Safety and efficacy of superior calyceal access versus inferior calyceal access for pelvic and/or lower calyceal renal calculi- a prospective observational comparative study

Objective

To compare efficacy and safety between superior calyceal access and inferior calyceal access for pelvic and/or lower calyceal renal stones.

Methods

Consecutive patients presenting with Pelvic and/or inferior calyceal renal calculi were allocated to the superior calyceal access (group 1) or inferior calyceal access (group 2) treatment arm. Allocation of treatment access was based on the surgeon’s preference. Variables studied included stone free rate, operating time, intraoperative and postoperative complications. Statistical analysis was executed using SPSS, Version 16.0. The statistical significance was evaluated at 5% level of significance (p value < 0.05).

Results

Between July 2018 and February 2019, 63 patients were included in each group. The percutaneous inserted guidewire entered the ureter in 92% in group1 and 74.6% in group 2 (p = 0.034). Stone fragments migrated to the middle calyx in 3.2% in group1 and 9.5% in group 2 (p = 0.033). A second puncture was required in one patient in group 1 and in 5 patients in group 2 (p = 0.04). The operative duration (minutes) was 13.46 ± 1.09 in the group 1 while 16.58 ± 1.44 in the group 2 (p = 0.002). Thoracic complications (hydropneumothorax) occurred to 2 patients in superior calyceal access group managed with intercostal tube drainage (p = 0.243).Post operatively blood transfusion was required in two patients in group 2 (p = 0.169). Angioembolization was done in one patient among the inferior calyceal access approach (p = 0.683). Complete stone clearance assessed at 3 months was 96.8% in group 1 and 85.7% in group 2 (p = 0.046).

Conclusions

Superior calyceal access is a safe and most efficacious in terms of achieving complete stone clearance rate with reduced operative time, minimal blood loss, less need for a second puncture and auxiliary procedures at minimal complications.

Study registration

Clinical trials registry – INDIA; CTRI/2018/07/014,687.

[Management of malignant ureteral obstruction.]

OBJECTIVE

To describe the different therapeutic alternatives in malignant ureteral obstruction (MUO), and to analyze short and long-term results.

METHODS

We conducted a bibliographic search about MUO in Spanish and English languages in PubMed and Google Scholar. We examined the most relevant reviews, original manuscripts and their respective citations. Last search was on April 2016.

RESULTS

Polymeric double J stent is the cheapest and most accessible internal urinary diversion, but has also the shortest duration. Early and late failure rates were 0-35% and 14-49% respectively. Mean time to late failure was 3-12 months. Percutaneous nephrostomy is the safest alternative in terms of failure rates, though it has frequent complications such as tube dislodgement, and may have a negative effect on quality of life. The only metallic double J stent with enough bibliographic background is the Resonance® stent. Early failure was 0-15% and late failure 4-41%, with a mean time to late failure of 2.6-13 months. Regarding metallic stents, Memokath 051® has obtained the best results, with 0-5% early failure rates, 19-49% late failures and mean time to late failure of 7-11 months. In patients with polymeric double J stent failure, patients benefited from tandem double J stents, metallic double J catheters or metallic stents, avoiding the need of a percutaneous nephrostomy. The evidence level was low in all cases.

CONCLUSIONS

Results in MUO are very heterogeneous and have a low evidence level. Factors that influence results include stent characteristics, status and prognosis of the obstructive condition and probably patient and physician's preferences. Polymeric double J stents seem to have higher early and late failure rates than metallic double J catheters and metallic stents. Even though, the difference is not clearly evident. Prospective, multicenter, multidisciplinary trials are necessary to elucidate convenience and adequate selection of each type of stent.

Utilization of multiparametric prostate magnetic resonance imaging in clinical practice and focal therapy: report from a Delphi consensus project

Purpose

To codify the use of multiparametric magnetic resonance imaging (mpMRI) for the interrogation of prostate neoplasia (PCa) in clinical practice and focal therapy (FT).

Methods

An international collaborative consensus project was undertaken using the Delphi method among experts in the field of PCa. An online questionnaire was presented in three consecutive rounds and modified each round based on the comments provided by the experts. Subsequently, a face-to-face meeting was held to discuss and finalize the consensus results.

Results

mpMRI should be performed in patients with prior negative biopsies if clinical suspicion remains, but not instead of the PSA test, nor as a stand-alone diagnostic tool or mpMRI-targeted biopsies only. It is not recommended to use a 1.5 Tesla MRI scanner without an endorectal or pelvic phased-array coil. mpMRI should be performed following standard biopsy-based PCa diagnosis in both the planning and follow-up of FT. If a lesion is seen, MRI-TRUS fusion biopsies should be performed for FT planning. Systematic biopsies are still required for FT planning in biopsy-naïve patients and for patients with residual PCa after FT. Standard repeat biopsies should be taken during the follow-up of FT. The final decision to perform FT should be based on histopathology. However, these consensus statements may differ for expert centers versus non-expert centers.

Conclusions

The mpMRI is an important tool for characterizing and targeting PCa in clinical practice and FT. Standardization of acquisition and reading should be the main priority to guarantee consistent mpMRI quality throughout the urological community.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-016-1932-1) contains supplementary material, which is available to authorized users.

Cryoablation of small kidney tumors

INTRODUCTION

Cryoablation (CA) has been broadly used mostly in the treatment of small renal masses (SRMs). The present review aims to define the current role of CA in the treatment of SRMs by assessing clinical indications and outcomes.

METHOD

A comprehensive review on patient selection, procedural details, perioperative complications, and short/long-term oncological and functional outcomes was conducted. For each section, a take-home message was formulated with level of evidence (LoE) according to Cochrane collaboration.

RESULTS

Age and comorbidity drive the choice of ablation in SRMs, although hospital setting also influences the decision. Technically in adequate CA or first post-CA control occurs in 3-5% of laparoscopic cryoablation (LCA) or percutaneous cryoablation (PCA) series. Meta-analysis does not evidence differences in the rate of residual tumor per person-year between the approaches (0.033 LCA vs. 0.046 PCA, p = 0.25). Perioperative complications (8-25%) are erratically reported. LCA has significantly lower likelihood of complications than minimally invasive partial nephrectomy (MIPN). Systematic reviews indicate 30-month local tumor progression rate of 8.5% for LCA in renal cell carcinoma but low metastatic progression (1-4.4%). Few LCA long-term follow-up series (mean/media 48-98 months) report recurrence-free survival (RFS) and cancer-specific survival (CSS) ranges of 80-100%. For PCA, Kaplan-Meier local disease-free survival (DFS) of 95.6% at 3-5 years [32] and 5-year overall survival and local RFS of 86.3% were reported. The decrease in renal function after CA is minimal, and the only risk factor associated is the basal estimated glomerular filtration rate (eGFR).

CONCLUSION

LoE 3a/b confirms lower CA perioperative complication rate and higher local progression rate than those for MIPN. CA preserves postoperative renal functional, without any evidence of differences in mid-/long-term follow-up compared to nephron sparing surgery.

[Advances in ultrasound techniques for the diagnosis and staging of prostate cancer. Elastography, Doppler ultrasound, ultrasound contrast media, ultrasound quantification media and MRI fusion]

OBJECTIVES

Transrectal ultrasound-guided prostate biopsy remains the gold standard in the diagnosis of prostate cancer. Various Ultrasound modalities have been proposed to increase the cancer detection rate. Our purpose is to evaluate each of these methods , and to present its current literature and clinical utility.

METHOD

A non structured review of the current literature was conducted over these different various ultrasound modalities used during the transrectal ultrasound-guided prostate biopsied in the diagnosis of prostate cancer.

RESULTS

The data investigation of the various modalities associated sonographic features exhibits great heterogeneity and highly variable results. Some new techniques sampling present promising results with high sensitivity and specificity, thus increasing the diagnostic yield of transrectal biopsy. It seems that elastography shows encouraging figures, especially given the recent introduction of the "shearvawe" elastography that decreases the user-dependent factor.

CONCLUSIONS

The ultrasound-guided prostate biopsy has an acceptable sensitivity in the diagnosis of prostate cancer, but its specificity is still low. Various modalities associated with ultrasound are available in clinical practice in order to increase cancer detection rate. Although some promising data have been published for some of the modalities, we believe the combination of these includes validated ultrasound guided biopsy protocols to accurately target and diagnose prostate cancer.

[Diagnosis of upper urinary tract tumors. A pending challenge]

Early diagnosis of upper urinary tract tumors is not easy. The development of endoscopic equipment has expanded the group of patients candidates for minimally invasive treatment. Only by providing accurate tumor staging and grading can clinicians decide which patients should be offered conservative therapies. We need diagnostic methods that allow us to make an early and accurate diagnosis for these lesions, as well as safe follow-up. Our proposal is to present a review of the most used diagnostic method, their features, and future diagnostic tools. The diagnostic arsenal requires further improvement. Only through accurate diagnosis, we will be able to safely provide conservative treatment. Developing new diagnostic techniques seem to move us closer to this goal even more. We propose a working algorithm on the management of these lesions.

Evaluation of renal masses with contrast-enhanced ultrasound

The clinical need for characterising small renal masses (SRMs) is increasing due to their rising incidental detection. This increase is especially seen in younger and older generations and concerns mainly SRMs. Diagnostics is mainly made by contrast-enhanced CT or MRI. However, these imaging methods fail to accurately distinguishing benign from malignant SRMs. Other disadvantages of CT or MRI are high costs, the use of ionizing radiation, nephrotoxicity induced by iodine contrast agents or nephrogenic systemic fibrosis (NSF) induced by gadolinium contrast agents. Contrast-enhanced ultrasound (CEUS) is based on ultrasonography and microbubbles to real-time visualize the renal blood flow without the use of nephrotoxic agents or ionizing radiation. This comprehensive review evaluates the capabilities of CEUS in the diagnostics of benign (angiomyolipomas, cysts, oncocytomas, pseudotumors) and malignant masses (renal cell carcinomas), and focuses on possible future treatment.

Laparoscopic cryotherapy for small renal masses: Current State

OBJECTIVES

To provide an up-to-date review of the available literature on laparoscopic cryotherapy for small renal masses (SRMs) including technique description, indications and outcomes.

METHODS

A systematic literature search was conducted in March 2012, using MEDLINE and EMBASE via Ovid databases, to identify studies on laparoscopic cryotherapy for SRMs published during the last 10 years. Only English-language and human-based full manuscripts reporting case series studies with >20 participants, patient characteristics, efficacy and safety data were included.

RESULTS

No randomised controlled trials (RCTs)were identified. In total, 27 full reports addressing laparoscopic cryoablation (LCA) for SRMs were selected. The number of patients per study ranged from 20 to 144. Mean age of treated patients across the series ranged from 62 to 73 years. Mean size of renal tumors ranged from 2.7 to 4 cm, being in most cases <3 cm. The number of cryoprobes used for cryoablation ranged from 1 to 6, and only 10 series described the use of 17-gauge (1.47 mm) third-generation needles. Overall, more than 55% of all ablated lesions were pathologically confirmed RCC. Mean follow-up ranged from 9 to 93 months. Only 7 series presented a long-term follow-up of more than 36 months. Most studies were limited by a relatively short follow-up. At least four urologic groups reported intermediate- and long-term outcomes. Persistence rates ranged from 0% to 17% and recurrence rates ranged from 0% to 14%. Overall complication rates ranged from 0% to 40%.

CONCLUSIONS

Retrospective observational data and a few prospective series on LCA of SRMs show acceptable oncological 3- to 5-year outcomes with a low recurrence rate. It has proven to be a safe procedure with an overall low complication rate. It is mainly indicated for SRMs in elderly patients affected by co-morbidity and high surgical risk bearing tumours in the anterior valve of the kidney or in contact with the ureter or neighbouring organs.

Maintaining success, reducing treatment burden, focusing on survivorship: highlights from the third European consensus conference on diagnosis and treatment of germ-cell cancer

In November 2011, the Third European Consensus Conference on Diagnosis and Treatment of Germ-Cell Cancer (GCC) was held in Berlin, Germany. This third conference followed similar meetings in 2003 (Essen, Germany) and 2006 (Amsterdam, The Netherlands) [Schmoll H-J, Souchon R, Krege S et al. European consensus on diagnosis and treatment of germ-cell cancer: a report of the European Germ-Cell Cancer Consensus Group (EGCCCG). Ann Oncol 2004; 15: 1377-1399; Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ-cell cancer: a report of the second meeting of the European Germ-Cell Cancer Consensus group (EGCCCG): part I. Eur Urol 2008; 53: 478-496; Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ-cell cancer: a report of the second meeting of the European Germ-Cell Cancer Consensus group (EGCCCG): part II. Eur Urol 2008; 53: 497-513]. A panel of 56 of 60 invited GCC experts from all across Europe discussed all aspects on diagnosis and treatment of GCC, with a particular focus on acute and late toxic effects as well as on survivorship issues. The panel consisted of oncologists, urologic surgeons, radiooncologists, pathologists and basic scientists, who are all actively involved in care of GCC patients. Panelists were chosen based on the publication activity in recent years. Before the meeting, panelists were asked to review the literature published since 2006 in 20 major areas concerning all aspects of diagnosis, treatment and follow-up of GCC patients, and to prepare an updated version of the previous recommendations to be discussed at the conference. In addition, ∼50 E-vote questions were drafted and presented at the conference to address the most controversial areas for a poll of expert opinions. Here, we present the main recommendations and controversies of this meeting. The votes of the panelists are added as online supplements.

New optical diagnostic tools in renal cell cancer

In modern medicine the profound use of abdominal imaging has led to a dramatic change of presentation of renal tumors. Smaller tumors and therefore more benign masses are being discovered, and as systemic use of renal mass biopsies is not recommended by the general guidelines, an appropriate tool to assess the biology of renal tumors is highly desirable. Apart from new developments of currently applied diagnostic modalities, several research groups focus on the potential of optical diagnostic techniques to contribute to the diagnostic process of renal tumors. They use the interaction of light with biological tissue to gather information on the optical properties of a tissue sample and therefore providing information on the histological composition of this tissue in a non-invasive manner and in real-time. In this review we provide an overview of novel diagnostic techniques starting with the future of conventional diagnostics like Contrast-enhanced ultrasonography (CEUS) and positron emission tomography-computed tomography (PET-CT) followed by optical technologies that are potentially employed in the nearby future to improve the diagnostic process of renal tumors with a focus on optical diagnostic techniques.

[Cryotherapy for renal tumors: current status and contemporary developments]

The proportion of renal tumors found incidentally dramatically increased in the past decade. More than half of them were diagnosed in patients over 70 years of age, a population with high associated comorbidity. Nephron-sparing minimally invasive surgical procedures are aimed at treating patients with small renal tumors and multiple comorbidities. Cryotherapy stands out among all other ablative procedures because of its better mid-term oncological outcome. A non-systematic review of the literature on cryotherapy as a treatment for renal tumors was made, analyzing its indications, actual and future application techniques, results, and complications.

Laparoscopic radical prostatectomy: A European virus

The evolution of prostate cancer treatment has now incorporated the principles of minimally invasive surgery. Laparoscopic radical prostatectomy, just like a virus, infected first Europe and three years ago the United States. This European virus has nowadays a potentially widespread application. Oncological efficacy and ability to preserve and improve continence and potency are the factors that will ultimately determine the role of laparoscopic radical prostatectomy and thus the future of this virus infection. This article reviews the current published experience with minimally invasive prostatectomy and provides comparisons to published data on radical retropubic prostatectomy to increase awareness about viability. Some prospective and retrospective non-randomized comparative studies of the two approaches are also included in the present review. The current practice patterns regarding urological laparoscopic surgery and the tendency of the urologic community in Europe and in the United States to establish minimally invasive radical prostatectomy in more urological departments are described.

Positive margins in laparoscopic partial nephrectomy in 855 cases: a multi-institutional survey from the United States and Europe

PURPOSE

Open partial nephrectomy has emerged as the standard of care in the management of renal tumors smaller than 4 cm. While laparoscopic radical nephrectomy has been shown to be comparable to open radical nephrectomy with respect to long-term outcomes, important questions remain unanswered regarding the oncological efficacy of laparoscopic partial nephrectomy. We examined the practice patterns and pathological outcomes following laparoscopic partial nephrectomy.

MATERIALS AND METHODS

A survey was sent to academic medical centers in the United States and in Europe performing laparoscopic partial nephrectomy. The total number of laparoscopic partial nephrectomies, positive margins, indications for intraoperative frozen biopsy as well as tumor size and position were queried.

RESULTS

Surveys suitable for analysis were received from 17 centers with a total of 855 laparoscopic partial nephrectomy cases. Mean tumor size was 2.7 cm (+/-0.6). There were 21 cases with positive margins on final pathology, giving an overall positive margin rate of 2.4%. Intraoperative frozen sections were performed selectively at 10 centers based on clinical suspicion of positive margins on excised tumor. Random biopsies were routinely performed on the resection bed at 5 centers. Frozen sections were never performed at 2 centers. Of the 21 cases with positive margins 14 underwent immediate radical nephrectomy based on the frozen section and 7 were followed expectantly.

CONCLUSIONS

Early experience with laparoscopic partial nephrectomy in this multicenter study demonstrates oncological efficacy comparable to that of open partial nephrectomy with respect to the incidence of positive margins. The practice of intraoperative frozen sections varied among centers and is not definitive in guiding the optimal surgical treatment.

[Advances in the ultrasound diagnosis of prostate cancer]

OBJECTIVES

Ultrasound guided biopsies are the mainstay in the diagnosis of prostate cancer. With the aim of improving diagnostic performances different protocols of prostate biopsy have been designed. The addition of vascular contrasts to the ultrasound allows for identification of hypervascular regions more likely to be cancer. The new ultrasound modalities enhance contrast signal and specifically differentiate its signal from the tissue reflections.

METHOD

A non structured review of the literature was conducted on the utility of the different ultrasound modalities and types in targeting the biopsies of the prostate.

RESULTS

There are four types of ultrasound guided biopsies of the prostate: ultrasound guided biopsy of hypoechoic nodes, systematic biopsy protocols, Doppler guided biopsy and Contrast Enhanced Doppler guided biopsy. In spite of the broad literature only few series possess a methodologically correct design related to the use of reference standards. The diagnostic performance of each one of the different types of biopsy varies widely. Sensitivity and specificity of ultrasound guided biopsy of hypoechoic nodes depends on the type of population included in the study but in general its positive predictive value is low. The protocols of systematic biopsy increase the sensitivity of the prostate biopsy but still specificity is low. The Doppler techniques offer a marginal benefit. Contrast Enhanced Doppler guided biopsies series have reported only a slightly increase in sensitivity and a significant improvement of the odds risk for diagnostic of prostate cancer. New arising ultrasound modalities present with promising preliminary results.

CONCLUSIONS

Ultrasound guided biopsy have an acceptable sensitivity in the diagnosis of prostate cancer, however specificity is overall low. Among the different ultrasound techniques only Contrast Enhanced Ultrasound improves significantly the diagnostic risk of the biopsy although the sensitivity remains quite stable. New specific contrast ultrasound techniques are currently under investigation.

Cryotherapy for renal-cell cancer: diagnosis, treatment, and contrast-enhanced ultrasonography for follow-up

Cryotherapy is a curative treatment option for patients with small (<4 cm) renal-cell cancers. For the followup of ablated lesions, imaging is the only available method, but the best tool has not yet been determined. The method selected should be able to determine the presence or absence of perfusion in the area and measure the lesion. Usually, contrast-enhanced CT or MRI is used. The accompanying video shows cryotherapy treatment along with contrast-enhanced ultrasound investigations before and afterward. We used a Siemens Acuson Sequoia device with contrast pulse sequence imaging and Sonovue (Bracco) as the contrast agent. The lesion could be identified and measured easily. Because this method enables selective detection of contrast, the presence and absence of perfusion can be determined objectively.

The Bell-Shaped Nitinol Prostatic Stent in the Treatment of Lower Urinary Tract Symptoms: Experience in 108 Patients

OBJECTIVES

To assess the efficacy, safety, and durability of the bell-shaped nitinol prostatic stent in the treatment of moderate to severe lower urinary tract symptoms caused by benign prostatic enlargement in otherwise healthy patients.

METHODS

Stents were inserted in an outpatient setting under local anaesthesia. Assessments included maximum urinary flow (Qmax), postvoid residual (PVR) urine volume, International Prostate Symptom Score (IPSS), including quality of life (QoL) item, at baseline and follow-up visits.

RESULTS

108 men were enrolled in the trial. Stents were successfully inserted in 97% of the patients. Spontaneous voiding was achieved in all patients. After one month Qmax (+3.7 ml/s), PVR (-99 ml), IPSS (-12) and QoL (-1.7) all showed statistically significant improvements compared to baseline. Substantial improvements, however, were maintained for only one to two months. The main complications were haematuria (19%), urge incontinence (22%), and migration (15%). The median indwelling time was 105 days. The main reason for removal of stents was worsening of symptoms, which might be attributable to the tilting of stents within the prostatic urethra, found upon removal.

CONCLUSIONS

Insertion of the bell-shaped nitinol prostatic stent temporarily improves voiding parameters and symptom scores. Because of the limited durability, however, the bell-shaped prostatic stent is not suitable for clinical practice.

Construct Validity of the Chicken Model in the Simulation of Laparoscopic Radical Prostatectomy Suture

BACKGROUND AND PURPOSE

For a simulation to be valid, it has to be close to reality, correlate with the performance in a real case, and be able to discriminate between individuals with different degrees of experience. We explored the construct validity (ability to discriminate between experienced and inexperienced subjects) of a simulation for the urethrovesical anastomosis during laparoscopic radical prostatectomy (LRP).

MATERIALS AND METHODS

Dead chickens were used. After partial emptying of the corporal cavity, an 18F catheter was placed through the esophagus to the stomach. In the Pelvic Trainer, a laparoscopic section of the esophago-glandular-stomach junction and a suture between the two edges were performed in the same fashion as for a urethrovesical suture in LRP. Five subjects with different levels of experience in laparoscopy, ranging from nil to more than 250 LRPs, tested two types of suture. One-way ANOVA was used to detect differences in suturing time among the operators. A multiple comparison test was used to detect specific differences between operators.

RESULTS

Although suturing time had a strong negative correlation with the operator's experience, significant statistical differences in suturing time were found only between the least experienced operator and the other ones. Qualitative differences in the suture were found among operators.

CONCLUSION

This simulation correlates well with the laparoscopic (LRP) subject's experience. It can discriminate between inexperienced and experienced subjects, exhibiting moderate construct validity, but failed to reflect the different levels of experience among the most experienced subjects.

Post-Void Residual Urine Volume is Not a Good Predictor of the Need for Invasive Therapy Among Patients With Benign Prostatic Hyperplasia

PURPOSE

We assessed the value of baseline PVR as predictor of the need for invasive therapy during long-term followup of patients with clinical BPH treated initially with alpha1-blockers or WW.

MATERIALS AND METHODS

The records of a cohort of 942 patients with BPH treated with alpha(1)-blockers or WW were reviewed. Baseline I-PSS scores, PSA, prostate volume, uroflowmetry, pressure flow parameters and followup data were collected prospectively. Correlations between PVR and other baseline parameters were calculated. The 5-year cumulative risks of invasive therapy were calculated with the Kaplan-Meier method. After stratification of PVR by various cutoff levels (50, 100 and 300 ml), rate ratios between large and small PVRs were calculated using proportional hazards analyses.

RESULTS

PVR has weak (-0.2<R <0.2) correlations with other baseline parameters. With increasing PVR cutoff levels, the 5-year cumulative risk of invasive therapy for the large PVR subgroup, increases from 45% to 64% and from 15% to 21% in the alpha1-blockers and WW group, respectively. Large PVR yields a significant 2-fold up to a 4-fold increased risk of invasive therapy compared to small PVR in both treatment groups. In multivariate models these significant risk differences largely disappear, although a statistically not significant higher risk remains for the large PVR (greater than 300 ml) patients.

CONCLUSIONS

In general, baseline PVR has little prognostic value for the risk of BPH related invasive therapy in patients on alpha1-blocker and WW. Only patients with large PVR have a 2-fold increased risk of invasive therapy compared to patients with smaller PVR.

Prognostic role of prostate-specific antigen and prostate volume for the risk of invasive therapy in patients with benign prostatic hyperplasia initially managed with alpha1-blockers and watchful waiting

OBJECTIVES

To investigate the prognostic role of prostate-specific antigen (PSA) level and prostate volume (PV) for the need for benign prostatic hyperplasia (BPH)-related invasive therapy among patients initially treated with an alpha1-blocker or watchful waiting (WW) in real-life clinical practice.

METHODS

Data were collected from 2264 consecutive patients with clinical BPH. Patients initially treated with an alpha1-blocker or WW were included in this study. They were stratified by baseline PSA level (less than 1.5, 1.5 to less than 3.0, 3.0 to 10.0 ng/mL) and PV (less than 30 and 30 to 200 cm3), and analyzed for the time to BPH-related invasive therapy.

RESULTS

Of the 2264 patients, 389 treated with alpha1-blockers and 553 who chose WW were included. Across the PSA and PV strata, the alpha1-blocker group had worse symptoms, peak flow, postvoid residual urine volumes, and obstruction than did the WW group. Increasing PSA levels produced an increase in the 5-year cumulative risk of invasive treatment: 20%, 34%, and 44% in the alpha1-blocker and 8%, 9%, and 15% in the WW group for a PSA level of less than 1.5, 1.5 to less than 3.0, and 3.0 to 10.0 ng/mL, respectively. The hazard ratio for the highest compared with the lowest PSA strata was 2.8 for alpha1-blocker and 2.7 for WW patients. An increasing PV increased the 5-year cumulative risk from 21% to 35% in the alpha1-blocker group and 8% to 11% in the WW group. The hazard ratio for the large versus small prostates in the alpha1-blocker group was 1.8 and in the WW group was 1.0.

CONCLUSIONS

A higher PSA level and larger PV resulted in a greater risk of BPH-related invasive therapy that was more pronounced in the alpha1-blocker than in the WW patients. However, symptom severity, flow parameters, and obstruction grade may have contributed to the difference in risk between the two treatment groups.

LONG-TERM FUNCTIONAL AND URODYNAMIC RESULTS OF 50 PATIENTS RECEIVING A MODIFIED SIGMOID NEOBLADDER CREATED WITH A SHORT DISTAL SEGMENT

PURPOSE

We assessed the long-term functional and urodynamic outcomes of a modified sigmoid neobladder.

MATERIALS AND METHODS

A total of 50 patients received a sigmoid neobladder with a short distal segment after radical cystoprostatectomy. Patients were followed at 3-month intervals the first year and every 6 months thereafter. Continence and voiding patterns were assessed using questionnaires and interview. The International Continence Society classification was used after 1996. Urodynamic assessment was performed 3 times during followup.

RESULTS

Mean sigmoid segment length +/- SD was 18 cm (+/- 2.8). Mean followup was 38 months (+/- 24.8). Ureter stricture and reflux were present in 8% and 17% of the reimplanted units, respectively. Mean creatinine serum levels did not change after surgery and remained stable during followup. At 2 years 89% of the patients were continent in the daytime and 90% had good or satisfactory daytime continence according to the International Continence Society classification. At 3 years 77% of the patients voided every 3 or 4 hours during the day. Nighttime continence was poor. Only 10% of the patients complied with an alarm program. Mean maximal capacity of the reservoir was 300 ml and remained stable during followup. Mean intrareservoir pressure at maximal capacity decreased from 61 to 51 cm H2O from the first to the third urodynamic evaluation. No patient required clean intermittent catheterization.

CONCLUSIONS

This modified sigmoid neobladder offers good daytime continence with low post-void residual and adequate daytime micturition frequency. Nighttime continence is poor. The presence of high intrareservoir pressures did not impair renal function.

Present Practice and Treatment Strategies in Endourological Stone Management

OBJECTIVES

The European Society of Urological Technology (ESUT) conducted a survey in order to assess and record the current trends between urologists with regard to the application of endourological stone management to identify trends and differences in treatment strategies among urologists.

METHODS

A total of 695 certified urologists and urological residents answered the ESUT Endourological Stone Management Questionnaire. There were 136 (28.7%) chief urologists, 240 (50.6%) staff urologists and 98 (20.7%) residents. The respondents were classified according to both the geographical origin (in four groups: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE) and Outside Europe (OE)), and department size (number of urological beds per department: small < or = 25, medium 26-50 beds, large > 50 beds) in order to identify any differences in the replies.

RESULTS

On average, 40.1 newly diagnosed patients and 73.6 revisits with urolithiasis are seen a month per department. According to the replies, there are no significant differences in total numbers of treatments in ESWL and/or endourological stone managements amongst the geographically based groups. Monthly, on average 68.5 ESWL treatments and 23.0 URS are performed per department. A significant majority of surveyed urologists performs URS with a rigid or semi-rigid instrument (79%) instead of a flexible instrument (21%, p = 0.003). URS is more frequently performed outside Europe (p = 0.02) with a more frequent use of dormia catheters (p < 0.001). On average, 20.9 double g-stents are placed monthly in each department, most commonly before or after endourological procedures (p < 0.001). Percutaneous procedures are performed by 69.6% of the respondents with a mean of 16.8 PNL procedures a month. PNL for stone management is mainly performed in Eastern Europe and non-European countries (p = 0.017). Nephrostomy tubes are used by 77.7% of the responding urologists. Monthly, 13.1 nephrostomy tubes are placed, mostly during PNL or after endourological procedures (40.7%).

CONCLUSION

The data obtained from the 695 urologists and residents provides information on the performed procedures and the use of material. In general, respondents from different geographical locations perform similar procedures and use identical material; however URS and PNL are performed more frequently outside of Europe, whereas laser lithotripsy is frequently used in Northern European counties.

Comparison of Orthotopic Sigmoid and Ileal Neobladders: Continence and Urodynamic Parameters

OBJECTIVES

The objective this of the study was to compare continence rates and urodynamic parameters among patients who had undergone orthotopic bladder substitution with sigmoid or ileal segments.

METHODS

Continent urinary reservoirs were constructed in 112 patients. Fifty patients received a sigmoid neobladder (SN) and 62 patients an ileal neobladder (IN). Thirty-four patients with an SN (mean age 64.4 years), and 20 with an IN (mean age 57.8 years) agreed to postoperative urodynamic evaluation at a median time after surgery of 18 and 37 months, respectively. Continence and urodynamic parameters were compared in both groups.

RESULTS

The average reservoir capacity of the SN (296 ml) was lower than the IN (546 ml). The majority of patients voided by the Valsalva maneuver and achieved good peak flow rates [SN group 16.6 (range 7-32) ml/s, IN group 25.5 (range 5-35) ml/s]. Of the patients with an SN 26 (76%) and with an IN 15 (75%) emptied to near completion with a post-void residual (PVR) of less than 100 ml. Daytime continence was achieved in 90% of IN patients and 85% of SN patients. Only 9% of patients with an SN and 60% of patients with an IN were continent at night.

CONCLUSION

A neobladder constructed from detubularized ileum or sigmoid achieves adequate capacity with a satisfactory daytime continence rate. Nighttime incontinence in patients with IN can be at least partly explained by periods of high pressure due to neobladder contractions in combination with a relaxed sphincter during sleep. The low nighttime continence rate of the SN is probably related to its small functional capacity.

Development of Laparoscopic Surgery and Training Facilities in Europe: Results of a Survey of the European Society of Uro-Technology (ESUT)

OBJECTIVE

The European Society of Uro-Technology (ESUT) conducted a survey in order to assess the application of laparoscopy and the facilitation of training programs within Europe.

METHODS

A total of 430 urologists and residents from European countries answered the ESUT survey during the XVIIIth Annual EAU Meeting in Madrid in 2003. The survey constituted of 11 questions of which nine with dual response (Y/N) options. Two questions, evaluating the importance of different training methods and different reasons not to be involved in laparoscopy, were assessed by means of a Likert type scale.

RESULTS

Laparoscopy was performed in 71% of urological departments. The majority (85%) of departments where no laparoscopy was performed, intended to establish it in the future. Two thirds of respondents believed laparoscopy would replace open surgery in the next 5 to 10 years. The access to training facilities was insufficient for 44%. Different methods of training were considered to be of equal importance. Among the reasons for not being involved in laparoscopic surgery a high variability was identified.

CONCLUSIONS

Laparoscopy is performed in the majority of urological departments in Europe. While there is a strong believe in the prominent role of laparoscopy in the mid-long future, access to training is still needed.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Laparoscopic Extraperitoneal Adenomectomy (Millin): Pilot Study on Feasibility

OBJECTIVE

The aim of the present work is to describe the surgical technique and to assess the feasibility of laparoscopic extraperitoneal adenomectomy in a pilot study.

METHODS

Eighteen consecutive patients in whom an open adenomectomy was planned were operated on in a laparoscopic extraperitoneal fashion. In all patients indication was based on objective signs of obstruction. The laparoscopic approach was standard in all cases as follows: creation of a preperitoneal workspace, haemostatic control of lateral venous vesicoprostatic pedicles, transversal anterior incision of the prostate capsule, progressive enucleation of the adenoma with the help of an harmonic scalpel, suture of the posterior bladder neck to the prostate fossa, closure of the prostate capsule, and retrieval of the specimen. Feasibility was assessed by objective operative parameters (reconversion, operating time, and blood loss and transfusion requirements) and per operative complications. Data on short term follow-up are also available.

RESULTS

Mean age of the patients was 67.8 years (S.D. 6.2) and mean prostatic weight calculated by TRUS 95.1cm(3) (S.D. 28.1). Mean maximal flow (Q(max)) was 4.3ml/s (S.D. 3.4) with four patients (22.2%) presenting in retention. Mean duration of intervention was 145min (S.D. 32.5) and mean blood loss 192ml (S.D. 178). Mean excised tissue was 47.6g (S.D. 30). Neither conversions to open prostatectomy nor transfusions were required. The urethral catheter remained in place an average of 3.0 days (S.D. 2.4) in 14 patients, while 4 needed a re-catheterization. Mean postoperative hospital stay was 5.9 days (S.D. 5.5). Five patients (27.7%) presented complications during follow-up, mild in most of the cases but one who required a secondary intervention for persistent obstruction.

CONCLUSIONS

Laparoscopic extraperitoneal adenomectomy (Millin's procedure) is feasible with a reasonable complication rate. Although comparison with open adenomectomy is not yet available, this technique might have potential advantages in terms of blood loss and postoperative catheter time.

Prostate-Specific Antigen as an Estimator of Prostate Volume in the Management of Patients with Symptomatic Benign Prostatic Hyperplasia

OBJECTIVES

To assess the ability of serum prostate specific antigen (PSA) to estimate prostate volume (PV) to aid in the management of patients with benign prostatic hyperplasia (BPH).

METHODS

From 1989 to 2002, data were collected from 2264 patients complaining of lower urinary tract symptoms (LUTS) who visited the Department of Urology of the University Medical Centre Nijmegen, The Netherlands. Baseline PV and serum PSA was determined using standard techniques. All patients who had a baseline PV < or =200 ml, as well as a baseline serum PSA 0-10 ng/ml, were included. Patients with a history of prostate surgery, prostate cancer and conditions other than BPH at baseline were excluded. A log-transformed linear regression model was used to estimate PV. Receiver-operating characteristic (ROC) curves were constructed to evaluate the ability of serum PSA to estimate threshold PVs in men with BPH, and to select the optimal serum PSA cut-off values.

RESULTS

The analyses included 1859 patients with a mean age of 63.5 years, mean baseline PV 43.9 ml, and mean baseline PSA value 3.1 ng/ml. PV as well as serum PSA increases with age. Linear regression analyses showed that PV and serum PSA have an age-dependent log-linear relationship, where 42% of the variance of PV can be explained by PSA and age. ROC's area under the curves (AUC) reveal that PSA has a good predictive value for assessing 'prostate enlargement', with AUC around 82% in the overall age groups irrespective of the PV cut-off values. Optimal serum PSA cut-off values for the overall study population irrespective of age are 2.0 ng/ml to detect PV >30 ml and 2.5 ng/ml to detect PV >40 ml.

CONCLUSIONS

This study suggests that serum PSA can estimate prostate enlargement sufficiently accurately to be useful for therapeutic, especially medical, management. It is well accepted that the outcome of pharmacotherapy for BPH depends on baseline PV. Therefore, in the absence of reliable direct measurement of PV, serum PSA determination may be used to optimise patient management.

Long-term results after external beam radiation therapy for T1-T2 localized prostate cancer

The incidence of organ-confined and early-stage prostate cancer has increased. The external beam radiation therapy has proven to be a good therapeutic option in terms of biochemical survival and overall survival. It has been modified throughout the years; consequently, the available data on the long-term efficacy of external beam radiation therapy are difficult to compare with the commonly used improved radiation strategies. Intensity-modulated conformal radiotherapy and three-dimensional conformal radiotherapy result in better tumor control at a lower complication rate. External beam radiotherapy seems to be favored in intermediate- and high-risk groups for relapse of prostate cancer and radical prostatectomy is favored in the low-risk group. However, they score similarly in terms of general health-related quality of life after treatment.

The endoscopic approach to the distal ureter in nephroureterectomy for upper urinary tract tumor

PURPOSE

We reviewed the current status of the endoscopic distal ureteral approach to nephroureterectomy for transitional upper urinary tract cancer.

MATERIAL AND METHODS

We reviewed the English, French and Spanish literature using a PubMed and MEDLINE search, and compared the stripping and pluck techniques. Statistical analysis was done using Fisher's exact test. Individual case reports are discussed but they were not included in the statistical analysis.

RESULTS

The mean rate of bladder carcinoma recurrence after ureteral resection and detachment is 19.3% for the stripping and 24% for the pluck technique. This difference is not statistically significant. In 3.1% of cases invasive bladder cancer has been noted but only after distal ureteral resection using the pluck technique.

CONCLUSIONS

The endoscopic approach to the distal ureter during nephroureterectomy is feasible. Bladder cancer recurrence was similar after each technique. However, isolated case reports illustrate the need for cautious selection of surgical candidates.

Transurethral hot water balloon thermoablation

The inclusion of a determinate technique among the "minimally invasive treatments" of the symptoms due to benign prostatic hyperplasia is a long and careful process. The technique has to be more patient-friendly than conventional techniques, but also needs to be time-tested against older methods. Most of these minimally invasive treatments are based upon distinct types of thermoablation; the method discussed here, hot water balloon thermoablation, is based on the heat conductive properties of the prostatic tissue.

EAU guidelines on testicular cancer

OBJECTIVES

To establish guidelines for the diagnosis, staging, treatment and follow-up of germ cell testicular cancer.

METHODS

A search of published work was conducted using Medline. Highly evidence-based articles were selected and their findings analysed by the members of the Oncological Urology Working Group of the EAU. Testis cancer is rare and affects young men in their 3rd and 4th decades of life. The majority of these tumours are derived from germ cells (seminomatous and non-seminoma germ cell testicular cancer), and more than 50% of patients are diagnosed with stage I disease. Epidemiological, pathological and clinical risk factors are well established. The tumour, node, metastasis (TNM) staging system is endorsed, and for metastatic disease a recently devised prognostic-factor-based staging system has proven to be useful. Staging assessment includes pre- and post-orchiectomy marker levels, pathology of the testis, and nodal and visceral status. Following orchiectomy, treatment depends on the tumour type, pathological risk factors for stage I disease and clinical prognostic factors for advanced disease. The cure rate is excellent for disease stages I and II, irrespective of the treatment adopted. However, the pattern of relapse (rate, timing and site) is highly influenced by therapeutic policy. For metastatic disease, survival depends on clinical prognostic factors and treatment. Follow-up schedules are tailored according to stage, tumour type and post-orchiectomy treatment schedules.

CONCLUSIONS

Excellent cure rates are achieved for early-stage germ cell testis tumours following accurate staging at diagnosis. Satisfactory survival rate can be achieved in advanced metastatic disease using a multidisciplinary therapeutic approach. Follow-up schedules vary, depending on the pathology and stage of the primary tumour and on the treatment policy adopted following orchiectomy.

Efficacy and safety of the new high-energy 30-minute transurethral microwave thermotherapy: results of 1-year follow-up in a multicenter study

PURPOSE

To assess the efficacy and durability of a new 30-minute algorithm for high-energy transurethral microwave thermotherapy (TUMT, Prostasoft 3.5) in the treatment of men with lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia.

MATERIALS AND METHODS

A total of 167 men (mean age 67 years) with bothersome LUTS were treated with the new TUMT protocol. Evaluation included assessment of the short- and long-term objective and subjective outcome measures of this treatment.

RESULTS

The treatment is well tolerated. The International Prostate Symptom Score improved from a mean of 19.2 at baseline to 7.9 at 12 months after treatment. Maximum urinary flow improved from 8.9 to 16.4 mL/s at 12 months. Mean duration of catheterization was 16.1 days. Urodynamic evaluation showed a change from the obstructed to the nonminimally obstructed zone. There were no serious complications.

CONCLUSION

High-energy TUMT using the new high-dose Prostasoft 3.5 protocol appears to be a safe, effective, and durable treatment. The faster procedure improves tolerance of the treatment. Subjective and objective improvements were significant and the treatment-related morbidity low.

Microwave thermotherapy: historical overview

The application of heat with curative aim is an old and very well-known principle in medicine. A review of the history of heat use in the treatment of prostatic disease is presented. The article is based on bibliographic research (MEDLINE Search and PubMed) and focuses on treatment of benign prostatic hyperplasia (BPH) since the first clinical documentation of transrectal hyperthermia for this condition. Then, in a chronological sequence, not only the evolution toward thermotherapy but also enhancements of the latest techniques are presented. The new advances in the field of patient selection, indications, and outcome predictors, as well as new trends in treatment are briefly considered.

[Percutaneous suprapubic bladder lithotripsy]

The authors present a case of multiple bladder stones in a patient with severe ankylosis of the lower extremities, treated via percutaneous suprapubic approach. The suprapubic tract was created with Teflon-coated dilators and an Amplatz tube and the stones were fragmented with the nephroscope and a pneumatic lithotriptor. The simplicity of the procedure and the ease of the manoeuvre accelerated the stone fragmentation process while avoiding unnecessary trauma of the urethra.

[Treatment of prostate benign hyperplasia (BPH) with visually controlled laser, assessment at 2 years, and anatomopathologic findings]

The endoscopically-guided lateral discharge laser (VLAP) has been considered an alternative in the management of benign prostate hyperplasia (BPH). The purpose of this paper is to describe the technique, results obtained in 20 treated patients, and pathoanatomical findings in those later treated with prostate transurethral resection. Four patients were carriers of an indwelling catheter, while IPSS/QL mean values in the other 16 patients were 23/4. Mean maximum flow was 7.01 mL/s. Assessment after one and two years shows a fall of mean IPSS/QL to 5/1 and mean maximum flow to 15.2 mL/s and 21 mL/s, respectively, but the difference is not significant. This paper also describes the morbidity affecting 65% patients, which is comparable to the retreatment rate (15%) obtained in other series published. The results are similar to those described in the literature although, in our view, the high rate of complications undermines this choice as an alternative in BPH management.

[Gastrocystoplasty for renal insufficiency in adults]

Vesical substitution or augmentation with various segments from the gut is a frequent occurrence in urology. In the presence of normal renal function there are few or no metabolic disorders. In the presence of renal failure the most suitable gut segment is the stomach due to its characteristics of Cl- and ammonium excretion, smaller mucus formation, acid pH provided to the urine and because it allows easy ureteral regrafting. This article contributes one case of gastrocystoplastia in a patient with trigonal bladder and chronic renal failure, presenting reno-vesical TB.

[Acute colonic pseudo-obstruction (Ogilvie syndrome) after nephrectomy for renal carcinoma: persistence after decompressive colonoscopy and spontaneous remission]

A 65-year-old male patient presented acute dilatation in the ascendant colon on the third post-operative day following nephrectomy due to renal adenocarcinoma. No changes in colonic diameter were seen after decompressive colonoscopy and, while the patient was asymptomatic, conservative therapy was instituted and the picture was resolved in just a few days. The case is used to review the issue of acute colonic pseudo-obstruction and its relationship to urological operations.

Carcinoma in situ as a prognostic factor for G3pT1 bladder tumours

G3pT1 bladder cancer has traditionally been regarded as a superficial tumour with a high risk of progression. We have studied 37 patients with initial G3pT1 bladder tumours treated between January 1981 and December 1985. They were divided into 2 groups according to the association with carcinoma in situ (Cis) at the time of diagnosis. Clinical behaviour was analysed at 5 years. The first group (without Cis) showed progression and recurrence rates similar to those of low grade, low stage bladder tumours. The second group (with Cis) had a similar rate of recurrence but their progression rate was 65%.