A randomized trial regarding antimicrobial prophylaxis (AMP) in transurethral resection of bladder tumor (TURB)

PURPOSE

To determine whether omitting antimicrobial prophylaxis (AMP) in TURB is safe in patients undergoing TURB without an indwelling pre-operative catheter/nephrostomy/DJ and a negative pre-operative urinary culture.

MATERIALS AND METHODS

A multi-centered randomized controlled trial (RCT) from 17-09-2017 to 31-12-2019 in 5 hospitals. Patients with a pre-operative indwelling catheter/DJ-stent or nephrostomy and a positive pre-operative urinary culture (> 10⁴ uropathogens/mL) were excluded. Post-operative fever was defined as body temperature ≥ 38.3 °C. A non-inferiority design with a 6% noninferiority margin and null hypothesis (H0) that the infection risk is at least 6% higher in the experimental (E) than in the control (C) group; H0: C (AMP-group) - E (no AMP-group) ≥ Δ (6% noninferiority margin). A multivariable, logistic regression was performed for AMP and post-TURB fever with covariates: tumor size and (clot-) retention. The R Project^® for statistical computing was used for statistical analysis and a p value of 0.05 was considered as statistically significant.

RESULTS

459 Patients were included and 202/459 (44.1%) received AMP vs 257/459 (55.9%) without AMP. Fever occurred in 6/202 [2.9%; 95% CI (1.2-6.6%)] patients with AMP vs 8/257 [3.1%; 95% CI (1.5%-6.1%)] without AMP (p = 0.44). Multivariable, logistic regression showed no significant harm in omitting AMP when controlled for (clot-)retention and tumor size (p = 0.85) and an adjusted risk difference in developing post-TURB fever of 0.0016; 95% CI [- 0.029; 0.032].

CONCLUSION

Our data suggest the safety of omitting AMP in patients undergoing TURB without an indwelling, pre-operative catheter/nephrostomy/DJ and a negative pre-operative urinary culture.

Surgical management of acquired rectourethral fistula: a retrospective analysis of 52 consecutive patients

BACKGROUND

Acquired rectourethral fistula (RUF) is an uncommon complication mostly resulting from surgery or radiation. Standardization of the surgical management is lacking. The aim of this study was to report our experience with surgery for RUF.

METHODS

This was a retrospective study of a prospectively maintained clinical database. The surgical strategy was tailored to complexity of RUF, presence of sepsis, history of radiation and residual urinary/fecal functionality. Outcomes measured were RUF closure and permanent fecal/urinary diversion. Impact of radiotherapy was also assessed.

RESULTS

Between November 2002 and January 2019, 52 patients were identified (100% males). Median follow-up was 10.5 (0.5-16.8) years. Three patients had RUF closure after conservative management. The remaining 49 patients had a total of 76 procedures. The cumulative closure rate after the first, second and third attempt was 55.1%, 85.7% and 95.9%, respectively. Fistula closure together with preservation of the fecal and urinary function was achieved in 49%, 65.3% and 67.3% after the first, second and third repair, respectively. The overall success rate for transanal, transperineal, restorative transabdominal and non-restorative transabdominal procedures was 35.7%, 64.3%, 57.1% and 94.1%, respectively. A significantly higher rate of urinary/intestinal stomas was observed in the irradiated vs non-irradiated patients (84.2% vs 42.4%; p = 0.004).

CONCLUSIONS

Surgery ensured healing in 96% of the patients. Radiotherapy led to higher rate of permanent urinary/fecal diversion. Nearly all irradiated patients who had transabdominal repair end up with a definitive stoma. When transperineal repair with gracilis flap interposition was used, the rate of fistula closure approached 90%. A treatment algorithm is proposed.

Fertility and sexuality in the spinal cord injury patient

BACKGROUND

After a spinal cord injury, patients have different perceptions of sexuality, sexual function, and potential for fertility. These changes can greatly impact quality of life over a lifetime.

PURPOSE

The purpose of this workgroup was to identify common evidence based or expert opinion themes and recommendations regarding treatment of sexuality, sexual function and fertility in the spinal cord injury population.

METHODS

As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury (SCI), a workgroup and comprehensive literature search of English language manuscripts regarding fertility and sexuality in the spinal cord injury patient were formed. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).

RESULTS

Genital arousal, ejaculation, and orgasm are significantly impacted after spinal cord injury in both male and female SCI patients. This may have a more significant impact on potential for fertility in male spinal cord injury patients, particularly regarding ability of generate erection, semen quantity and quality. Female patients should be consulted that pregnancy is still possible after injury and a woman should expect resumption of normal reproductive function. As a result, sexual health teaching should be continued in women despite injury. Pregnancy in a SCI may cause complications such as autonomic dysreflexia, so this group should be carefully followed during pregnancy.

CONCLUSIONS

By understanding physiologic changes after injury, patients and care teams can work together to achieve goals and maximize sexual quality of life after the injury.

Long-term functional results after unilateral mid-urethral sling transection for voiding dysfunction

OBJECTIVE

To investigate the long-term outcomes of unilateral mid-urethral sling transection to treat voiding dysfunction after synthetic mid-urethral sling placement for stress urinary incontinence.

STUDY DESIGN

Twenty-three patients who underwent an unilateral sling transection were analyzed retrospectively. Patient records were analyzed for subjective outcome, and pre- and postoperative flow patterns were used as objective outcome parameters.

RESULTS

At the first postoperative follow-up, 77.3% of the patients remained dry. After a mean follow-up of 42 months, 73.9% of patients were continent. The flow pattern after lateral sling transection was significantly better than pre-operatively, with higher maximum flow rate (24.2ml/s, p=0.001), higher mean flow rate (10.4ml/s, p=0.001), higher voided volume (308.5ml, p=0.002) and lower residual volume (28.7ml, p=0.003). At final postoperative follow-up, eight patients (34.8%) reported urgency and six patients (26.1%) were incontinent; four of these patients (17.4%) mainly had urge incontinence.

CONCLUSIONS

Unilateral mid-urethral sling transection is a safe, effective technique to treat voiding symptoms with good preservation of continence. The technique repairs the obstructive flow effectively. Urgency and urge incontinence after mid-urethral sling placement are difficult to treat with transection alone.

Conservative bladder management in advanced multiple sclerosis

Anticholinergics and intermittent catheterization are the cornerstones of bladder management in early multiple sclerosis (MS). In advanced MS however, bladder management is based more on tradition than on evidence. Nurses seem to deal with catheter problems and chronic incontinence. Despite the abundant use of indwelling catheters, there is a lack for guidelines on catheter-induced problems. The psychosexual and social impact of bladder problems in advanced MS is often neglected. The international multidisciplinary special interest group on sexual, urological and bowel dysfunction in MS (SUBDIMS) as a special interest group of the Rehabilitation in Multiple Sclerosis (RIMS) was confronted with a high variability in practice and a lack of guidelines. A literature review was prepared during three multidisciplinary expert meetings. This review will be the basis of further initiatives to improve the urological treatment of patients with advanced MS.

Is low-grade prostatic intraepithelial neoplasia a risk factor for cancer?

INTRODUCTION

High-grade prostatic intraepithelial neoplasia (HGPIN) is generally accepted to be a precursor lesion of prostate cancer. The likely outcome of isolated low-grade PIN (LGPIN) lesions in prostate biopsies remains unclear. A follow-up study of 106 patients with LGPIN- and HGPIN lesions was performed.

MATERIALS AND METHODS

In a 2-y period, 207 men were diagnosed with isolated PIN on standard systematic sextant biopsy of the prostate. In total, 104 patients had LGPIN and 103 had HGPIN. No patients had ever received androgen deprivation therapy, chemotherapy or radiation therapy. In all, 106 patients who underwent repeat second or third sextant biopsies were analysed in the study; 30% of these patients received a selenium-vitamin E supplement for at least 6 months.

RESULTS

In total, 43 had LGPIN and 63 HGPIN on the first biopsy. The mean age was 63.5 y (range 46-77) in the LGPIN group and 64.9 y in the HGPIN group. The mean total PSA was 6.96 ng/ml (range 0.59-34.13) in the LGPIN group and 8.44 ng/ml (range 0.59-35.3) in the HGPIN group. In the LGPIN group, 30% of the patients had cancer in at least one of the repeat biopsy cores. In the HGPIN group, 27% had cancer in at least one of the repeat biopsy cores. The mean total PSA of patients who had cancer in repeat biopsies with LGPIN was 7.84 ng/ml (range 2.92-34.13). The mean total PSA of the patients who had cancer in repeat biopsy in the HGPIN was 6.73 ng/ml (range 0.56-25). There was no significant difference in PSA and pathological stage between those patients who did and those who did not receive selenium-vitamin E supplements.

CONCLUSIONS

These data are intriguing since the risk of finding prostate carcinoma on repeat sextant biopsy in the LGPIN group is 30%. This is higher than commonly reported. The importance of recognising and re-biopsying HGPIN was confirmed. If chemoprevention could be shown to be effective, it might be beneficial not only in HGPIN but also in LGPIN. The possible activity of chemopreventive agents and their combination with iso-flavonoids needs further investigation.

Potency after unilateral nerve sparing surgery: a report on functional and oncological results of unilateral nerve sparing surgery

The objective of the study was to evaluate unilateral nerve sparing prostate surgery. Patient files of men who underwent unilateral nerve sparing radical prostatectomy were analyzed retrospectively after a minimum follow-up period of 18 months. Of 46 patients who received unilateral nerve sparing surgery, 14 (30.4%) regained full potency after surgery. In 92.9% of these patients, recovery occurred within a period of 18 months. Age is the single most important factor in the recuperation of potency after unilateral nerve sparing surgery. Most of the patients (84.8%) reported the ability to achieve orgasm. Of eight patients with positive section margins, two had positive section margins at the spared side only. Unilateral nerve sparing surgery remains a feasible treatment option for prostate cancer.