score 8.0 vs. 10.3; quality of life score 1.47 vs. 1.31; benign prostatic hyperplasia impact index 1.53 vs. 0.58; International Index of Erectile Function erectile function domain score 11.6 vs. 9.21; International Continence Society male voiding score 4.2 vs. 3.0; International Continence Society male incontinence score 3.07 vs. 1.17. A significant difference was found in re-treatment rate. While none of the patients from the HoLEP group required a second intervention, three of the seventeen patients undergoing classical TURP needed a re-operation due to recurrence. Perioperatively, there were significant advantages for HoLEP in terms of the amount of removed tissue, catheter time and length of hospital stay. Just 6.7% of patients required postoperative bladder irrigation after HoLEP, compared to 70% in the TURP group. The authors conclude that HoLEP is at least equivalent to TURP in the long term with fewer re-operations being necessary. However, there are some problems with this study: The size of the sample is relatively small, owing to the length of the study period and the age of the patients. The authors did not make clear if mono or bipolar TURP was used. This would make a significant difference as bipolar resection in saline can be considered as the new ‘gold standard’ of transurethral resection. Furthermore, Peter Gilling is one of the world experts in HoLEP – it is questionable if his results are equivalent to the results of other centres.
Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years.
Gilling PJ, Wilson LC, King CJ, et al.
BJU INTERNATIONAL
2012;109(3):408-11.
Hypospadias correction in childhood
Reviewed by: Henrik Steinbrecher
Mar/Apr 12 (Vol 16 No 3)
It is clear that long-term outcomes of hypospadias surgery should only be carried out after puberty as pubertal growth can change final cosmesis and psychosexual development is not yet fully obtained. Long-term studies are scarce compared to the myriad of operations performed for hypospadias worldwide. Current thinking is again turning to contemplating whether or not we should actually be operating on distal hypospadias in childhood, which is essentially a cosmetic procedure in many cases. This review paper presents long-term data on hypospadias repair using PubMed / Medline and Embase database searches. All children included had their operation before age six and were seen after age 14. There were 20 eligible studies up to February 2010 comprising a total of 1060 patients with 742 controls. Most authors obtained their data by using questionnaires with a mean response rate of 48%. This makes truly valid comparisons difficult, however, reasonably accurate trends could be observed. Patients with hypospadias reported lower urinary tract symptoms twice as commonly as controls and these symptoms included poor flow, spraying and feeling of incomplete emptying. Flow was lower in hypospadias patients (measured by Qmax). Patients with hypospadias were generally less satisfied with cosmetic outcomes and this was worse with severe hypospadias. Eighty-one percent of hypospadiac patients expressed sexual satisfaction, compared to over 90% of controls and this was borne out by objective recordings of first sexual encounters, erectile dysfunction and ejaculatory dysfunction (especially in severe cases). The paper highlights the significant errors of using pooled data, pooled papers and an extended time period where operations and techniques have changed over the years. It is evident that prospective studies from centres carrying out high volume hypospadias surgery are essential to help us improve our surgery in the long term.
Functional, cosmetic and psychosexual results in adult men who
underwent hypospadias correction in childhood.
Rynja SP, de Jong TPVM, Bosch JLHR, et al.
JOURNAL OF PEDIATRIC UROLOGY
2011;7(5):504-15.
Persistent RAS activation after anti-reflux surgery and its management
Reviewed by: Henrik Steinbrecher
Mar/Apr 12 (Vol 16 No 3)
The pathophysiological events which lead to renal scarring are mediated by the renin-angiotensin system (RAS) activation resulting in apoptosis and renal scarring. Renal scarring causes tubular ischaemia and destruction of proximal tubules. Microalbuminuria is the most sensitive and specific test for early identification of renal injury. Glomerular hyperfiltration by remaining unscarred glomerular-tubular units may be responsible for the progressive increase of urinary microalbumin. In this study, 39 children (mean age 30 months, range 6-96) who underwent anti-reflux surgery for high grade primary vesicoureteric reflux (VUR) had a number of parameters measured pre and post surgery including plasma renin activity (PRA), urinary microalbumin, and renal scars (on DMSA). Angiotensin-converting-enzyme (ACE) inhibitors were given to children who had microalbuminuria whether or not they had renal scarring. The results indicated that early postoperative improvement in renal parameters (rise in split renal function, rise in glomerular filtration rate (GFR) fall in PRA) was not sustained. ACE inhibitor treatment demonstrated improvement in split renal function and GFR and a fall in microalbuminuria. The authors of this paper argue that prolonged medical treatment before surgery sets into motion a cascade of events that reduce the benefit of surgery as a result of ongoing recurrent activation of the renin-angiotensin system causing ongoing renal damage. They infer that current indications for VUR surgery, such as the appearance of scars or progression of existing scars are far too late. In addition they advocate early treatment with ACE inhibitors soon after anti-reflux surgery.
Persistent renin-angiotensin system activation after anti-reflux surgery and its management.
Bajpai M, Bal CS, Kumar R, et al.
JOURNAL OF PEDIATRIC UROLOGY
2011;7(6):616-22.
Risk of end stage renal disease in patients with posterior urethral valves
Reviewed by: Stephen Griffin
Mar/Apr 12 (Vol 16 No 3)
Posterior urethral valves (PUV) are known to cause end stage renal failure (ESRF) in a significant number of cases. This retrospective study over a 50-year period, that spans the introduction of prenatal ultrasonography, looks at renal outcome in boys diagnosed with PUV and followed into adult life. It is based at a tertiary centre in Helsinki, Finland. Hence follow-up and capture of long-term data is excellent. There was data available on 193 of 200 patients diagnosed with PUV. Only 15% of the patients were diagnosed prenatally. Postnatal presentation was associated with urinary tract infection (UTI), neonatal difficulties, enuresis, haematuria and poor urinary stream. Almost 90% of these were diagnosed before the age of one. Fifteen patients were diagnosed after the age of 10 years. Initial surgical management was with primary valve ablation or loop ureterostomy to allow the bladder to cycle. Mean patient evaluation was at 31 years (range 6-69). Kaplan-Meier analysis revealed a lifetime probability of 28.5% for ESRF, which is similar to previously published data. The cumulative risk was 17% in the group born pre-routine antenatal scanning compared with 37% in those born after 1982 when routine prenatal ultrasound examination was introduced in Finland. This may be higher than in other countries as termination of pregnancy for prenatal hydronephrosis in Finland is rare. The authors also postulate that they are diagnosing more severe cases in the antenatal period. In this study progression to ESRF was relatively constant to 34 years with some steepening of the curve in the first year of life and in adolescence. High serum creatinine at diagnosis and during the first year after valve resection is associated with renal progression in this study. This is similar to previous reports. Bilateral, but not unilateral vesicoureteric reflux was also found to be associated with increased risk of ESRF here. Previous reports yield inconsistent results in this regard. Repeat UTIs post valve ablation were also associated with increased risk of ESRF in this report. Pneumothorax was found in 7% of patients at diagnosis. ESRF developed later in 50% of these patients. However, although urinary incontinence was found in 36% of boys over five years, this was not associated with increased risk of ESRF. As there is a paucity of quality long-term studies in the paediatric urology literature, the authors are to be commended for this study. This should help with both antenatal and postnatal counselling with respect to renal outcome for patients with PUV.
Long-term risk of end stage renal disease in patients with posterior urethral valves.
Heikkilä J, Holmberg C, Kyllönen L, et al.
JOURNAL OF UROLOGY
2011;186(6):2392-6.
On-demand opioid in treatment of premature ejaculation
Reviewed by: Christian Bach
Mar/Apr 12 (Vol 16 No 3)
Before the recent introduction of the short-acting serotonin re-uptake inhibitor (SSRI) dapoxetine, there has been no specific drug treatment against premature ejaculation. Several studies have confirmed in the meantime that the SSRI increases latency time between penetration and ejaculation by an average of one to three and a half minutes and has an acceptable rate of side-effects. In this recent issue of Urology, the Turkish urologist, Dr Mehmet Kaynar reports a similar success with the opioid tramadol. In his study, 60 men suffering from premature ejaculation (latency less than a minute) have been treated with an on-demand medication. Two hours before sexual intercourse one half took a supplement containing 25mg tramadol, the other half received a placebo. With a watch the patients determined and recorded their latency after penetration. In addition, they were interviewed after eight weeks regarding their ability to control ejaculation and satisfaction with their sex life. With placebo, the latency period of about half a minute had doubled to almost one minute. With tramadol however, the latency increased fourfold from an average of 39 seconds to 155 seconds or nearly two and a half minutes. On a four-point scale the ability to control ejaculation increased from 0.9 to 1.5 with placebo and from 0.8 to 2.8 with tramadol. Sexual satisfaction was also determined on a four-point scale; it increased with placebo from 0.8 points to 1.3 points, with the opioid from 1 point to 2.8 points. The tramadol group had significantly (P<0.001) greater values for all three parameters (intravaginal ejaculation latency time, ability of ejaculation control, and sexual satisfaction score) compared with those in the placebo group. The study authors state that tramadol is an effective alternative to SSRIs, especially when SSRIs are ineffective or not well tolerated. The opioid mechanism of action is not yet fully understood but is believed to be mediated by the stimulation of µ-opioid receptor, and by blocking norepinephrine and serotonin reuptake.
On-demand Tramadol Hydrochloride Use in Premature Ejaculation Treatment.
Kaynar M, Kilic O, Yurdakul T.
Urology
2012;79(1):145-9.
Risk factors for progressive deterioration of semen quality in patients with varicocele
Reviewed by: Ashley Ridout
Mar/Apr 12 (Vol 16 No 3)
This study compared two age-matched groups of adult males with left-sided varicocoele (Grades 1-3), undergoing conservative treatment and assessed their progressive deterioration of semen quality (PDSQ). Group 1 (n=32, mean age 22.3 years) had impaired semen quality as judged by sperm density, motility and morphology, total sperm count and total motile sperm count, compared to Group 2 (n=30, mean age 21.9 years). PDSQ was defined as decreased sperm density, total sperm count or total motile sperm count greater than 45%, or deterioration of motility or morphology greater than 20% during follow-up. Each patient underwent annual assessment of semen quality, peak retrograde flow (PRF) and spontaneous venous reflux, body mass index, serum concentration of luteinising hormone (LH), follicle-stimulating hormone (FSH), prolactin and testosterone, testicular volume / discrepancy, scrotal temperature and grade of varicocoele – mean follow-up time was 63.2 months (range 60-66 months). Rate of PDSQ throughout the study was significantly greater in those who had prior abnormal semen quality (87.5%, n=28), compared to those whose semen quality was initially normal (20%, n=6). Multivariate analysis only revealed significant differences in peak retrograde flow and scrotal temperature, and indeed, of those patients with normal semen quality at the start of the study, these variables also conveyed a greater risk of developing PDSQ. There were no patients in this relatively small study who showed improved semen quality or downgrading of varicocoele, perhaps indicating the importance of considering surgery in a particular subset of patients with impaired semen quality and greater peak retrograde flow.
Risk Factors for Progressive Deterioration of Semen Quality in Patients with Varicocele.
Chen S-S, Chen L-K.
UROLOGY
2012;79(1):128-32.
Extracorporeal shock wave lithotripsy for ureteric calculi
Reviewed by: Ann Crump
Jan/Feb 2012 (Vol 16 No 2)
This retrospective study examined 108 patients who had undergone extracorporeal shock wave lithotripsy (ESWL) over a two and a half year period. To be included in the study the patient must have had a single ureteric stone less than 20mm in size and have had no previous intervention. As well as stone size, stones were classified into their position within the ureter, i.e. i) the pelvi-ureteric junction (PUJ), ii) upper ureter – between PUJ and sacroiliac joint, and iii) lower ureter – distal to sacroiliac joint. All ESWL was performed using a Storz Modulith SLX. If the patient was completely stone-free on KUB or CT-KUB two weeks post-procedure then the treatment was considered a success. The overall ureteric stone-free rate was 78.7%. Of these stone-free patients, 29 out of 85 required a single treatment with ESWL, 36 required two treatments and 19 required three. There was no benefit seen with giving any further treatments. As expected, the success rate was higher the smaller the stone. Clearance for stones less than 6mm was 90%, 77% for those between 6 and 10mm and 73% in stones greater than 10mm in size. More proximal stones were more likely to be cleared than lower ureteric stones. Eighty-six percent of PUJ stones were cleared, compared to 79% for upper ureteric stones and 71% for lower ureteric stones. Having a JJ stent in situ greatly decreased the success rate of ESWL from 87% to 64%. Although retrospective, this study is useful in clarifying which patients are more likely to benefit from ESWL for their ureteric calculi, i.e. small, proximal stones without a stent.
Testicular microlithiasis study
Reviewed by: Ann Crump
Jan/Feb 2012 (Vol 16 No 2)
This prospective study provides the follow-up to a study originally published by this group in 2000, which recommended that all patients with testicular microlithiasis (TML) be followed up with regular ultrasound. Of 4819 patients who were referred to this unit for scrotal ultrasound, 57 men were found to have TML alone. The mean age of these patients was 34.1 (range 8-54). These men were followed up for a mean period of 28.4 months (3-102) and had either six-monthly or annual ultrasound. Over this time period only one tumour developed and this was in a 32-year-old man who had an atrophic contra lateral testes, which is known to be an independent risk factor for testicular malignancy. The conclusion of the authors has now differed from their original advice and with this long-term data recommend self-examination in patients with TML and only to follow up patients with ultrasound if they have other risk factors for malignancy.
Does pelvic anatomy influence the complications from radical prostatectomy?
Reviewed by: Mark Harris
Jan/Feb 2012 (Vol 16 No 2)
The perceived wisdom of pelvic surgery is that a narrow and deep pelvis, combined with a large and deep prostate gland, increases the risks during prostatectomy. This US and German retrospective study of 934 patients examined this relationship by taking a variety of pelvic measurements from pre-operative magnetic resonance imaging (MRIs) and correlating them with the risk of subsequent complications. Sixty-seven percent of cases were open and 33% laparoscopic, with 267 complications being noted on a detailed record review (109 medical, 158 surgical). Seventy-one percent of cases were pT2 and 27% pT3, with 11.6% of cases having a positive surgical margin (PSM). Despite using a variety of measurements, none were found on a Cox multivariate analysis to be significant predictors of operative complications. This is in contrast to other urological studies, albeit of smaller size, and also differs from rectal cancer trials, where the narrow pelvis results in higher complication rates. Other factors, such as increased age, higher prostate specific antigen (PSA), higher Charlson score and body mass index (BMI), along with low surgeon volume, have previously been shown to be independent risk factors, whereas in this study the risks were increased by a higher PSA, using a laparoscopic approach, having vascular co-morbidity or a higher modified Charlson score. There were insufficient numbers to permit an analysis of the impact of ethnicity, as previous studies have suggested that the morphology of African-American men makes dissection more difficult. Whilst this study is retrospective, it is the largest study to disprove the link between anatomy and surgical outcome, using a retropubic approach. Whether this is true for robotic prostatectomy remains to be seen.
Who is really at risk after radical cystectomy and needs more intense surveillance?
Reviewed by: Mark Harris
Jan/Feb 2012 (Vol 16 No 2)
Despite the data suggesting that 10-25% of patients with pT2 disease recur and die after radical cystectomy, they are often felt to be lower risk, not included in complex trials or offered neo-adjuvant chemotherapy infrequently. This trial aimed to stratify the risk of patients with pT2N0 disease, finding 707 chemotherapy naïve patients from nine academic units. Median follow-up was 61 months, with 364 patients having pT2N0, 170 pT2N0 and 173 pT2bN0.
Cox regression analysis was used to identify risk factors for recurrence, with advanced stage, high grade and lymphovascular invasion showing predictive power, whilst age and number of lymph nodes removed did not matter. The authors used a mix of the factors to create three groups (low, intermediate and high risk) that could be used to predict outcome. The respective five-year recurrence-free survival rates were 95%, 86% and 62%, with the overall survival rates being 89%, 78% and 58% respectively. Whilst this study was limited by being retrospective, lacking a standardised lymphadenectomy and surveillance programme and being unable to control some potential confounding elements, it does highlight which groups may best benefit from more intensive surveillance and treatment. Having calculated an individual’s risk, those at higher risk could be offered more chemotherapy or trials, whereas those with lower risk disease could be followed up more infrequently. The trial also benefits from having less heterogeneity, thereby reducing confounding factors. Ultimately, if these results were confirmed in larger trials, patients with muscle-invasive disease of the bladder could then have a far more tailored approach, thereby improving results and avoiding unnecessary treatments.
Does a reduced intake of omega-6 fatty acids decrease the risk of prostate cancer?
Reviewed by: Christian Bach
Jan/Feb 2012 (Vol 16 No 2)
A team from Los Angeles, led by Dr William Aronson, served 55 men with prostate cancer four to six weeks prior to the removal of the gland two different meals. Half of the patients received the usual Western diet, where 40% of calories come mostly from saturated fat, with a ratio of omega-6 to omega-3 fatty acids of 15:1. The other half was served a low fat diet, where only 15% of calories came from fats, and the ratio of omega-6 to omega-3 fatty acids was 2:1. To achieve this, the participants in the latter group also received 5g of fish oil daily. After undergoing radical prostatectomy, histopathologic investigation showed that in group two, the ratio of fatty acids in the cell membrane had shifted in favour of omega-3 fatty acids. Even more interesting was the proliferation rate of the prostate cancer cells: under fish oil diet, this rate was less than one third compared to men with a normal diet. As a high prostate cancer proliferation rate is associated with a poor prognosis, high risk of recurrence and an increased risk of metastatic disease, these findings are highly interesting. In a further step, the scientists used serum of men under the fish oil diet in an ex vivo bioassay, where it was applied directly on prostate cancer cells. Here it showed to slow down the proliferation of prostate cancer cells too – in contrast to serum of men with a conventional diet. It remains unclear by which factors this beneficial effect is mediated. Initially, the researchers had hoped to reduce the blood concentrations of proliferation-promoting growth factor IGF-1 with the fish oil diet, which was not the case and, therefore, suggests other mechanisms.
Urethral recurrence after cystectomy – what are the risk factors?
Reviewed by: Christian Bach
Jan/Feb 2012 (Vol 16 No 2)
The incidence of urethral recurrence after radical cystectomy for urothelial carcinoma is higher for patients in whom the prostate is involved, the carcinoma occurred multifocal in the bladder and for patients with orthotopic neobladder. This is the result of a recent study by Stephen A Boorjian, Mayo Clinic, Rochester, USA, et al. The authors looked retrospectively into the data of 1506 patients undergoing radical cystectomy, average follow-up was 13.5 years. Eighty-five patients (5.6%) suffered a urethral recurrence, which occurred on average 13.3 months after cystectomy. In 80 patients (6.4%) of a total of 1243, a cutaneous urinary diversion had been formed; five (2.1%) of a total of 242 had received a neobladder. The following risk factors for a urethral recurrence could be identified:
• involvement of the prostate (hazard ratio [HR]: 4.89, p<0.0001)
• multifocal primary bladder cancer (HR: 2.34, p=0.0001)
• orthotopic neobladder (HR: 0.34, p=0.02).
The five-year survival depended crucially on whether the diagnosis of the recurrence was made in an already symptomatic or asymptomatic patient. Eighty percent of asymptomatic patients, where recurrence was diagnosed by a positive cytology, were alive after five years, compared to only 41% of patients with a symptomatic recurrence (p<0.0001).
The authors conclude that, even if urethral recurrence after radical cystectomy is rather rare (5.6%), continued postoperative evaluation of the urethra of these patients is necessary in order to detect recurrence as early as possible and in an asymptomatic stage to considerably increase the patient’s chance of survival.
Meatal stenosis in children following neonatal circumcision
Reviewed by: Henrik Steinbrecher
Jan/Feb 2012 (Vol 16 No 2)
This paper from Iran makes a case for close follow-up of any child who has undergone circumcision, especially in the neonatal period, but we could add that meatal stenosis has a high incidence in neonatal circumcision and, therefore, this practice should be avoided. The authors looked at 132 patients who had been circumcised neonatally using interviews and clinical examination (including insertion of a 5F feeding tube into the meatus). The patients had been referred for other surgical conditions. Twenty-seven of 132 (20.4%) had meatal stenosis (diameter <5 Fr), and 25 of these 27 had decreased flow width and prolonged voiding times. Of the 25, 10 mentioned soaking their feet on voiding and 18 / 25 had frequency and nocturia. Three had bladder wall thickening and bilateral hydronephrosis due to vesicoureteral reflux (on a micturating cystourethrogram). All 27 patients had meatotomies and all but three had resolution of their symptoms. The paper highlights in the discussion that meatal stenosis is common post any circumcision and should be looked for on follow-up.
The return of the solitary testis
Reviewed by: Henrik Steinbrecher
Jan/Feb 2012 (Vol 16 No 2)
Various clinical scenarios can lead to a solitary testis and there is no conformity as to what is the best treatment option. This paper reflects on the outcome of a survey of paediatric urologists in France asking them to respond to a questionnaire which asked the following questions: Do you fix the remaining testis following intravaginal torsion in a child / following extravaginal testicular torsion / following negative exploration for cryptorchidism / following orchidectomy for tumour or torsion? A further set of questions asked whether or not the surgeons had witnessed testicular torsion of a solitary testis or testicular necrosis following orchidopexy? Of 28 practitioners, all of whom answered the questionnaire, the responses showed unanimity only in the first question, i.e. all fixed the remaining solitary testis following intravaginal testicular torsion in a child. Five replied that they had seen torsion of a solitary testis and three had seen necrosis following orchidopexy. A similar study from the UK in 1992 from Bristol showed similar heterogeneity in practice. The real problem is no valid scientific explanation for torsion in some cases and no accurate definition of what is extravaginal or intravaginal in terms of high insertion of tunica vaginalis. Similarly, there is no definitive method of fixation as all have been documented to have a risk of recurrent torsion or testicular damage, although the sutureless dartos pouch fixation method has the lowest risk of problems and is the preferred method of fixation amongst paediatric urologists. The paper concludes that whether or not to fix the solitary testis should depend on the attending surgeons’ clinical belief, which is experience based, not evidence based.
Factors affecting complication rates of ureteroscopic lithotripsy in children
Reviewed by: Stephen Griffin
Jan/Feb 2012 (Vol 16 No 2)
There is little doubt that the advent of smaller instruments for accessing the ureter has lead to increased use of ureteroscopic techniques for management of renal tract calculi in children. This multi-centre retrospective review, from a part of the world where stones are endemic, presents data collected from over 600 paediatric cases, collected over a 10 year period, treated with semi-rigid ureteroscopic lithotripsy. Clinical features, in order of frequency, were colic (59%), haematuria (12%) and urinary tract infection (7%). Seven percent presented incidentally. Pre-operative urinary culture was positive in 10% and hydronephrosis was reported in >80% on pre-treatment USS. Where stone analysis was available, 74% were calcium oxalate stones and 15% cystine. Stone-free rates with a mean follow-up of 13 months were 93%. Duration of operation ranged from 10-180 minutes (mean 46 minutes). Eight percent experienced complications. By far the most common was febrile UTI (3%) despite prophylactic antibiotics peri-operatively. Other notable complications were stone migration (1%), inability to access stone / ureter (1%), ureteral perforation (0.8%) and VUJ obstruction (0.6%). Operative duration was the only factor, on multivariate analysis, associated with increased risk of complication. The authors make interesting comments with respect to volume of cases, the role of stents and active ureteric orifice dilation. In one of the tables they present a ‘p’ value suggesting those centres performing more ureteroscopy have significantly lower complication rates. However, analysis of the figures provided show that only three of 16 units performed over 60 cases over a 10 year period. This pales into insignificance when compared to a large adult stone unit and makes conclusions in relation to improved safety with increased caseload tenuous in my view. Stents were used in approximately 62% of cases. This is at the higher end of the spectrum in paediatric practice. Children tend to pass stones and fragments easier than adults and one would expect less use of stents post ureteroscopy than in adult practice. One area where stents are undoubtedly useful in children is when one is unable to access the ureter. Active ureteric orifice dilation, under vision with a balloon, is also an option, but may predispose to vesico-ureteric junction VUJ obstruction, which was uncommon in this study. All in all, this study demonstrates high efficacy for ureteroscopic treatment of ureteric stones in children with low complication rates. The senior authors are however strong proponents for ureteroscopy, and extracorporeal shock wave lithotripsy (ESWL) for ureteric stones should not be discounted, particularly where ureteroscopic skills are not available or where anatomy deems ureteroscopy impossible.
Kidney transplantation: immunosuppression unnecessary
Reviewed by: Christian Bach
Jan/Feb 2012 (Vol 16 No 2)
In a letter to the editor, Samuel Strober and his colleagues from the Stanford School of Medicine report their initial experience with induction of immune tolerance by combined organ and hematopoietic-cell transplantation. In a Phase IIa clinical trial, twelve patients, after receiving a HLA-compatible donor kidney, have been treated by a highly enriched donor-cell infusion, containing CD34+ hematopoietic progenitor cells mixed with CD3+ T cells. Furthermore, the patients received a conditioning regimen of total lymphoid irradiation and anti–T-cell antibodies. After the donor-cell infusion, all patients received mycophenolate mofetil for one month and at least six months of cyclosporine. The latter one was discontinued, as soon as DNA chimerism was continuously detectable for at least six months according to short-tandem-repeat analysis of blood granulocytes and lymphocytes and if patients showed no graft versus host disease and no other signs of rejection. Eight of those 12 patients did not need to take any anti-rejection medication. Follow-up was between 12 and 36 months. In four patients it was necessary to continue immunosuppressive drugs due to recurrence of focal segmental glomerulosclerosis in one and rejection episodes in the others. Overall, the majority of patients were able to stop their immunosuppressive medication and all these patients continued to have an excellent graft function. After these encouraging results, the next step will be to apply this protocol in patients with mismatching of one HLA-haplotype.
Is there any value investigating persistent haematospermia?
Reviewed by: Ann Crump
Nov/Dec 2011 (Vol 16 No 1)
This prospective study examined men over a 12-year period with persistent haematospermia. Patients were included if they had had either a single or multiple episode of haematuria within a six-month time period. A total of 118 men were divided into two groups: those under 40 (14) and those over 40 years of age (104). All men underwent a history, clinical examination, MSSU, PSA and a TRUS (+/- biopsies). The mean age of the patients was 53. Of the under 40 group all had a normal PSA. TRUS revealed prostatic calcification in two of these patients. No patient in this group had any evidence of prostatic malignancy. In the over 40 age group all patients who were subsequently found to have prostatic malignancy (7/104) had a raised PSA. An abnormal DRE was found in six out of these seven patients. This equates to a 6.7% incidence of prostate cancer in this group and 5.9% incidence in the study overall. The study demonstrates that a TRUS in patients presenting with haematospermia is unnecessary unless an abnormal PSA or DRE is noted. This is further reassurance of the low incidence of prostatic disease in this group of patients. The question this study doesn’t answer is whether a flexible cystoscopy is required in these patients and, if so, which group of patients require this further investigation as only prostatic cancer was looked for and not urethral or bladder cancer.
Hypospadias repair with tabularised incised plate
Reviewed by: Henrik Steinbrecher
Nov/Dec 2011 (Vol 16 No 1)
One of the recognised complications of hypospadiac surgery is bladder outflow obstruction and consequent bladder malfunction with over activity. Urologists rely on clinical and parental observation as well as flow rates to determine whether or not the meatus post operatively is adequate functionally. This study looked at the change in flow patterns with time following hypospadias surgery. In 48 boys, old enough for flow rate analysis, 11 had symptoms of obstruction resulting in intervention. For 37 boys, analysis was carried out at one year and seven years post operatively. Flow max increased from 13.6ml/s +/- 5.6 at one year to 19ml.s +/- 8.1 at seven years. At one year, 49% had flows below fifth centile, whereas at seven years this had fallen to 32%. Proximal hypospadias repairs were more often associated with obstructive flow. These authors conclude that long-term follow-up is important since there does not seem to be any way to predict which boys will deteriorate and develop obstruction that requires intervention, although it does appear that the majority of poor flow rates improve with time.
Increase of resistant bacteria – growing danger after prostatic biopsy
Reviewed by: Christian Bach
Nov/Dec 2011 (Vol 16 No 1)
Over the past 20 years the number of infectious complications following prostate biopsy has significantly increased. This has been published by a team of urologists and oncologists from Johns Hopkins Medical Institution in Baltimore and the National Institutes of Health in Bethesda which had looked into the data from a sample of over 65-year-old Medicare beneficiaries. 17,472 of the patients underwent a prostatic biopsy in the years between 1991 and 2007. The control group, with similar characteristics but not undergoing the procedure, served 134,977 other insured persons. Comparison was made between the frequency with which the men 30 days after the biopsy or in a corresponding randomly chosen date in the control group required hospitalisation.
Hospitalisation rate was 6.9% for the biopsied, for non-biopsied 2.7%. After adjusting parameters such as age and comorbidities, the risk of hospitalisation during the first 30 days after the biopsy showed to be raised by the factor of 2.65. The interesting point is that the rate of non-infectious complications remained stable over the years, however, the rate of infections has increased significantly: in 1991 only 0.5% of men after prostate biopsy needed infection related inpatient treatment, whereas this rate was 1.2% in 2007. According to the authors, the main reason for this increase of serious infections is the steady rise of resistant bacteria; therefore patient selection should be carried out even more carefully taking into account these new findings.
Body mass index, prostate-specific antigen and tumour volume at radical prostatectomy
Reviewed by: Ashley Ridout
Nov/Dec 2011 (Vol 16 No 1)
Numerous factors have been used to estimate prognosis in prostate cancer. Tumour volume correlates directly with pathological stage and chance of PSA recurrence, and therefore can be used as a prognostic measure. It was previously accepted that there was a strong correlation between pre-operative PSA and tumour volume in prostate cancer. However, given increasingly widespread serum PSA measurement and earlier detection of prostate cancer, this relationship is being challenged, and it has been shown that PSA is becoming less predictive of tumour volume. There is an ongoing search to define this and, in particular, how it is possible to link pre-operative PSA and tumour volume. In our population, the prevalence of obesity continues to increase, and subsequently this has a significant impact upon our practice. The relationship between PSA and obesity is under investigation – it has previously been postulated that increased plasma volume in obese men leads to haemodilution of serum PSA, thereby decreasing the serum PSA estimation. However, the prognostic implications of this phenomenon have not been confirmed. This retrospective study evaluates a large cohort of patients who underwent radical prostatectomy, excluding those who had neoadjuvant therapy (n=14,293). Multiple linear regression analysis was used to assess the relationship between BMI, pre-operative PSA and tumour volume. The authors ask whether PSA haemodilution in obese men could account for the decreasing association between pre-operative PSA and tumour volume in current practice and, if so, should PSA be corrected to account for BMI? Their results showed that increased PSA was associated with increased Gleason score, prostate size and tumour volume, but only the latter was statistically significant. There was no significant correlation between BMI and pre-operative PSA and, therefore, it was concluded that pre-operative PSA does not need to be corrected to account for BMI.
Another rung in the hormonal ladder: low dose ketoconazole in CRPC
Reviewed by: Mohamed Hussin
Sep/Oct 2011 (Vol 15 No 6)
Patients with castrate resistant prostate cancer (CRPC) are often difficult to treat due to the heterogeneity of their disease and because they are typically older men with co-morbidities that preclude treatments such as docetaxel. This small, single-arm phase 2 trial was designed to assess the efficacy and safety of low dose fluconazole, which is believed to have some hormonal effect through its inhibitory action on adrenal androgen synthesis and other enzymes, such as cytochrome p450. Thirty-seven patients were recruited, with 31 having demonstrable metastases and six showing prostate-specific antigen (PSA) progression, despite hormonal manipulation. The mean PSA was 28.8ng/ml, with 15 men having had prior docetaxel treatment. Fluconazole was administered at 200mg, with monthly PSA monitoring and three-monthly imaging (CT or bone scintigraphy, assessed using Response Evaluation Criteria In Solid Tumors (RECIST)) until signs of disease progression or adverse effects. Two patients had a complete biochemical response, six a partial response, 13 were stable on imaging and 14 progressed, meaning that 21% had some response and 56% had disease control. One patient in the cohort of 15 post-docetaxel patients had a complete response and four more had a partial response. Median progression-free survival was 21 weeks. Treatment was generally well tolerated, with no grade 3 side-effects and grade 2 effects of asthenia in 27% and vomiting and/or abdominal pain in 8%. This trial suggests that there is a potential role for low dose fluconazole in CRPC, even post docetaxel, and that it is well tolerated, although lowering the dose reduces the efficacy. However, no quality of life analysis was performed and the small size means that it is still unclear which sub group of patients would benefit most. Further work also needs to establish the optimal time to use fluconazole in the therapeutic ladder.
Maintenance BCG: the gold standard?
Reviewed by: Mohamed Hussin
Sep/Oct 2011 (Vol 15 No 6)
Since the Lamm trial was published, the benefit of bacillus Calmette-Guérin (BCG) maintenance after transurethral resection of the bladder tumour (TURBT) in non–muscle-invasive bladder cancer (NMIBC) has been debated. This randomised controlled trial of 115 patients was designed to assess the effect of an induction course of BCG versus induction with maintenance versus epirubicin. Patients had to have at least three tumours at initial TURBT, or have at least three recurrence episodes or a recurrence within one year of TURBT to qualify. Patients with CIS, muscle-invasive disease or prior intravesical chemotherapy (mitomycin excluded) were not eligible. The primary endpoint was recurrence free survival, with cystoscopic and cytological surveillance. At a two-year median point, the recurrence-free survival rates were 84.6% for the induction and maintenance group versus 65.4% for the induction only group versus 27.7% for the epirubicin cohort. The difference between the maintenance and induction only groups was significant (p=0.019) as was the difference between BCG and epirubicin. Seventy percent of the maintenance group completed 18 months of treatment, which compares favourably to the 16% in the Lamm trial, and could have been higher if reduced dosing or quinolones were permitted. No patient in the maintenance arm progressed, whereas 21.9% of the epirubicin arm did. In addition, the likelihood of developing a recurrence persisted for much longer in the epirubicin arm. This trial, therefore, demonstrates that prolonged use of BCG should be the standard of care in reducing the risk of recurrence and progression in NMIBC.
Is routine histology necessary in circumcision?
Reviewed by: Ann Crump
Sep/Oct 2011 (Vol 15 No 6)
This retrospective audit essentially reinforces the paper from Pearce and Payne (2002). It reviewed 114 patients who underwent circumcision over a year period. All patients had histology sent and histological diagnosis was compared to preoperative clinical diagnosis. Of patients with lichen sclerosis, 84% were predicted preoperatively. Three cases of squamous cell carcinoma (SCC) were identified and all of these were identified preoperatively. The most common diagnoses were balanoposthitis and lichen sclerosis. The cost of processing the specimen from a circumcision is approximately £40 and this paper argues, as did the previous one, that routine histology is unnecessary, as long as the patient has been properly assessed preoperatively. They recommend that only lesions that look suspicious of lichen sclerosis or SCC need be sent to the laboratory.
Describing disorders of sex development
Reviewed by: Henrik Steinbrecher
Sep/Oct 11 (Vol 15 No 6)
How we describe and classify things play an important role in understanding conditions but they also affect our patients’ understanding, perception and reaction to the problem. This paper describes the use of a questionnaire to evaluate the acceptance of the new classification of describing disorders of sex differentiation (DSD, previously called ‘intersex states’ since 1923), adopted in 2006. Nineteen parents of children with DSD, 15 health professionals and 25 parents of other children (seen in the diabetic clinic) were surveyed. Comparing the term DSD to ‘intersex’, overall 86.4% preferred the term DSD. This was higher in parents who had a child with DSD (94.7%). Health professionals preferred the genotype definitions (46 XX DSD, 46 XT DSD ovotesticular DSD and 46 XX testicular DSD) compared to the previous intersex descriptions of hermaphrodite, pseudo hermaphrodite, virilisation, over / under masculinisation, XX sex reversal (XX male). Parents found these genotype terms confusing. Only 36.8% of parents of children with DSD considered the term ‘disorder of sex development’ acceptable to describe an individual’s overall condition when it was not possible to assign gender at birth. The paper concludes that while specific and precise classifications are useful to health care professionals, they are no substitute for full and clear description and communication with parents of the problems their children face.
Single port nephrectomy in infants
Reviewed by: Henrik Steinbrecher
Sep/Oct 11 (Vol 15 No 6)
Even in children, single port laparoscopy is beginning to replace conventional laparoscopy in the hope of reducing scars and wounds with their associated complications. This paper reviews six infants who underwent laparoendoscopic single-site (LESS) nephrectomy using the Advanced Surgical Concepts (ASC) TriPort for a multicystic dysplastic kidney (four) and burned out pelvi-ureteric junction obstruction (two). Operation duration ranged from 90 to 120 minutes (mean 100) and hospital stay was one to four days (mean two). Followup was four to nine months (mean seven) with no complications. The authors comment that the ergonomics, learning curve and instrument technical challenges remain. This paper shows that even in infants, LESS surgery can be carried out, although one has to perhaps still question the widespread future role of this in children where small holes are generally the surgical approach, and where a 2.5 umbilical incision could be thought of as a mini-laparotomy, given that the abdominal wall is very mobile and the wound could be moved to the site of surgery as in the para umbilical pyloromyotomy. Comments such as ‘the umbilicus, which is a naturally obliterated orifice’ also suggest that new concepts bring with them new philosophical questions and debates.
Urinary biomarkers in prenatally diagnosed unilateral hydronephrosis
Reviewed by: Henrik Steinbrecher
Sep/Oct 2011 (Vol 15 No 6)
Prenatally diagnosed hydronephrosis provides a problem in that we do not have a good mechanism for deciding which ones postnatally require surgery given that only about 35% of the patients have pelviureteric junction obstruction (PUJO). This paper summarises the current state of urinary biomarkers for obstruction. Transforming growth factor beta1 (TGF-beta1) is localised in the renal tubular cells, macrophages and interstitial fibroblasts and is the main modulator of healing following tissue injury. It is increased in children with pelviureteric junction obstruction (PUJO). N acetyl beta–d glucosaminidase (NAG), is localised in tubular epithelial cells, is an indicator of renal damage and is increased in unilateral PUJO. Monocyte chemotactic peptide-1 (MCP-1) is localised in tubular epithelial cells, is a cheotactic factor for monocytes, and is increased in PUJO. Epidermal growth factor (EGF) is localised in tubular epithelial cells, is a mediator of normal tubulogenesis and tubular regeneration after injury and is decreased in PUJO. Endothelin 1 (ET-1) is localised to glomeruli and collecting ducts and renal vessel endothelium, is an endogenous vasoconstrictor and is increased in PUJO. Studies using urinary proteom (the entire complement of proteins produced by an organism, which varies with time and environment) have been able to standardise urine collection for normal subjects and those with PUJO, yielding a proteomic profile of 51 polypeptides that, with 94% precision, could predict the clinical outcomes of patients with PUJO (Decramer et al. Nat Med 2006;12(4):398-400). The sensitivity and specificity, however, are not high enough to make it a sole test for decision making. Given that the ideal biomarker is measurable in the bladder urine and has to have high sensitivity, specificity and predictive value, we are still some way off to finding this elusive compound.
Urinary flow patterns in infants with distal hypospadias
Reviewed by: Henrik Steinbrecher
Sep/Oct 11 (Vol 15 No 6)
It is well recognised that even though we correct hypospadias cosmetically and positionally, the flow rate postoperatively is rarely normal, usually being of a low flow max. This study measured preoperative flow rate in 21 hypospadiac boys (median age 14 months, range 12.8-21.6mths) before surgical input and compared them with 19 normal boys (median age 12 months, range 9.2-19.8mths) using a 1mm transit time ultrasound flow probe mounted around the base of the penis to continuously register flow. Median maximum flow rate was significantly lower in hypospadiac boys (2.4 versus 4.4ml/s, p<0.01) and flow curve patterns were plateau-shaped in 31% of hypospadiac boys, whereas there was none of this type in the normal group. Other studies have previously shown a plateau shaped curve in up to 5% of normal boys, which disappears by the age of one year. Meatal size did not correlate with flow max and disco-ordinated curves were less common in hypospadiacs. This would make sense, as the spongiosum is often deficient more proximally than the apparent meatus, possibly providing less outflow resistance. It may be that in future, to fully evaluate our hypospadias surgery, we should be measuring preoperative flow as well as postoperative flow.
Silodosin for men with chronic prostatitis / chronic pelvic pain syndrome
Reviewed by: Christian Bach
Sep/Oct 11 (Vol 15 No 6)
Although chronic prostatitis or chronic pelvic pain syndrome (CP / CPPS) is the most common form of prostatitis, there is widespread confusion about its causes and the appropriate treatment. Mostly, treatment attempts, which are made with antibiotics, are not very successful – probably because CP / CPPS is not a bacterial infection. Alpha blockade, however, relaxes the muscles of the bladder neck and the prostate and can provide relief. According to a Canadian study, treatment with the alpha-blocker silodosin helped about 60% of the men, who suffered from CP / CPPS. In this multicentre, randomised, double blind, phase II study, 151 participants received 4 or 8mg silodosin, which worked equally well in terms of a significant overall decrease in the National Institutes of Health Chronic Prostatitis Symptom Index score (-12.1±9.3) versus placebo (-8.5±7.2, p=0.0224) and a significantly increased Medical Outcomes Study Short Form 12 physical component scores (4.2±8.1, placebo 1.7±9.0, p=0.0492). After administration of a placebo, only 30% of the patients showed improvement of their symptoms. Main side-effects of silodosin were dizziness, orthostatic hypotension, nasal congestion and diarrhoea.
Swedish reflux trial in children
Reviewed by: Stephen Griffin
Sep/Oct 11 (Vol 15 No 6)
There are not many multicentre prospective randomised controlled trials in paediatric urology. Therefore, when one comes along, it is worthy of comment. This study, which ran over nine years, investigated management strategies of prophylaxis, endoscopic treatment and surveillance in relation to future risk of febrile Urinary Tract Infection (UTI), vesicoureteric reflux (VUR) resolution or downgrade and renal outcome in patients with VUR. A proportion also underwent noninvasive urodynamic assessment to investigate the effect of bladder dysfunction on outcome. Findings from this study were published in a series of five papers in the July 2010 edition of the Journal of Urology. 203 patients (128 girls, 75 boys) between one and two years old with grade 3 to 4 reflux were randomly assigned to one of three treatment arms – prophylaxis, endoscopic treatment (standard STING with Deflux®) or surveillance. Pre-randomisation investigations included renal tract ultrasound scan (USS), dimercaptosuccinic acid (DMSA) renogram and micturating cystourethrogram (MCUG). After two years a further DMSA renogram and MCUG were scheduled. The endoscopic group had additional MCUGs three months post injection. Median age at follow-up was 3.8 years. Over 95% of patients had their exit DMSA renogram. Similar numbers had an exit MCUG, except in the endoscopic arm where this fell to 79%. Febrile UTIs were more common in girls than boys. During the study period, there was no significant difference in the incidence of febrile UTI between three groups in boys. However, in girls, there was significantly less in both the endoscopic and
prophylaxis groups compared to the surveillance group. In addition, the time to first febrile recurrence was quicker in girls in the surveillance group. VUR resolution or downgrading (to grade 1-2) was recorded in approximately 40-50% of patients in the prophylaxis and surveillance groups. Seventy-one percent resolution or downgrading was observed after one injection, increasing to 86% after two injections in the endoscopy group. Interestingly, 20% of previously successful injections were noted to have failed at two years on MCUG. Abnormal DMSA findings were found at entry in 124/203 patients (61%). These were predominantly boys, supporting the fact that congenital damage is more common in boys. New damage, in previously unscarred kidney areas, or greater than 3% decreased relative function during the study was observed in 24 patients (12%). These were predominantly girls. Overall, there was no significant difference in acquired renal damage between the three arms (p=0.11). However, acquired renal damage was seen in 15/49 (31%) with and in 9 /152 (6%) without recurrent febrile UTIs (p=0.0001). A little less than 70% of participants underwent non-invasive urodynamic assessment – namely urinary flow, post-void residual urine, a voiding questionnaire and functional bladder capacity calculation – throughout the study. Lower urinary tract dysfunction was categorised into two groups – filling phase (overactive bladder) and voiding phase dysfunction. Twenty percent displayed bladder dysfunction at the outset of the study and 34% at the end. Bladder dysfunction did not influence incidence of febrile UTI throughout the study. However, those with voiding phase dysfunction in the prophylaxis and surveillance arms had significantly lower spontaneous resolution of VUR compared to those with normal lower tract function. Furthermore, those with lower urinary tract dysfunction were more likely to have renal damage both at the outset and end of the study. Although this study closed before reaching its target number of participants and did not have a placebo arm, it was very well designed and is unlikely to be repeated for a number of years. The main messages are endoscopic treatment leads to early VUR resolution or downgrading in approximately 85% after two injections. Twenty percent fail at two years post treatment. Spontaneous resolution occurs in 40-50% of cases and is more likely if the bladder functions normally. Treatment does not influence recurrence of febrile UTIs in boys. However, endoscopic treatment and prophylaxis significantly decrease febrile UTIs in girls. Few boys have new renal damage, regardless of treatment. New renal damage occurs predominantly in girls with febrile UTI. There was no statistical difference in renal deterioration among the three groups.
Is urethral tape ‘pull-down’ the best way of managing postoperative urinary retention post TVT?
Reviewed by: Ann Crump
Jul/Aug 2011 (Vol 15 No 5)
In this study two consecutive cohorts of patients who had undergone tension-free vaginal tape (TVT) insertion were reviewed. Two successive years were studied. Of the 283 patients in the first group, 4.6% had postoperative retention and were managed with clean intermittent self catheterisation (CISC). In the second group of 242 women there was a 4.9% urinary retention rate. The patients in this group were managed with a ‘pull-down of tape’ procedure performed within 72 hours of the original operation. This sub-group of patients who developed urinary retention was then assessed for whether normal voiding returned and if so, how long did it take for this to occur. The presence of any new overactive bladder symptoms, recurrence of stress incontinence and whether division of the tape was necessary was also reviewed. Almost half (45.5%) of the CISC group returned to normal voiding after a median of nine weeks, whilst all of the patients in the ‘pull-down’ group could void normally after a maximum of seven days. All of these patients were continent. However, in the CISC patients in whom normal voiding did not resume six (55%) required division of the tape, and half of these were incontinent post-procedure. Five patients also developed de novo overactive bladder symptoms. In the ‘pull down’ group only one patient required medical treatment for overactive bladder (OAB) symptoms. Complications were minimal in both groups with three in the CISC group and two in the ‘pull-down’ group developing urinary tract infection (UTIs). There was one incidence of tape erosion in the ‘pulldown’ group which was managed with surgical closure. The study is interesting in providing some data on how to manage this problem. Unfortunately the study group includes patients who underwent TVT, combined with another procedure as well as those who underwent a TVT alone. Despite the large numbers in the study, the overall patients being studied with retention is small and whether the results could be translated when bigger numbers are examined is difficult to say. Followup is only for three months. Ideally it would be good to see this study performed prospectively in matched patients undergoing just a TVT procedure and followed up for a longer period of time.
NMP22 versus urine cytology
Reviewed by: Ann Crump
Jul/Aug 2011 (Vol 15 No 5)
Patients attending for flexible cystoscopy provide a large amount of most urology departments workload and the hunt is always on to try and find an alternative for this invasive procedure in the diagnosis of bladder cancer. NMP22 is an immunochromatographic assay which is easy to use in a clinic setting and one of the many tests trying to gain popularity in this area. This prospective study involving 162 patients in total aimed to assess the sensitivity and specificity in patients attending a haematuria clinic compared to standard urine cytology and flexible cystoscopic findings. One hundred and ten patients in the study group had a bladder cancer diagnosed (group 1) whilst there were 52 patients in the control arm. The patients in group 1 underwent subsequent TURBT and the grade and stage of tumour were recorded. The results showed that when the overall performance of the two tests were compared 63% of patients had a positive result with NMP22 compared to a 52% positivity with urine cytology in the patients in whom a tumour was found. The tumour detection rate for both tumours improved with increasing histological grade. The sensitivity being 18.2% in the NMP22 group compared to 0% in the cytology group for grade 1 tumours. This increased to 73.1% in the NMP22 group and 75% in the cytology group for Grade 3 / CIS tumours. Overall the study showed that the NMP22 BladderChek® had a superior performance compared to conventional urine cytology but this advantage was only marginal and not statistically significant. The shows that NMP22 is not a replacement for flexible cystoscopy but could replace urine cytology on both a practical and financial level in units where urine cytology is included in the protocol for haematuria assessment.
Robotic partial nephrectomy - is it feasible?
Reviewed by: Ann Crump
Jul/Aug 2011 (Vol 15 No 5)
In this single centre prospective study 23 patients were operated on and the results audited. The mean tumour size was 2.53cm (range 1.5-3.87cm), and the median operating time was 198 minutes. The median warm ischemic time was 30 minutes (range 15-57minutes). The conversion rate was 9% (2); one conversion was due to a single bull dog failing to control the bleeding adequately (2 clips are now utilised) and the other due to difficulty mobilising the kidney. Final histology showed 17 of the lesions to be renal cell carcinomas. The complication rates included blood loss and oncological outcomes were all within acceptable limits on this limited follow-up of maximum two years. Although this study has only small numbers it is exciting. Long-term renal and cardiovascular outcomes are known to be better in patients in whom nephron-sparing surgery has been possible and combined with this minimally invasive technique it is now possible to give patients the long-term advantage of a partial nephrectomy combined with a quicker postoperative recovery. Larger studies are needed but it is certainly encouraging and with practice and advancement along the learning curve warm ischemic times can only improve.
Urethral length and prostate volume on preoperative magnetic resonance imaging can predict urinary continence after robot assisted radical prostatectomy
Reviewed by: Christian Bach
Jul/Aug 2011 (Vol 15 No 5)
Multiple studies have shown that nerve preservation, prostate size, patient age, urethral length and body mass index (BMI) have an influence on recovery of urinary continence. In this study the authors use a 1.5 Tesla endorectal coil magnetic resonance imaging (MRI) to precisely analyse prostate anatomy. In 80 patients, prostate size, urethral length and spincter thickness was preoperatively assessed before undergoing robot assisted radical prostatectomy by a single surgeon. At monthly intervals patients completed questionnaires regarding pad use. Primary and point was time to achieve 0 to 1 pad per day (social continence / total continence). Mean age was 59.7 (SD 7.1) years, mean prostate size was 34.7g (SD 17.8) and mean urethral length was 17.1mm (SD 4.5mm). Ninety-eight percent of the patients had bilateral nerve sparing. The authors could show that, patients with preoperative prostate volumes <50g were more likely to achieve better postoperative continence results than those >50g. Looking at urethral length, patients with <20mm had a swifter return to total continence. Increased age was also a significant predictor of longer time to continence whereas BMI and sphincter thickness proved not to be related to postoperative urinary outcome. The effect of nerve sparing has not been investigated in this analysis. In conclusion the authors state that advanced age and bigger prostate size are negatively correlated, while a longer urethra increases the chances of postoperative continence.
Does androgen stimulation prior to hypospadias surgery increase the rate of healing complications?
Reviewed by: Henrik Steinbrecher
Jul/Aug 2011 (Vol 15 No 5)
Androgens have a positive effect on penile growth in children. Dermatologists report a regressive effect on healing of skin tissue. This paper describes a retrospective study comparing outcomes of only urethroplasties with (30 patients) or without (96 patients) preoperative androgen stimulation. Treatment in the form of either beta human chorionic gonadotropin (HCG) or testosterone was given at between 1 month and 24 months pre surgery if penile length was <25mm, if there was marked ventral hypoplasia or if there was an undescended testis. Median follow-up post surgery was 34 months. Treatment group has a healing complication rate of 30% (9/30) whereas this was 17.7% (17/96) in the non treatment group. Treatment within three months of surgery caused a healing complication rate of 57% (4/7) and 21.7% (5/23) if treatment was before this time. The difference was not statistically significant for either testosterone or beta HCG. Limitations of the study are recognised as being small sample size, and large variation of timing of hormonal stimulation. The study does imply, however, that the balance of increasing size to perform the surgery with more tissue, versus healing processes has to be taken into account more than has previously been the case.
The microvessel density of the hypospadias prepuce in children
Reviewed by: Henrik Steinbrecher
Jul/Aug 2011 (Vol 15 No 5)
The blood supply of the prepuce is crucial for success in hypospadiac surgery. This study prospectively took samples of foreskins during hypospadiac surgery (24 patients) surgery and analysed them with immunohistochemistry to get microvessel density and compared them with age matched controls having circumcisions (nine patients). Patients who had preoperative hormonal stimulation were excluded. Microvessel density was significantly reduced the more severe the hypospadiac abnormality (p<0.05). Other studies have shown that prepucial axial blood supply is absent in the 30% of hypospadiac foreskins, mean epidermal growth factor decreased in skin adjacent to the hypospadiac defect, and estrogen receptors are expressed more dominantly in hypospadiac foreskins. All these factors probably work against even the most diligent surgeon from having a 0% complication rate when performing this type of surgery.
Critical outcome analysis of staged buccal mucosal graft urethroplasty for prior failed hypospadias repair in children
Reviewed by: Stephen Griffin
Jul/Aug 2011 (Vol 15 No 5)
Failed hypospadias surgery remains a significant challenge to the paediatric urologist. This retrospective review over a five-year period, from a large Canadian tertiary centre, looks at the outcome of staged urethroplasty with buccal mucosal grafting for patients requiring redo hypospadias surgery. The first procedure requires removal of distal urethra to proximal healthy urothelium, splitting of the glans and onlay of a thinned buccal mucosal graft (BMG). This is secured with a tie-over dressing which is left in place, with a urethral catheter, for seven days. The second procedure is performed at least six months later. This requires creation of a neomeatus and graft tubularisation in two layers with further local flap coverage using dartos or tunica vaginalis. Data for 30 patients (32 repairs) is presented. Over 80% had a proximal or midshaft meatus at presentation. Almost one-third had biopsy proven balanitis xerotica obliterans. Thirteen percent (4/30) required additional grafting procedures with BMG due to fibrosis or contraction of the graft prior to the second stage procedure. Reported complications after the second stage procedure were urethral stenosis (16%), glanular dehiscence (9%) and urethrocutaneous fistula (9%). Presence of balanitis xerotica obliterans (BXO) or initial meatal position did not influence complication rates. However, subjective classification of grafts as favourable (smooth and supple, n=21) or unfavourable (areas of fibrosis / induration, n=11) revealed significantly different rates (19% versus 82% respectively). Their overall complication rate is comparable to similar series. However, their requirement for regrafting seems high at 13%. They hypothesise that previous penile surgery impacts the inosculation process for the graft. In addition, they propose fibrotic grafts are evidence of suboptimal vascularisation which in turn increases complication rates post tubularisation. Staged repair with BMG certainly has a role in redo hypospadias repair. However, further work is required to understand how best to optimise graft take and subsequent outcome.
Does physical activity raise serum PSA concentration?
Reviewed by: Christian Bach
Jul/Aug 2011 (Vol 15 No 5)
Data to this question is contradictory. Therefore the authors of this interesting study assessed prostate specific antigen (PSA) levels of 21 male volunteers after they exercised with moderate intensity on a cycling ergometer and a treadmill. The tested group represented a typical benign prostatic hyperplasia (BPH) collective with a mean age of 61+-5 years, a total prostate specific antigen (tPSA) of 7.7+-ng/ml and a prostate volume of 55+-18ml. Blood samples were drawn before and several times after the exercise up to seven days. After cycling, the tPSA showed to be significantly elevated in all participants with 1.9+-1.7ng/ml (25%). Even after the light treadmill exercise the tPSA level was significantly increased by 12%. Further analysis showed that the free prostate-specific antigen (fPSA) was even more sensitive than tPSA. Forty-eight hours respectively one hour after the physical activity the blood levels returned back to normal although it could take longer in individual cases. The authors conclude that in patients with an enlarged prostate and a basic PSA level above 4ng/ml physical exercise, especially in combination with mechanical irritation can lead to significant elevated PSA levels. In consequence PSA testing should not performed earlier than 24 hours after physical activity.
Electrical stimulation versus tolterodine for urge and urge incontinence
Reviewed by: Ann Crump
May/Jun 2011 (Vol 15 No 4)
This study aimed to test the hypothesis that electrical stimulation treatment would be more successful than traditional anticholinergics in the treatment of urge and urge incontinence. Although anticholinergics are the mainstay of treatment in overactive bladders (OAB) they are not without their problems. Side-effects are common and their effects on incontinence episodes and number of voids are not always as good as one would hope. Transvaginal or transanal electrical stimulation is another treatment for this condition and few studies have compared the two treatments. A prospective, randomised open trial was performed on 72 women in total. All were assessed using a 48-hour micturition diary and a version of the King’s Health Questionnaire at baseline, six weeks and six months. The 37 women in the transvaginal electrical stimulation arm had, over a period of five to seven weeks, 10 treatments. Each treatment lasted 20 minutes and was given at a frequency of 5-10Hz. The 35 patients in the drug arm received 4mg tolterodine SR orally once daily. No significant difference was observed between the two groups when comparing the number of micturitions in 24 hours or overall quality of life; however both were better than baseline. There was a 73% improvement in the electrical stimulation group and a 71% improvement in the tolterodine group. No side-effects were reported in the electrical stimulation group whereas 30% of patients reported side-effects in the tolterodine group. A small number of the original patient group were followed up at 12 and 24 months. The results remained the same. I doubt at the present time whether transvaginal electrical stimulation will replace drug therapy but it could be considered in patients who have an improvement with anticholinergics but are unable to tolerate their side-effects or in patients who would rather have a short course of treatments rather than a long-term daily tablet.
Is Bulkamid® any different from other urethral bulking agents?
Reviewed by: Ann Crump
May/Jun 2011 (Vol 15 No 4)
This prospective open label multicentre trial aimed to assess the safety and efficacy of the relatively new urethral bulking agent Bulkamid® (polyacrylamide hydrogel). Although only introduced as a urethral bulking agent in 2006, polyacrylamide hydrogel has been used for plastic surgery in the former Soviet Union and China for over 15 years with minimal problems and in mainland Europe for almost seven years. The attractiveness of urethral bulking agents is the fact that they are minimally invasive. Unfortunately they tend to have a poor success rate and when they do work the effects tend to be short-lived. Bulkamid® appears promising as it has been shown that when used in a plastic surgery setting it is present within the tissues for a minimum of eight and a half years. It appears to achieve this by causing vessel in growth of the surrounding host tissues. In this study 135 women with urinary incontinence (67 stress and 68 mixed) had submucosal injections of Bulkamid® and were followed up for a period of 12 months. They were all assessed at the start of the study with a three-day micturition diary; the International Consultation on Incontinence Questionnaire (ICIQ) and a quality of life (QoL) visual analogue scale (VAS) score. All injections were performed under local anaesthetic and 0.2-0.8ml was injected at the 2, 6 and 10 o’clock positions. If the first procedure was unsuccessful after a month a further injection was offered within eight weeks. Thirty-five percent of women had a second injection. At the end of the study there was a subjective response rate of 66%. The number of incontinence episodes and urinary leakage in 24 hours decreased significantly (from 3.0 to 0.7 and 29g to 4g respectively). Interestingly the efficacy between the pure stress group and the mixed incontinence group appeared to be very similar. Of note the cure rate was worse in patients in whom a second injection was required. Over this short follow-up, in this particular role, Bulkamid® appears to be a safe agent, the most likely side-effect being a urinary tract infection (n=10). It also appears to have a subjective cure rate in two out of three women with stress or mixed incontinence. This has been suggested previously in a smaller study. This study did show, however, as is the case with most procedures, that the patient outcomes in units performing more of this procedure were better. This appears a safe and relatively successful technique. After one year it will be interesting to see if these effects can be maintained over a longer time period.
Intrarenal pressures generated during deployment of various antiretropulsion devices in an ex vivo porcine model
Reviewed by: Bill Papadopoulos
May/Jun 2011 (Vol 15 No 4)
To prevent retrograde stone migration during ureteroscopic lithotripsy, numerous antiretropulsion devices have been developed. Animal studies have also shown that pressurised saline irrigation, commonly used during ureteroscopy, can lead to pyelovenous, pyelolymphatic, and pyelosinus back flow, resulting in postoperative pain, sepsis and possibly irreversible renal damage. This group from the Columbia University Medical Center in New York compared the intrarenal pressures generated during the deployment of two anti-retropulsion devices in an ex vivo porcine model. The two devices were the Stone Cone (SC) and the Accordion (AC). The SC is a coil device, while the AC is a multifold film occlusive device. Pressure measurements were taken with saline irrigation at gravity (i.e. at a height of 85cm), 150 and 300mmHg of pressure, both with and without the deployment of the SC and AC respectively, in the proximal, mid and distal ureter. The deployment of the SC lead to an increase in intrarenal pressures in all ureteral levels and at each irrigation pressure when compared to ureteroscopy alone. In contrast the deployment of the AC resulted in lower intrarenal pressures at an irrigation pressure of 300mmHg when compared to pressures without its deployment. For the rest of the configurations, the AC was not significantly different or only slightly higher when compared to its nondeployment. A comparison of both devices showed the deployment of the AC resulted in significantly lower intrarenal pressures compared to the SC at all configurations. The SC may result in increased intrarenal pressures by allowing fluid past its coils while impeding the return of fluid. The result from the AC may be the result of its occlusive nature, preventing flow proximal to the device, thus preventing the accumulation of fluid in the renal pelvis. A very nice study in which future in vivo testing, evaluating pressures with the ureter undergoing peristalsis and in an hydronephrotic state will be invaluable. Testing other occlusive devices will also be useful.
Predicting effectiveness of extracorporeal shockwave lithotripsy by stone attenuation value
Reviewed by: Bill Papadopoulos
May/Jun 2011 (Vol 15 No 4)
The efficacy of extracorporeal shock wave lithotripsy (ESWL) is dependent on factors such as stone size, location, type of shockwave generator and the presence of obstruction and infection. The composition and thus the fragility of a stone ultimately governs the outcome of ESWL. If stone fragility could be predicted, it could be a valuable factor in determining the best treatment option for urinary stones, and thus a very important counselling tool with regards to determining stone clearance, retreatment and possible auxiliary procedures. Numerous studies have shown that stone fragility can be predicted by the stone attenuation or the Hounsfield unit (HU) from a computerised tomography (CT) scan. This group from Muljibhai Patel Urological Hospital in India have looked at this in their prospective study. Ninety-nine patients with single stones less than 2cm in either the kidney or upper ureter were studied. They were divided into two groups. Group A consisted of 42 patients with stones of <1200HU, while 57 patients were in group B with stones of >1200HU. The mean number of shocks, retreatment rate, auxiliary procedure rate, complication rate, complete clearance rate and effectiveness quotient (EQ) were analysed. Patients in Group A had a significantly lower mean number and intensity of shock impulses, as well as a lower retreatment rate. The EQ was higher in Group A, even though the clearance rates between Group A and B were not statistically significant. A further analysis showed that the number of shocks and intensity of shock impulse required for fragmentation and clearance of stone, increased as the HU of a stone increases. Knowing the fragility of a stone before ESWL will impact on the efficacy of ESWL, reduce hospital visits and possible costs. A very nice study indeed that will hopefully be repeated on a large number of patients.
Endoscopic treatment of vesicoureteral reflux in an adult population
Reviewed by: Henrik Steinbrecher
May/Jun 2011 (Vol 15 No 4)
Endoscopic antireflux surgery in children using a dextranomer / hylauronic acid co pulymer (DEFLUX) is now commonplace in children since the first description of the STING procedure two decades ago. This paper looks to assess whether or not it is useful in the adult population. Between 1998 and 2008, 49 adult patients with a mean age of 33.6 years (18-64) underwent endoscopic treatment of vesicoureteric reflux (VUR). There were 81 refluxing units of which 71 were primary reflux (14 grade 1, 46 grade 2, 17 grade 3, 4 grade 4).Thirty-eight patients had Teflon injected and 11 DEFLUX. The indication in all was recurrent febrile urinary tract infection (UTI). Reflux was corrected in 63 refluxing units after first injection, nine after the second and four after the third injection. In three refluxing units the reflux was downgraded. Only two patients had failed treatment and underwent open re-implantation. This paper shows that endoscopic injection in the adult population with VUR is as successful as in children and that if there are continuing febrile UTIs following the injection then further investigations to rule out ongoing reflux should be carried out followed by further injection therapy. The long-term outcome of DEFLUX injection in the adult population still remains to be seen.
Initial experience with percutaneous selective embolisation
Reviewed by: Henrik Steinbrecher
May/Jun 2011 (Vol 15 No 4)
The current management of the adolescent varicocoele still oscillates between no treatment, laparoscopic Palomo or radiological intervention in the form of sclerotherapy or embolisation. Deciding factors as to what is offered depends on the constitution of the patient, the grade of varicocoele and the perceived risk benefit of complications and therapy. Postoperative hydrocoele development occurs in up to 20% of patients undergoing a Palomo, although this is reduced if it is carried out laparoscopically with lymphatic identification. This paper is a retrospective review of 27 patients (age 13-19) who had undergone percutaneous embolisation or sclerotherapy for their varicocoele, with a mean follow-up period of nine months (1-39 months) of 21 patients. Sedation was carried out with midazolam and fentanyl. Local anaesthetic is carried out with lidocaine. A venogram was performed while the patient carried out a valsalva manoevre (I am not sure how easy that is under midazolam and fentanyl!). A mixture of fibred coils and 3% sodium tetradecyl sulfate foam were placed in the spermatic gonadal veins. All varicocoeles were left sided and unilateral. Forty-eight percent had pain, 30% had large varicocoeles with testicular asymmetry in 22%. Of the 21 patients followed up (6 of the initial 27 were lost to follow-up), 19 (91%) had successful treatment with no hydrocoele postoperatively. Two patients had failed treatment due to difficult venous anatomy. This paper adds further evidence that radiological intervention in the adolescent varicocoele is feasible and successful in the majority of cases and reduces hydrocoele risk significantly in the short term.
Pelvic floor exercise for post radical prostatectomy incontinence
Reviewed by: Tharani Nitkunan
May/Jun 2011 (Vol 15 No 4)
Post radical prostatectomy urinary incontinence is a significant morbidity. This study is a prospective randomised control trial involving 208 men aged between 51 and 84 with incontinence persisting at least one year after radical prostatectomy. Exclusion criteria included men with fewer than two incontinence episodes per week and current active prostate cancer treatment. Participants were stratified by incontinence type (stress, urgency, or mixed) and severity (<5, 5-10, or >10 episodes per week). Patients were randomised to one of three groups: eight weeks of behavioural therapy (pelvic floor muscle training and bladder control strategies); behavioural therapy plus in-office dual channel electromyograph biofeedback and daily home pelvic floor electrical stimulation at 20Hz, current up to 100mA (behaviour plus); or delayed treatment, which served as the control group. At eight weeks, instructions for a maintenance program of daily pelvic floor exercises, continued use of bladder control strategies and fluid management were provided in the two active treatment groups. The reported results included a reduction in mean incontinence episodes from 28 to 13 per week (55% reduction) after behavioural therapy and from 26 to 12 (51% reduction) after behaviour plus therapy. Both reductions were significantly greater than the reduction from 25 to 21 (24% reduction) observed among controls. However, there was no significant difference in incontinence reduction between the treatment groups. Improvements were durable to 12 months in the active treatment groups. They concluded that behavioural therapy was an effective treatment for post-prostatectomy incontinence. However, the addition of biofeedback and pelvic floor electrical stimulation did not result in greater effectiveness.
Male breast cancer represents a challenge for urologists
Reviewed by: Christian Bach
May/Jun 2011 (Vol 15 No 4)
Male breast cancer is rare, accounting for less than 1% of alignancies in men. Its incidence is rising with age and peaking between 60 and 70 years. With their article the authors want to raise awareness amongst urologists and andrologists and inform about epidemiology, risk factors, clinical picture, and current strategies of diagnosis and treatment. As in women, major risk factor is hormonal imbalance such as elevated oestrogen levels, i.e. in obese patients or under androgen deprivation therapy, as well as testosterone deficiency, i.e. in patients with testicular impairment or Klinefelter syndrome. Positive family history for breast cancer is another major risk factor, and ionising radiation or heat exposure, i.e. in furnace workers, represent external risk factors. Generally, the prognosis for men is worse than for women due to a higher age and a more advanced stage at diagnosis. However, between men and women of the same age and tumour stage there is no difference. Other prognostic factors are tumour size and number of positive lymph nodes. Histologically, >90% of tumours are invasive ductal breast cancers. As >75% are detected as painless palpable breast nodules, a suspicious finding in the male breast should be further investigated with ultrasound and mammography, potentially followed by biopsy. First line therapy for localised breast cancer is the modified radical mastectomy with or without adjuvant radiotherapy. Systemic therapy follows therapy strategies in women. As >90% of male breast cancers express hormonal receptors, tamoxifen is a therapeutic option. The authors conclude that the challenge for the urologist is the early detection of male breast cancer and the referral to a breast centre with appropriate experience and patient volume to improve the overall prognosis for the patient.
Minimal invasive kidney surgery with NOTES, LESS and SILS, a report of experience with 10 cases
Reviewed by: Christian Bach
May/Jun 2011 (Vol 15 No 4)
Over the last 20 years, laparoscopic kidney surgery has established itself as state of the art and has even made its way into the guidelines. Recent development goes towards even fewer invasive techniques, using a single port as in laparoendoscopic single site surgery (LESS) and single incision laparoscopic surgery (SILS), or to access the organ transvaginal as in natural orifice transluminal endoscopic surgery (NOTES). A total of 10 operations were performed - two transvaginal nephrectomies, six nephrectomies in trans-abdominal LESS technique, and two retroperitoneal LESS procedures of the kidney. All procedures could be completed without conversion to open surgery. However, for better exposure the additional placement of two trocars was necessary in the first single port nephrectomy. The mean age of patients was 59 years, mean operating time 131 minutes, and mean blood loss 70ml. Postoperative recovery was unremarkable and all patients were discharged on the sixth postoperative day as planned. The postoperative evaluation of patient satisfaction revealed excellent results. The authors conclude that NOTES, LESS and SILS as minimal invasive methods can be used safely and successfully in kidney surgery. To train the team properly beforehand and to select the cases carefully is the key to success.
Is it safe to avoid quinolones for antibiotic prophylaxis in prostate biopsy?
Reviewed by: Arun Jain
Mar/Apr 2011 (Vol 15 No 3)
In recent years there has been increasing pressure to minimise the use of flouroquinolone antibiotics due to their potential role in development of more virulent strains of Closridium difficile (C. difficile). Hori et al. from Bury St Edmunds, UK, present the results of a study comparing a retrospective historical group of 119 men who received ciprofloxacin 500mg orally one hour before transrectal ultrasound-guided prostate biopsy (TRUSgpb) followed by 500mg twice a day for three days (group A) with a prospectively followed interventional group consisting of 110 men given co-amoxiclav 625mg orally one hour before TRUSgpb followed by 625mg three times daily for three days (group B) to evaluate the effect of shifting from quinolone to penicillin antibiotics for prophylaxis during this procedure. Two men in group A (1.68%) compared to 8/110 (7.27%) men in group B developed sepsis after TRUSgpb requiring hospital admission and intravenous antibiotic treatment (P=0.036; two-tailed Fisher’s exact test). Escherichia coli (E. coli) was the only organism isolated on culture in this study. One case in each group grew flouroquinilone resistant E. coli on blood culture, whereas, the organism was sensitive to co-amoxiclav in all cases. There were no incidences of C. difficile infections in either antibiotic prophylaxis groups. During data collation, the authors observed that a large number of patients in group B were returning to hospital with post-TRUSgpb sepsis, hence the regime was stopped after seven months. Notwithstanding the significant limitations of the study, the authors conclude that ciprofloxacin is superior to co-amoxiclav for prophylaxis in men undergoing TRUSgpb and was not associated with an increased risk of C. difficile infections. Changing antibiotic prophylaxis from a quinolone-based regime may therefore put patients at an increased risk of serious infectious complications after TRUSgpb.
Is prompt surgical correction of acquired undescended testis justified?
Reviewed by: Arun Jain
Mar/Apr 2011 (Vol 15 No 3)
Prompt surgical correction is generally advocated for management of acquired cryptorchidism yet is controversial due to lack of longitudinal follow-up data justifying such a practice. Hack et al. from Netherlands present results of a prospective study outlining the natural history and long-term testicular growth of acquired undescended testis (UDT) after spontaneous descent or orchidopexy at puberty. Acquired UDT was defined as a testis previously residing in the scrotum that can no longer be manipulated into a stable scrotal position. Between 1996 and 2008, 391 boys with 464 acquired UDT were included in the study. Mean age at referral for acquired UDT was 9.3 years. After referral, testis position and volume (measured using an orchidometer and compared with the Dutch standard) and puberty stage were assessed and then, in accordance with Dutch consensus on non-scrotal testes, patients were monitored annually until adolescence awaiting spontaneous descent. Orchidopexy was performed at puberty, if testis remained undescended. All investigations were carried out by the same physician. Eighty-four boys were also clinically assessed and scanned by a second physician blinded to the findings of the first. During a mean follow-up of 4.7 (range: 0.1–12.0) years, 253 acquired UDT reached the scrotum with spontaneous descent in 196 (77.5%; mean age at descent 12.9 years, range 9.8–16.9) and pubertal orchidopexy performed in 57 (22.5%). Five cases required orchidectomy. Spontaneous descent occurred in 82.6% of initially high scrotal testes compared to 67.4% initially inguinal / impalpable testes (P= 0.006). Of the 494 testis volume measurements after spontaneous descent, 458 (92.7%) were at ?10th centile for age, 63.0% ?50th centile and 21.7% ?90th centile. After pubertal orchidopexy for nondescent, of the 85 measurements, 79 (92.9%) were at ?10th centile, 53 (62.4%) ?50th centile and 12 (14.1%) ?90th centile. In unilateral cases, after spontaneous descent 174/294 (59.2%) retained testes were smaller than their counterpart and 90 (30.6%) were equal in size; whereas, after pubertal orchidopexy, 40/51 (78.4%) testes were smaller and nine (17.6%) were equal in size. Authors conclude that spontaneous descent by puberty can occur in 77.5% cases of acquired UDT and in nearly all cases, after spontaneous descent or after pubertal orchidopexy, long-term testicular growth is within the normal range. These results fail to justify prompt surgical correction of acquired UDT.
Risk of disease progression after surgery for localised renal cell carcinoma
Reviewed by: Mark Harris
Mar/Apr 2011 (Vol 15 No 3)
Many of the current nomograms for predicting disease progression in renal cell carcinoma (RCC) include all stages of disease. In this single centre case series, from 1994-2007, 925 patients were identified with purely organ-confined disease, treated with radical or partial nephrectomy. A multitude of variables were studied using logistic regression analysis to identify predictors of disease progression. In total, 5.7% of the group progressed, at a median of 26.6 months, with the risk in pT1 tumours being 2.6% and 21.9% in pT2. Many factors were shown on univariate analysis to predict progression, but only five were relevant on multivariate analysis. These were the presence of symptoms at presentation, pT2 stage, being male, having sarcomatoid changes and macroscopic necrosis on histology. No patients progressed if none of these factors were present, whilst 3.2% progressed if one or two factors were present (representing 68.6% of the cohort). This was at a median of 37.1 months. If three or more factors were found, the risk of progression was 25.4%, with a shorter median follow-up of 25.2 months. Whilst a laparoscopic approach seemed to confer some benefit in the risk of progression, the authors felt this was probably due to the shorter period of follow-up. With some nomograms differing about which factors matter most, this study has identified five readily available markers of adverse prognosis in pT1-2 stage disease. If these results are reproduced in other population groups, it suggests that surveillance of low-risk disease is not required, with the attendant benefits of reducing patient radiation, anxiety and inconvenience, as well as producing substantial cost savings. It also informs a more tailored approach to higher risk disease, so that surveillance can be targeted towards the period of maximal progression risk.
Risk of UTI post Botulinum Toxin-A injections
Reviewed by: Ayman Younis
Mar/Apr 2011 (Vol 15 No 3)
Botulinum toxin-A (BoNT-A) is currently used as a second line treatment for neurogenic detrusor overactivity (NDO) refractory to anticholinergics with successful and sustained effect. No guidelines have been produced with regards to using prophylactic antibiotics prior to this procedure. In this single-centre study, the authors have assessed patients who received intradetrusal BoNT-A injections for NDO without receiving antibiotics prior to the procedure to determine whether prophylactic antibiotics are required. In this prospective non-randomised open-labelled study performed between June 2007 and July 2008, a total number of 42 patients diagnosed with NDO (with no history of recurrent urinary tract infection (UTIs)) have received intradetrusal BoNT-A with no prophylactic antibiotics. Within the first week, the incidence of ‘symptomatic’ UTI was found to be 7.1%. Bacterial colonisation rate was 31% and 26% at six days and six weeks respectively. E. coli was the most common pathogen identified. Despite the non-randomised nature of this study, the authors concluded that prophylactic antibiotics are necessary prior to intradetrusal BoNT-A injections for NDO (level 4 evidence).
Chewing gum and enhanced recovery
Reviewed by: Ann Crump
Mar/Apr 2011 (Vol 15 No 3)
Enhanced recovery protocols (ERPs) are currently being developed to hopefully improve the postoperative recovery of patients following major surgery. In urology this is particularly relevant to patients undergoing radical cystectomy. Current regimes have managed to reduce the inpatient length of stay of patients but the time taken for bowel function to return to normal appears to have been unaffected. This study aimed to see whether the addition of chewing gum could alter this. Chewing gum has been used by general surgeons for this reason and has been seen to have a beneficial effect. One hundred and twelve patients in total were reviewed retrospectively – 56 in each study arm. In the chewing gum group the chewing gum is introduced on day one postoperatively and involves chewing one stick of gum three times a day. The chewing gum group’s median time to defecation was four days compared to the standard group which was six days. The length of inpatient stay was unaffected, however, although the group report a trend of earlier discharge in the chewing gum group. It is not clear whether other factors kept the patients in hospital such as managing stoma care rather than general postoperative recovery. Postoperative complications appeared to be the same in both groups. This study suggests that cheap chewing gum could, if used in sufficient patients, lead to savings due to reduced hospital stay.
Are transurethral injections a waste of time?
Reviewed by: Ann Crump
Mar/Apr 2011 (Vol 15 No 3)
This study aimed to evaluate the long-term efficacy of transurethral hyaluronic acid / dextranomer (NASHA/Dx gel) injections for the treatment of stress urinary incontinence (SUI). Eighteen out of twenty-one patients were followed up over a period of just under seven years. All patients were assessed initially with urodynamics. Three months following the first injection six patients received a second injection as their symptoms had not improved. Seven out of the 21 patients had adverse reactions to the procedure including two abscesses. At one-year follow-up 11 out of the original 21 patients (52.3%) reported an improvement in their symptoms. Almost seven years later the case notes of the patients were reviewed for any new urinary symptoms and patients were also sent a questionnaire (Incontinence Questionnaire-Short Form) to assess their current symptoms. Only one patient was continent and had not needed to undergo a further continence procedure. The study concluded that NASH/Dx gel in women with SUI is ineffective in the long term and associated with complications.
Urodynamics - what's the point?
Reviewed by: Ann Crump
Mar/Apr 2011 (Vol 15 No 3)
This is a retrospective study reviewing the correlation between urinary symptoms reported by patients and their subsequent urodynamic findings. Five hundred and thirty-seven patients (both men and women) were reviewed in total. Urinary incontinence was defined by combining the patients’ history, examination and a short version of the Urogenital Distress Inventory (UDI-6) questionnaire. Just over half (52%) of the patients complained of urge urinary incontinence. Of these, on urodynamic testing 59% had confirmed detrusor overactivity. The study also reports that 308 patients had stress urinary incontinence and that only 45% of patients had this confirmed at urodynamics. Maximum cystometric capacity was also examined and did not seem to be significantly associated with the symptom of urinary frequency. From these numbers it seems obvious that a number of patients must have complained of mixed urinary incontinence but unfortunately this group has not been selected out. This is a shame as it would have been interesting to know the urodynamic correlation with symptoms in this often neglected group of patients. Having said that this study reinforces the importance of performing urodynamics in patients on whom you are planning surgery, as otherwise the incorrect procedure or advice may be performed or given.
Long-term outcome of severe hypospadias
Reviewed by: Henrik Steinbrecher
Mar/Apr 2011 (Vol 15 No 3)
There are over 200 operations described for the surgical correction of hypospadias. Most practitioners have three to four in their armamentarium for this congenital abnormality. Each believes that their way of doing things is better than someone else’s. What happens in the long term? This paper describes the use of a questionnaire to evaluate patients aged 20-35 who had a severe hypospadias repaired as an infant. Of 48 patients, 13 were lost to follow-up; 35 patients were sent the questionnaire of whom 27 answered (77% response). Fifteen patients had a proximal shaft hypospadias and in12 it was scrotal. Complication rate was as expected, high with 33% fistulae, 26% stenosis and an average number of procedures of 3.7. Sexual and global satisfaction rates using a visual analogue scale were 68% and 63%, respectively. Satisfaction was statistically correlated to the presence of early complications of stenosis but not fistula. Satisfaction seemed more affected by subjective feelings rather than anatomical result. This confirms that even in these cases beauty may be in the eye of the beholder.
Pelvis / cortex ratio
Reviewed by: Henrik Steinbrecher
Mar/Apr 2011 (Vol 15 No 3)
Kidney obstruction is difficult to define. The result of our surgery for pelviureteric junction obstruction (PUJO) is, consequently, also difficult to standardise, especially if a MAG3 is equivocal and a minimal reduction pyeloplasty has been carried out. This paper looks at the use of the pelvis / cortex ratio to decide on a postoperative success following pyeloplasty in children. Twenty-four children (mean age 13 months, range two months to five years) had a standard pyeloplasty carried out and reduction in pelvis size and increase in cortical thickness was measured postoperatively. Reduction in size of anteroposterior (AP) renopelvic diameter and cortical thickness per se were not significant at three months but both were significant at one year. However, the pelvis / cortical thickness ratio was significantly improved by three months. In addition a postoperative MAG3 could only confirm good postoperative recovery and resolution at one year, not at three months. This paper shows that early success of a pyeloplasty can be confirmed by measuring the pelvis cortical thickness ratio at three months.
Pyospermia in an adult cohort with persistent lower urinary tract symptoms and a history of ablated posterior urethral value
Reviewed by: Henrik Steinbrecher
Mar/Apr 2011 (Vol 15 No 3)
The long-term effects of posterior urethral valves in boys include bladder dysfunction and renal failure. There are few data documenting sexual function and fertility. This paper looked to assess seminal fluid characteristics and urinary tract symptoms in an adult cohort. Of 42 patients, 29 agreed to take part in the study (mean age 21.5 years, range 17-51). All had a detailed clinical examination and history taken with urinalysis, ultrasound scan (USS) and micturating cystogram. Semen samples were obtained from 10 who had intractable lower urinary tract symptoms (LUTS) but two were excluded (one had had a vasectomy and one had transported the sample incorrectly). In eight patients semen samples were sent for culture and analysis. Clinically, of the 29 patients, 62% had epididymitis, 66% urethritis, 41% urinary tract infection, 52% night time incontinence, 31% daytime incontinence and 28% both day and night time incontinence. Of the eight where semen samples were analysed, three (38%) had low sperm counts, seven (88%) exhibited significant bacterial growth and pyospermia, six (78%) had low motility, and four (50%) had significantly low percentage of normal forms. Culture showed growth in all eight patients. A magnetic resonance imaging showed an increased craniocaudal length of the prostrate in 50%. This paper is a good summary of long-term sexual function in posterior urethral valve (PUV’s) but the authors recognise that the population sample is small and that paternity rates have not been assessed. The findings of pyospermia and bacterial growth in semen cultures is a relatively new description.
Transitional cell carcinoma of the bladder in children and adolescents
Reviewed by: Henrik Steinbrecher
Mar/Apr 2011 (Vol 15 No 3)
Clinical macroscopic haematuria should alert one to a transitional cell carcinoma (TCC) of the bladder even in young children. This is rare. Currently there are only about 125 cases reported in the literature under the age of 20. This series of six children between 1984 and 2007 includes a 6, 9, 12, 13, 14 and 17-year-old. Diagnosis is made on ultrasound scan (USS) and cystoscopy / biopsy. About 75% are located in the trigone area and nearly all are low grade papillary lesions. This series had a 100% successful endoscopic excision rate.
Alpha-blockers, antibiotics and anti-inflammatories for chronic prostatitis
Reviewed by: Tharani Nitkunan
Mar/Apr 2011 (Vol 15 No 3)
Chronic prostatitis / chronic pelvic pain syndrome is an entity defined as urological pain or discomfort in the pelvic region, associated with urinary symptoms and / or sexual dysfunction, lasting for at least three of the previous six months. A systematic review was conducted comparing mean symptom scores and treatment response among alpha-blockers, antibiotics, anti-inflammatory drugs, other active drugs (phytotherapy, glycosaminoglycans, finasteride, and neuromodulators), and placebo. Twenty-three randomised control trials were analysed. Compared with placebo, alpha-blockers and antibiotics were associated with significant improvement in symptoms with regards to symptom, pain, voiding, and quality-of-life scores. Patients receiving alpha-blockers or anti-inflammatory medications had a higher chance of favourable response compared with placebo, with pooled relative risks of 1.6 and 1.8 respectively. Combining alpha-blockers and antibiotics yielded the greatest benefits compared with placebo, with corresponding decreases of -13.8 for total symptom scores, -5.7 for pain scores, -3.7 for voiding, and -2.8 for quality-of-life scores. As has been suggested by the Nickel snowflake theory of management of prostatitis they conclude that alpha-blockers, antibiotics and a combination of these therapies achieve the greatest improvement of symptoms.
Intra-abdominal testis: histological alterations and significance of biopsy
Reviewed by: Stephen Griffin
Mar/Apr 2011 (Vol 15 No 3)
This paper addresses the age old question of timing of orchidopexy for undescended testes in a sub-group of patients with intra-abdominal testes. The authors state that although much has been written in relation to the histology of the palpable undescended testicle and the possible relationship with future fertility, this is not the case with impalpable testes. Their study obtained open testicular biopsies from intra-abdominal testes at the time of laparoscopic single stage orchidopexy or laparoscopic first stage Fowler Stephens orchidopexy in 31 patients. Two patients were excluded from the study. Biopsies from 29 patients revealing seminiferous tubules formed the study material. There was a significant correlation between reduction in numbers of germ cells per tubule and increasing age at orchidopexy. Above the age of three years, 93% (13/14) of specimens revealed no germ cells. In addition, mean seminiferous tubular diameter was smaller in this study group than age matched controls with normal testes. Their study supports the contention that intra-abdominal testes, along with bilateral undescended testes, are at higher risk of sub-optimal fertility. Tantalisingly, this group could also benefit from adjuvant hormonal therapy to aid maturation and transformation of germ cells, as has been recently reported. Although they present evidence for the safety of testicular biopsy in the discussion, currently only small numbers of paediatric urologists would perform testicular biopsy in this setting. In addition, assessing numbers of spermatogonia is difficult. In 55% of their samples, none were found. Here, they used mean seminiferous tubular diameter measurements compared to age matched controls with normal testes. However, no explanation is made as to where this control group comes from. This study adds to the body of evidence that earlier orchidopexy improves histological features in relation to fertility in cryptorchid boys. However, there still remains a lack of correlation with true fertility in later life.
Solifenacin to treat OAB in children
Reviewed by: Stephen Griffin
Mar/Apr 2011 (Vol 15 No 3)
Those of you who work with children in urological practice will be aware that many of the agents we use lack a licence for use in the paediatric population. A particular case in point is in the treatment of children with overactive bladder (OAB). The current British National Formulary for children informs the reader that oxybutynin is not licensed in patients under five years of age and that tolterodine is not licensed at all for use in children. This paper explains the situation is similar in North America where only oxybutynin is licensed. This open label prospective study looks at the efficacy of solifenacin in a paediatric population with detrusor overactivity of neurogenic and non-neurogenic origin who failed behavioural therapy and one other anticholinergic treatment. A rigorous assessment at the outset of the study included voiding questionnaire, physical examination, urodynamics and abdominal ultrasound scan. A micturating cystourethrogram was performed in neurogenic patients and non-neurogenic patients with a history of urinary tract infection (UTI). A similarly zealous three to six month follow-up ensued with similar investigations. Solifenacin was prescribed using an adjusted dose regimen at doses of 1.25mg to 10mg daily with dosage changes prescribed by the treating physician dependant on response and side-effect profile. Seventy-two patients in all were included in the study with mean treatment duration of 15.6 months. Approximately one third became completely dry with a further 60% having a 90% plus reduction in incontinence episodes. Twenty-one percent experienced adverse effects similar to those reported in adult practice
Can the urologist still live without the robot?
Reviewed by: Christian Bach
Mar/Apr 2011 (Vol 15 No 3)
The number of radical prostatectomies performed with the da Vinci Surgical System is growing worldwide. This fact represents an impressive example of successful marketing, highlighting amongst other advantages a shorter hospital stay, less blood loss, and faster recovery. The latest model of the da Vinci robot costs at least 1.5 million euros. More than 150,000 euros a year have to be calculated for its maintenance. In addition, disposables for a single operation cost between 2,000 and 3,000 euros. Regarding the outcome compared to open prostatectomy, the author refers to the Medicare data from USA on robotic prostatectomy which show less perioperative complications, a shorter hospital stay, but a 1.4 times higher incidence of anastomotic strictures, and a three times higher probability of a later salvage therapy. In a similar analysis, the American Surveillance, Epidemiology and End Results (SEER) data confirmed a shorter hospital stay, fewer blood transfusions and fewer postoperative respiratory complications for robotic surgery. In contrast to the Medicare data, a lower number of anastomotic strictures and a similar number of salvage treatments were found. However, the rate of postoperative incontinence and erectile dysfunction was significantly higher. Despite those contradictory results, marketing slogans promise better results, faster recovery and fewer complications to their customers, the patient. Therefore, it means a considerable image improvement for the urologist and the hospital if they can offer robotic treatment, and they might feel urged to jump on the bandwagon in time. Additional costs are considerable and have to be carried not only by the hospital but also by the health system. The author concludes that up to now, there is no evidence that robotic prostate surgery is better or worse than radical prostatectomy. It seems therefore that robots are currently not purchased to offer better patient care, but for other reasons as outlined above.
Does a PSM inevitably lead to BCR in pT2 prostate cancer?
Reviewed by: Mark Harris
Jan/Feb 2011 (Vol 15 No2)
Whilst the prognosis is usually excellent after radical prostatectomy in organ-confined disease, the consequences of a positive surgical margin (PSM) are hotly debated. This study analysed 2,095 men with pT2N0Mx disease and after exclusion criteria were applied, found 932 with adequate data. The objective was to identify risk factors for a PSM and to assess its relationship with biochemical recurrence (BCR). Overall, 12.9% had a PSM, which occurred in 13.9% men who had a nerve-sparing procedure versus 7.8% in non-nerve sparing. The BCR rate was 8.8%. They found that tumour volume, nerve technique and surgical volume were independent risk factors for a PSM and that those with a PSM had a higher BCR rate (21.7% vs. 6.9%). The most important factors (in decreasing order of significance) were percentage of high-grade tumour volume, Gleason score and then PSM. However, 80% of those with a PSM did not develop BCR, so care must be exercised when adjuvant therapy is considered to avoid over-treatment. Interpretation of the results also has to be tempered by the knowledge that technique and equipment has improved drastically over recent years such that the PSM rate is lower in recent series. It does suggest further evidence that procedures such as this should be done in high volume centres by fewer surgeons.
Does LVI predict poor outcome after radical cystectomy?
Reviewed by: Mark Harris
Jan/Feb 2011 (Vol 15 No2)
Lymphovascular invasion (LVI) has been suggested to be a predictor of adverse outcome after radical cystectomy in other studies but the evidence to date is weak. In this multicentre level 1b study from Germany - 2,011 cystectomy patients were reviewed and after exclusion criteria were applied, a cohort of 1,099 patients were analysed. Of the group 39.1% had T3 disease or worse and 43.8% were high-grade. LVI was found in 26.8%. They found that LVI correlated significantly with stage and grade, in a similar quantity to other studies. It was also associated with early disease recurrence and cancer-specific survival, regardless of nodal status. The most striking difference was in node positive patients with advanced stage or high-grade disease. A significantly shorter overall survival was also seen, in both node positive and negative patients. On multivariate analysis, LVI was an independent predictor of recurrence-free, cancer-specific and overall survival. On this basis, the authors suggest using LVI in risk stratification, especially as it is felt to act as a surrogate for micro metastases. Similarly to germ cell testes tumours, it could be used to upstage in the TNM classification. With other studies showing that LVI from TUR specimens increases the chance of detecting LVI in cystectomy analysis, as well as an increased risk of pelvic nodes, the potential to use chemotherapy in a neo-adjuvant or adjuvant setting seems attractive. However, work on standardising and reducing errors in histopathological analysis is required and large prospective trials will need to be conducted before this can be used as a routine marker of high-risk disease.
Performing urodynamics in the over 80 year old is worthwhile
Reviewed by: Ann Crump
Jan/Feb 2011 (Vol 15 No2)
This study looks retrospectively at 53 patients who were over 80-years-old over a five-year period. These patients were all capable of co-operating with urodynamics. The majority of these patients (49) complained of storage symptoms – 42 patients complaining of storage symptoms alone. Urodynamics showed, however, that detrusor overactivity was present in only 12 of the patients. Almost 50% of patients actually had urodynamic stress incontinence. The study found that these findings resulted in a complete change in patient management in 43% of patients. They conclude that there is poor correlation between storage symptoms and urodynamic diagnosis in this group of patients and therefore it is worth performing urodynamics in order to avoid empirical prescribing in this clinically vulnerable population. The study is interesting in that, although small at the moment, with the ageing population this group of patients is likely to grow. This is also a group of patients in which one would wish to limit the use of anti-cholinergics unless absolutely necessary in view of side-effects of the drugs themselves or to avoid polypharmacy.
TOT for treatment of stress urinary incontinence: how should we assess its equivalence with TVT?
Reviewed by: Ann Crump
Jan/Feb 2011 (Vol 15 No2)
This is yet another study comparing the outcomes for tension-free vaginal tape (TVT) and transobturator tape (TOT) procedures. Although it is a prospective trial it involves much smaller numbers than the other study reviewed, with only 19 patients undergoing TVT and 21 undergoing TOT. Preoperatively patients underwent urodynamics and a cough stress test. Postoperatively the cough stress test was repeated and patients were assessed using an Arabic form of the anti-incontinence score. Follow-up was only on average 20 months. To be counted as a success patients had to be both objectively and subjectively dry. The results from this study showed that the success rate in the TVT group was 94% and 66.6% in the TOT group. From this the conclusion was made that TVT and TOT are effective procedures for stress urinary incontinence but TOT is inferior in terms of complication rates and efficacy. I think that these are quite strong conclusions to draw from such a small study with such a short follow-up. There is no mention in the study as to whether the surgeon performing the procedure was new to TVT or TOT to account for a learning curve or whether a single surgeon or multiple surgeons were involved. I also don’t feel that the study fully answered the question proposed in the title. It would be nice to see whether these results were borne out with larger numbers and for a longer period.
Frequent post radical prostatectomy PSA surveillance is unnecessary in patients with low risk prostate cancer
Reviewed by: Ayman Younis
Jan/Feb 2011 (Vol 15 No2)
The incidence of prostate cancer (PCa) has significantly increased since the introduction of prostate specific antigen (PSA) as a tumour marker in the early 1990s. It has revolutionised the diagnosis and treatment outcomes for prostate cancer. The need for PSA surveillance in patients who have had radical surgical treatment for low-risk disease is still debatable and poorly understood. Despite the low risk of progression, patients with low-risk disease are still under frequent PSA follow-up. In this retrospective cohort study, the investigators have examined PSA recurrence rates of over 2,000 patients who underwent radical prostatectomy between 1994 and 2004 for low-risk disease. The study demonstrated that the risk of biochemical failure rate (defined as PSA>0.4ng/ml) is inversely proportional to PSA-free interval following radical surgical treatment. It has also suggested that yearly PSA surveillance does not seem to be necessary after three-year PSA-free interval. Instead, every other year may capture the majority of those who experience PSA recurrence. The frequency of subsequent follow-up measurements can further be decreased if PSA is still undetected after five years. This conclusion may result in more cost-effective use of PSA testing as well as reducing patient anxiety associated with the frequent PSA measurement and the probability of false-positive readings. Although this subject was not the focus of previous research projects, the authors admit that the limitations of this study are the retrospective nature of it and the “solitary experience” of their high-volume centre.
Can post-void residual urine predict the occurrence of urinary tract infections?
Reviewed by: Christian Bach
Jan/Feb 2011 (Vol 15 No2)
This working group from Germany has tried to clarify the answer to this question. Recently Truzi et al. defined a post void residual (PVR) of 180ml as a cut-off point for the occurrence of significant bacteriuria in asymptomatic men with a sensitivity and specificity of 87% and 98.5%, respectively. In this prospective study, 225 asymptomatic patients with a median age of 66 years have been evaluated to assess the relationship between ultrasound measured PVR and urine culture by using a receiver operator characteristic (ROC). The independent influence of urine dipstick test, prostate specific antigen (PSA) value, transrectal ultrasound scan (TRUS) measured prostate volume, International Prostate Symptom Score (IPSS) and peak urinary flow rate on the incidence of urinary tract infection was measured using multivariate regression analyses. In these 225 men, the mean residual urine was 63ml. Sixty percent were able to completely empty the bladder (PVR?10ml). Nearly one third of the asymptomatic men (31%) had a significant bacteriuria. Escherichia Coli was found in 59 of these 69 patients (86%). Patients presenting with urinary tract infection (UTI) had significantly higher mean PVR than patients with negative urine culture (113 vs. 41ml, p<0.001). Regarding the coincidence of UTI, in ROC analysis a cut-off value of 150ml PVR revealed the highest AUC value (0.617). In multivariate regression analysis only PVR had an independent significant influence on detection of UTI (urine culture: p=0.006; urinary test strip: p<0.001) although men with a UTI had a significant higher IPSS and a lower maximum flow rate. Although there was a significant correlation between PVR and UTI, no cut-off value could be determined to predict positive urine culture with sufficient sensitivity and specificity. The cut-off of 180ml calculated by Truzi et al. could not be confirmed. It showed sensitivity and specificity of 28% and 94%, respectively (AUC: 0.606; p=0.012). Hence a PVR volume at which UTI is more likely to occur requiring therapeutic intervention, could not be given based on the results of the present study and currently available data from the literature. To answer this question, longitudinal studies leading to multifactorial nomograms would be necessary.
The role of cytoreductive radical prostatectomy in lymph node-positive prostate cancer
Reviewed by: Christian Bach
Jan/Feb 2011 (Vol 15 No2)
Radical prostatectomy (RP) is a recommended, evidence-based therapy option for localised prostate cancer (PC). In locally advanced or lymph node-positive PC the value of RP is not so clearly defined. Traditionally recommended treatments are watchful waiting (WW), primary androgen deprivation therapy (ADT) or external beam radiation therapy (RT). Many centres would not do an RP after detecting positive lymph nodes whilst the latest European Association of Urology (EAU) guidelines define the RP as a therapeutic option even for lymph node-positive PC. Based on the data in the literature, Heidenreich et al. discuss in their recent article the potential advantages and disadvantages of RP in patients with locally advanced, lymph node-positive PC and they draw the following conclusion: WW or ADT as a single therapy should be reserved for patients with a low life expectancy due to other co-morbidities. In recent studies RP has been shown to lower mortality rates. This finding may be as a result of prostate specific antigen (PSA) testing leading to detection of more early stage cancer. The main purpose of RP in lymph node-positive patients is local tumour control and reduction of local and systemic complications which are likely as most of these patients have a poorly differentiated PC. RP in these cases should not be seen as a monotherapy but as one component of a multimodal therapy where, according to the pathology, adjuvant hormone therapy, radiation treatment or even both can be added. This multimodal concept significantly improves tumour-specific survival and reduces the necessity for palliative interventional procedures. Good candidates for such a treatment are patients with not more than two local micro metastases, complete resectability of the primary cancer and a life expectancy > 10 years. Preoperative assessment should include choline positron emission tomography – computed tomography (PET-CT) scan and all patients should be informed about the possibility of such a multimodal treatment. Regarding surgical technique, an extended pelvic lymphadenectomy and an extended RP with complete resection of the bladder neck and the seminal vesicles is proposed. Finally, even in patients with extensive locally advanced PC or large pelvic metastases radical cystoprostatectomy is an option to gain local cancer control and to prevent significant local and supravesical complications. In these cases, the indication should be discussed in a multidisciplinary tumour meeting. Using the proposed multimodal therapy approach, the tumour-specific survival rate after 15 years is between 60-80%.
Predicting the outcome of saturation prostate biopsies with a nomogram
Reviewed by: Mark Harris
Nov/Dec 2010 (Vol 15 No 1)
The management of men with a persistently raised prostate specific antigen (PSA) and repeat negative biopsies poses a common clinical dilemma, which has yet to be clarified. In this retrospective study of 540 men with complete data, the results of a previously developed nomogram were compared to the observed results of saturation biopsy, over a six-year period. All of the men had been previously biopsied, with no malignancy found and received no adjuvant treatment. 39.4% of the cohort had positive biopsies, with 93% being stage T1c, 9.3% having high-grade prostatic intraepithelial neoplasia (HGPIN) and 5.6% demonstrating atypical small acinar proliferation (ASAP). Over a third had Gleason 6 disease. As would be expected, the cancer detection rate dropped as the number of prior biopsies increased. They analysed the predictive value of common variables from the initial biopsies to see which factors were most accurate. Free PSA and gland volume were the most accurate and were better than digital rectal examination (DRE) finding or total PSA, which are commonly used as the method of determining the need for repeat biopsy. The correlation between predicted and observed cancer detection was very strong and the nomogram had a predictive accuracy of 77.1%. This makes the nomogram very useful in giving patients an accurate prediction of saturation biopsy outcome prior to the procedure. There are limitations however. It is unclear whether the saturation technique used and results obtained would be applicable to the perineal route and no mention was made of tumour location. They acknowledged that the pathological data was complicated by the multitude of centres referring cases to them, thereby introducing inter observer variation to interpretation. There was also no clear idea of how many cores had previously been taken. However, this does seem to be a useful tool that requires further clinical validation. It also agrees with other studies that HGPIN is not a powerful predictor of subsequent malignancy on repeat biopsy.
Intercostal nerve block and PCA should be the gold standard analgesia post PCNL
Reviewed by: Ann Crump
Nov/Dec 2010 (Vol 15 No 1)
Percutaneous nephrolithotomy (PCNL) is a painful procedure postoperatively and this study aimed to see whether the addition of an intercostal nerve block added any analgesic advantage over routine analgesia. One hundred patients were analysed retrospectively – 50 patients having routine analgesia and 50 with the addition of an intercostal block. Postoperative pain was assessed using a visual analogue score and analgesic requirements were measured by assessing the patients’ use of a morphine syringe driver (PCA). The outcomes of this study show that the addition of an intercostal nerve block in these patients does significantly reduce the amount of analgesia required and, importantly in this day and age, increased patient mobilisation and reduced inpatient stay (by 35 hours). In view of this the authors recommend an intercostal nerve block with a PCA as the gold standard after a PCNL.
Is PSA testing being used appropriately in a hospital setting?
Reviewed by: Ann Crump
Nov/Dec 2010 (Vol 15 No 1)
This study aimed to look at the appropriateness of prostate specific antigen (PSA) requests over a three-month period by non-urologists. As a potential tumour marker they wished to see whether PSA was being misused in their hospital. It was a retrospective study and 95 patients’ notes were subsequently reviewed. A proforma was designed stating what reasons were considered appropriate or inappropriate for a PSA request. It was found that 27% of PSA tests were requested for what was considered an appropriate reason. Of the remaining requests 52 patients had no reason given in their case notes to justify a PSA. Only 24 digital rectal examinations (DRE) were performed in conjunction with the PSA test. Unsurprisingly the study concluded that the majority of PSA tests by non-urologists were inappropriate. They state the reason for this is a lack of knowledge on the indications for PSA testing. They suggest more education is needed on when to perform a PSA and the importance of PSA. Unfortunately it does not suggest how we can get our other specialty colleagues interested enough to take it on board and / or to improve their note keeping!
Evidence for improved fertility indices in UDT after GnRH therapy and orchidopexy
Reviewed by: Henrik Steinbrecher
Nov/Dec 2010 (Vol 15 No 1)
Enhanced recovery protocols (ERPs) are currently being developed to hopefully improve the postoperative recovery of patients following major surgery. In urology this is particularly relevant to patients undergoing radical cystectomy. Current regimes have managed to reduce the inpatient length of stay of patients but the time taken for bowel function to return to normal appears to have been unaffected. This study aimed to see whether the addition of chewing gum could alter this. Chewing gum has been used by general surgeons for this reason and has been seen to have a beneficial effect. One hundred and twelve patients in total were reviewed retrospectively – 56 in each study arm. In the chewing gum group the chewing gum is introduced on day one postoperatively and involves chewing one stick of gum three times a day. The chewing gum group’s median time to defecation was four days compared to the standard group which was six days. The length of inpatient stay was unaffected, however, although the group report a trend of earlier discharge in the chewing gum group. It is not clear whether other factors kept the patients in hospital such as managing stoma care rather than general postoperative recovery. Postoperative complications appeared to be the same in both groups. This study suggests that cheap chewing gum could, if used in sufficient patients, lead to savings due to reduced hospital stay.
Danger of alcohol abuse associated with presence of a bladder augmentation
Reviewed by: Stephen Griffin
Nov/Dec 2010 (Vol 15 No 1)
In this study the senior author keeps a prospective record of his patients undergoing bladder augmentation which was retrospectively scrutinised for patients with excessive alcohol use. This was defined, according to American criteria, as two or more drinks on average per day. Over 200 patients with bladder augmentation and alcohol consumption history were identified, of which 24 (12%) had a history of excessive alcohol usage. This incidence approximates well with the overall figure for alcohol misuse in the United States (12-18%). Bladder perforation in those with excessive alcohol intake was significantly higher in the excess alcohol group (10 perforations in 5 of 24, 21%) compared to the control group (5 of 179, 2.8%) at a median age of 19 years. Of the five patients with perforation in the excess alcohol group, three had multiple episodes of perforation; cardiopulmonary resuscitation was required on three occasions and one patient died. Three patients overall were converted to ileal conduits – two in the control group for non-compliance with catheterisation and associated progressive hydronephrosis with renal insufficiency and one in the excess alcohol group due to multiple perforations and failed rehabilitation from alcohol misuse. Given the significantly higher incidence of this potentially fatal complication, this group now preoperatively counsel their patients in respect of the danger of excessive alcohol consumption associated with presence of a bladder augmentation. Furthermore, should such patients fail rehabilitation for alcohol misuse, they recommend considering conversion to an ileal conduit.
Diabetic stone formers excrete more oxalate than non diabetic counterparts
Reviewed by: Ayman Younis
Nov/Dec 2010 (Vol 15 No 1)
Previous studies have proved the association between type 2 diabetes mellitus and uric acid nephrolithiasis which is believed to be due to low urine pH. In this study, the authors have retrospectively looked at 24-hour urine composition of 462 stone formers assessed in their metabolic stone clinic. Nearly 10% of those stone formers are type 2 diabetics. The study demonstrated that diabetic stone formers produce significantly larger urine volumes and about 15% more urinary oxalate. It was also noted that diabetic stone-formers excrete more acidic urine and lower urinary levels of phosphate, potassium and creatinine than their non-diabetic counterparts. Stone analysis was performed in the diabetic group only, and that showed the majority of patients who have stone analysis available formed calcium oxalate stones. The authors have mentioned that the increase in urinary excretion of oxalate was independent of the dietary intake and they theorised their findings to be related to the pathophysiology of diabetes. The authors declared that the retrospective nature of the study is a drawback. Also, difference in group sizes mystified the statistical analysis process. The study focused only on stone formers and cannot be applied to the general renal stone population. Despite the limitations of this study, the authors concluded that they were the first group to examine and establish the increased risk of developing calcium oxalate stones among type 2 diabetic patients.
Accidental destruction of Dormia basket and guidewire during endoscopic stone treatment
Reviewed by: Christian Bach
Nov/Dec 2010 (Vol 15 No 1)
Guide wires, dormia baskets or stone cones can be accidentally destroyed during endoscopic lithotripsy procedures with laser (Hol:YAG), ultrasound or mechanical stone breaking devices (electromechanical or pneumatic). Although the authors have performed an extended literature research, only five studies dealing with this, not uncommon, problem could be identified. Apart from the laser, other stone cracking devices have not been investigated. In these studies, a normal guide wire could be destroyed after exposing it to a laser from a distance of 0-5mm with 0.8-2J and 5-10Hz after 55-103 seconds. A thin titan wire could stand for 20-40 seconds, a dormia basket for 15-34 seconds, a thin nitinol broke after 1-4 seconds and a stone cone after 17.4 seconds. The intraoperative destruction of the (safety) guide wire may lead to the potential loss of a secured access to the upper urinary tract with potentially serious consequences. A broken dormia basket can easily form a hook which can lead to ureteric mucosal stripping. According to the authors the following strategies can be adopted to avoid such accidents: lithotripsy should only be performed under clear vision; when using the laser the operator should avoid drilling a hole into the stone which may lead to destruction of the guide wire lying behind it; dormia baskets should be opened or even removed after bringing the stone into an appropriate position before starting the treatment. Finally, what can be done to extract a broken dormia? It can either be completely disassembled and then removed in several parts or it can be caught with a ureteral catheter and pulled into it. Ultimately open surgery may be necessary if all else fails. As a perspective to avoid these problems in future, the authors propose the evolution of a laser which is able to automatically distinguish between stone and foreign bodies such as wires and which adapts its energy accordingly. Different materials for guide wires or dormia baskets such as silicone or copper, which have proved to be less destructible by a laser, would be another option.
Does testosterone level influence survival in advanced prostate cancer management?
Reviewed by: Mark Harris
Sep/Oct 2010 (Vol 14 No 6)
Measuring the testosterone response to luteinising hormone-releasing hormone (LHRH) analogue initiation in men with metastatic prostate cancer has increasingly become the norm. Nevertheless the significance of how far the level drops on survival is not well understood. This was a retrospective analysis of 129 men presenting consecutively with metastatic prostate cancer involving bone only. They were all treated with three monthly LHRH analogue and had regular quarterly prostate specific antigen (PSA) and testosterone measurements. The mean presenting PSA was 185.8ng/ml with a mean nadir of 2.7ng/ml. The mean baseline, six-monthly and nadir testosterone levels were 440, 40 and 21ng/dL. 37.2% of men had Gleason 8-10 disease whilst 33.3% had Gleason 7. At a mean of 47.5 months’ follow-up, 71 patients (55%) had died, although 12 of these were from unrelated causes. It took 9.5 months to reach a PSA nadir but this was 17.1 months for testosterone. When analysing which factors correlated with the risk of death, Gleason score, six-monthly PSA and the six-monthly testosterone level were all significant. These results suggest that lowering the testosterone level sufficiently has survival implications and with other studies suggesting that breakthrough testosterone surges imply a worse survival, it seems prudent to regularly measure and control testosterone levels as tightly as possible. Ideally this should be to below 20ng/dL although this is not always achieved with LHRH analogues.
Complete continence in idiopathic detrusor overactivity incontinence after Botox injection
Reviewed by: Arun Jain
Sep/Oct 2010 (Vol 14 No 6)
Khan et al. present the outcome of a non-randomised open label study to evaluate the complete continence rate four weeks after intradetrusor injection of botulinum neurotoxin Type A (BoNTA) in patients with urodynamically proven refractory idiopathic detrusor overactivity incontinence (OI). Seventy-four patients (51 females and 23 males) with a median age of 56 years were treated between January 2002 and September 2008 using 200IU BoNTA at 1:10 dilution injected at 20 sites excluding the trigone in an outpatient setting. Patient reported continence was assessed using urgency incontinence (UI) and stress incontinence subscales of the Urogenital Distress Inventory (UDI-6) questionnaire before and four weeks after BoNTA injection. Post void residual (PVR) scan was done two weeks after the injection and clean intermittent self catheterisation (CISC) was initiated if PVR was above 100ml and if lower urinary tract symptoms (LUTS) persisted. Forty-five percent of patients reported UI and 55% mixed incontinence prior to treatment. Fifty-one percent reported complete restoration of continence (score of 0 in both the urgency and stress incontinence subscales of the UDI-6) after BoNTA injection with no difference between the UI and mixed incontinence subgroups. Age and sex did not affect the outcome. Overall median UI scores reduced significantly from 100 to 0, median stress incontinence scores from 33 to 0 and median urinary frequency score from 100 to 33. Antibiotics treatment for urinary tract infection (UTI) was required in 15% patients post injection and 39% patients required CISC. Notwithstanding the non-randomised and uncontrolled nature of the study, patient reported complete continence rate of >50% in an unselected population refractory to anticholinergic treatment strongly supports this emerging treatment. The optimal dose and the duration of continence effect are other crucial questions that require further investigation.
Detrusor muscle in specimen is a surrogate marker of quality of bladder tumour resection
Reviewed by: Arun Jain
Sep/Oct 2010 (Vol 14 No 6)
Mariappan et al. from Edinburgh analyse the quality of transurethral bladder tumour resection (TURBT) based on the recurrence rate at first follow-up cystoscopy (RR-FFC) after TURBT using a prospectively maintained bladder tumour database. They added data of 356 patients with new bladder tumour who underwent TURBT over a two-year period, where the tumour was clinically considered to be non-muscle invasive and completely resected. Overall, detrusor muscle was present in 67.7% cases. Larger tumours, G3 tumours, T1 tumours and resection by a senior surgeon (Year 5/6 trainee or consultant) were the independent predictors of presence of detrusor muscle (DM) in the TURBT specimen. DM was present in 72.6% resections performed by seniors as compared to 56.8% resections by juniors. RR-FFC analysis of 234 patients with histologically non-muscle invasive tumours revealed that overall RR-FFC rate was 30.3%, and T1 stage, absence of DM and resection by a junior surgeon were independent predictors of early tumour recurrence. Resection by junior surgeon increased the risk of RR-FFC by two-fold (OR: 2.0; 95% CI 1.1-3.6; p=0.02) and absence of DM in specimen by nearly three-fold (44.4% vs. 21.7%; OR: 2.9; 95% CI 1.6-5.4; p=0.002). In particular, absence of DM in patients with G3 tumours increased the risk of RR-FFC by five-fold (OR:5.1; 95% CI 1.7-15.9; p<0.001), in T1 tumours by eight-fold (81.3% vs. 43.9%; OR 8.1; 95% CI 1.7-42.9; p=0.002) and in patients with large tumours (>3cm; n=40) by 20-fold (85.7% vs. 23.1%; OR: 20.0; 95% CI 2.9-180.4; p<0.001). Authors conclude that resection by a less experienced surgeon and absence of DM in the first apparently complete resection under conventional white-light cystoscopy, increase the risk of early recurrence at the time of first check cystoscopy or early re-resection.
Can we predict who will fail with a mid-urethral sling procedure?
Reviewed by: Ann Crump
Sep/Oct 2010 (Vol 14 No 6)
This retrospective study reviewed over 1,200 women who had undergone a midurethral tape procedure over an eight-year period. Nine hundred and fifty-five patients underwent a transvaginal tape (TVT) whilst the remaining 270 underwent a transobturator tape procedure (TOT). Patients were followed up annually after the first year and a telephone follow-up with a questionnaire was performed for those patients who did not attend their clinic appointments. There was an overall 91% response rate. Results were comparable to other studies with an overall subjective cure rate of 85%. When multivariate logistic regression models were used, five independent variables were identified which appeared to affect outcome. These were body mass index (BMI) >25, having urodynamically proven mixed urinary incontinence, diabetes mellitus, previous continence surgery and intrinsic sphincter deficiency. Despite being a retrospective study I think this is useful in providing further evidence to patients of the importance of weight loss prior to anti-incontinence surgery. Patients with a normal BMI had a success rate of over 80% compared to only a 50% success rate if the BMI was over 35. It also raises the question about what is the better operation for women with urodynamically proven stress incontinence. Would a Burch colposuspension have better results than a midurethral tape in this patient group or should these patients accept that whatever procedure they undergo they will have a poorer outcome (30% at eight years)?
Cloacal exstrophy: a comprehensive review of an uncommon problem
Reviewed by: Henrik Steinbrecher
Sep/Oct 2010 (Vol 14 No 6)
This really IS a comprehensive review. It is up to date, well laid out and an easy read for all. Given that exstrophy is part of the FRCS(Urol) curriculum (even though it is only a very small part) it may come up in the exam in some form or other, even if it is only to discuss long-term issues. This article is worth keeping on the shelf for this.
Investigating febrile UTI in infants: is a cystogram necessary?
Reviewed by: Henrik Steinbrecher
Sep/Oct 2010 (Vol14 No 6)
Since the National Institute for Health & Clinical Excellence (NICE) guidelines for the management of urinary tract infection (UTI) in children were published in 2007 there has been much debate on their accuracy and on whether or not significant pathology will be missed if they are not followed accurately. This paper from Sheffield reviews retrospectively a single institution’s 10-year pre-NICE guideline investigation of all infants aged less than one year presenting with a febrile UTI where the investigations had been using the standard Royal College of Physicians guideline of 1999 (renal ultrasound – USS, micturating cystourethrogram – MCUD and dimercaptosuccinic acid scan – DMSA). The authors confirm that a MCUG is not necessary if the renal USS is normal. Two groups (A = 354 patients = normal USS, B = 73 patients = abnormal USS) were compared. In A, 11% had abnormal DMSA scans, and of these 55% had low grade vesicoureteric reflux (VUR) on MCUG. Of the 99% with normal DMSA only 15% had VUR and this was low grade. In B, 59% had abnormal DMSA scans and 53% of these had VUR on MCUG. Of the 41% without scarring, 73% also had VUR on MCUG suggesting that the presence or absence of scarring is not associated with VUR in this group. One worry about not performing MCUG in male infants with a UTI is the possibility of missing posterior urethral valves (PUV) but with modern USS and specialist paediatric radiology, other features such as bladder wall thickness, the visualisation of the dilated posterior urethra on USS and antenatal features will often raise awareness well before a UTI occurs. It appears that the MCUG for UTI is best reserved for selective cases only.
The meatal / urethral width in healthy uncircumcised boys
Reviewed by: Henrik Steinbrecher
Sep/Oct 2010 (Vol14 No 6)
It is always interesting and clinically stimulating to read papers that explore the normal variation of anatomy and function and this paper fulfils this in relation to the meatal width of normal boys. This is relevant when it comes to creating a new meatus during hypospadias surgery or other penile reconstruction in children. After ethical approval, 60 healthy uncircumcised boys aged five months to 16 years were examined under anaesthesia during unrelated surgery. Hegars dilators sizes 1-8mm were used to calibrate meatal size without causing injury or bleeding to the urethra. There was a gradual increase in urethral width with age, the minimum being 3.5mm and the maximum 7.5mm. This is larger than previous reports, albeit the latter were carried out in circumcised boys and could be as a result of meatal stenosis post circumcision. The authors plot a normogram for boys and suggest that this is a useful tool, coupled with Hegar measurements, of determining the size of meatus to create during hypospadias surgery.
Percutaneous Tibial Nerve stimulation vs. Sham in treatment of OAB
Reviewed by: Ayman Younis
Sep/Oct 2010 (Vol14 No 6)
Treatment of overactive bladder syndrome (OAB) remains challenging as traditional therapies available are largely pharmacological and behavioural, which is associated with poor compliance and adverse events in a large proportion. The option for refractory detrusor overactivity has been major surgery in the past. More recently, minimally invasive techniques such as neuromodulation and botulinum toxin injections have become available. Sacral nerve stimulation has been approved by the National Institute for Health & Clinical Excellence (NICE) in the UK but requires a high capital cost outlay. More recently peripheral nerve stimulation of the posterior tibial nerve (PTNS) has become available as a more cost-effective alternative. In this multicentre, double-blind, randomised trial, a total of 220 patients with OAB were recruited to receive either PTNS or sham inactive intervention. Efficacy was the primary outcome measure. Success was defined as moderate to marked improvement in overall bladder symptoms on the global response assessment. It reported 54.5% improvement for PTNS vs. 20.9% improvement in the Sham group. The study demonstrated a statistically significant improvement in symptoms of frequency, urgency, urge incontinence and nocturia among patients in the PTNS arm. Quality of life scores were superior in the PTNS group. However, the primary limitation of this study is its short follow-up period (12 week). This study provides level 1 evidence to support the use of PTNS and demonstrates its safety and efficacy. It provides a cost-effective option for patients with refractory OAB. A key strength of this treatment modality is that no significant adverse effects have been reported from these trials. However, further studies will be required to assess the efficacy of PTNS for extended indications such as urinary retention and pelvic pain, and its efficacy in comparison to botulinum toxin injections. It is interesting that this is the first study of neuromodulation using a validated sham component.
Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Sham Efficacy in the Treatment of Overactive Bladder Syndrome: Results From the SUmiT Trial.
Peters K, Carrico D, Perez-Marrero R, Khan A, Wooldridge L, Davis G, MacDiarmid S.
THE JOURNAL OF UROLOGY
2010;183:1438-43.
Testicular microlithiasis in boys and young men with UDT
Reviewed by: Stephen Griffin
Sep/Oct 2010 (Vol14 No 6)
Having read Peterson’s paper (J Urol 2001;166:2061) some years ago in preparation for the FRCS(Urol), I was convinced epidemiologically that testicular microlithiasis was not a risk factor for testes cancer, but that 1 in 20 asymptomatic men would have it. Would the presence of two risk factors – one putative (microlithiasis) and one definitive (undescended testis – UDT) lead to increased risk of testes cancer? Would this change my nonchalant approach to the follow-up of microlithiasis for this sub-group of patients? I read this article with interest and concluded the answer was ‘no’ to each question. This Dutch group prospectively assessed over 500 boys with either congenital or acquired undescended testes (n=320), with a mean age of 12.5 years, using testicular ultrasound examination. Testicular microlithiasis was observed in 2.8%. This is comparable to other reports in boys. Identical rates were calculated for those with congenital or acquired UDT. No testicular tumour was observed in the study group. Hence my conclusion to the two questions above. However, the discussion goes on to present some fragile evidence suggesting microlithiasis may have a role in development. Furthermore, they quote a figure for lifetime risk for testicular germ cell tumour of 0.3-0.7%, which increases to 3-5% with a history of UDT, from one of the definitive papers demonstrating earlier orchidopexy reduces testicular cancer risk (Pettersson et al. N Engl J Med 2007;356:1835). Having read this paper in depth, I believe their calculations are incorrect. Peterson’s group found 56 testicular cancers in a group of almost 17,000 who had a history of UDT (0.3%), and for all ages calculated a three-fold increase in risk of testes cancer with prior UDT. In addition, the lifetime risk figure quoted is not one I could find and prevalence data from Surveillance, Epidemiology, and End Results – SEER (Testicular cancer, 0.07%) suggests this may also be high. Therefore, I will continue with the level 5 evidence of advising testicular self-examination after puberty for this group of patients whether there is a history of UDT or not.
Management of CPPS
Reviewed by: Suresh Jay Mathias
Sep/Oct 2010 (Vol14 No 6)
Chronic prostatitis (CP) and interstitial cystitis (IC) are disorders whose precise aetiologies are poorly understood. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) classification of prostatitis has replaced the older terms ‘nonbacterial prostatitis’ and ‘prostatodynia’ with category III chronic prostatitis / chronic pelvic pain syndrome (CP/CPPS or, as now commonly called, CPPS). These patients have a variety of symptoms including pelvic and genital pain, often associated with urinary and sexual symptoms, but no microbiologically proven urinary tract infection (MPUTI). One of the biggest hurdles for successful treatment is the lack of biomarkers. IC is referred to as bladder pain syndrome or painful bladder syndrome. A multimodal therapy will be ideal for the above mentioned conditions but it has not been studied in a systematic way. In view of similar symptoms for both the conditions, the NIDDK has coined a new term ‘urologic chronic pelvic pain syndromes’ (UCPSS). This study is to propose clinical phenotyping of patients with UCPSS and to direct treatment based on their individual needs. It should encompass a detailed history-taking compounded with questionnaires like National Institute of Health (NIH) Chronic Prostatitis Symptom Index (CPSI) in men and the O’Leary Sant Interstitial Cystitis Symptom and Problem Indices (ICSI and ICPI). Patient Health Questionnaire and Pain Catastrophizing Scale (PCS) may also be used. It should be followed with a complete physical examination and standard investigations. The six domains are (U) urinary symptoms, (P) psychosocial dysfunction, (O) organ specific findings, (I) infection, (N) neurologic dysfunction and (T) tenderness of muscles (UPOINT). (U) Patients with bothersome urinary symptoms could be offered ?-blockers, anticholinergics, specific intravesical treatments, dietary changes and neuromodulation. (P) For patients with catastrophizing symptoms, counselling, cognitive behavioural therapy and antidepressants may be given. (O) Documentation is mandatory including ongoing inflammation, Hunner’s ulcers in the bladder, typical glomerulations with hydrodistension, biopsy documentation of inflammation or relief of pain following the anaesthetic bladder challenge test. Therapies include dietary modifications, restriction of offending agents (e.g: non-steroidal anti-inflammatory drug), Quercetin, bee pollen, misprostol, pentosan polysulfate, intravesical therapy with agents like dimethyl sulfoxide, alkalinisation, alkanised lidocaine, heparin, steroids and surgery reserved for definitive indications (electrocoagulation of Hunner’s ulcers). (I) Some patients with chronic prostatitis who do not have MPUTI and women with IC-like symptoms do respond to antibiotic regimes. (N) Coexisting neurological conditions should be managed with neuroleptics like Gabapentin, pregabalin and amitriptyline. (T) These symptoms are best managed with pelvic muscle physical therapy, stress reduction, antispasmodics and neuromodulation. The overall management is for amelioration of symptoms and not intended for cure. Since patients with UCPSS are not homogenous, treatment should be tailored to their needs.
Long-term outcomes of prenatal diagnosis
Reviewed by: Henrik Steinbrecher
This study aimed to evaluate the long-term efficacy of transurethral hyaluronic acid / dextranomer (NASHA/Dx gel) injections for the treatment of stress urinary incontinence (SUI). Eighteen out of twenty-one patients were followed up over a period of just under seven years. All patients were assessed initially with urodynamics. Three months following the first injection six patients received a second injection as their symptoms had not improved. Seven out of the 21 patients had adverse reactions to the procedure including two abscesses. At one-year follow-up 11 out of the original 21 patients (52.3%) reported an improvement in their symptoms. Almost seven years later the case notes of the patients were reviewed for any new urinary symptoms and patients were also sent a questionnaire (Incontinence Questionnaire-Short Form) to assess their current symptoms. Only one patient was continent and had not needed to undergo a further continence procedure. The study concluded that NASH/Dx gel in women with SUI is ineffective in the long term and associated with complications.