Objective To test our hypothesis that a targeted rectal screening protocol before transrectal ultrasound (TRUS)-guided biopsy would potentiate streamlined prophylaxis, thereby reducing postbiopsy ...infectious rates while minimizing unnecessary broad-spectrum antibiotic use. To this end, we instituted preprocedure rectal cultures in an effort to identify fluoroquinolone (FQ)– resistant flora using selective media to optimally direct targeted prophylactic antibiotic administration. The inexorably increasing prevalence of multidrug-resistant microorganisms, notably extended spectrum beta lactamase (ESBL)–producing and FQ-resistant Enterobacteriaceae has increased the post-TRUS prostatic biopsy infection rates, including life-threatening sepsis. Methods A total of 235 rectal swabs were obtained and plated directly onto MacConkey agar plates containing 10-μg/mL ciprofloxacin. Following the screening procedure, antimicrobial susceptibility results were used to develop a customized antibiotic prophylaxis regimen to be administered before biopsy. Following the biopsy procedure, the patients were seen in follow-up within 7 days, and information was gathered on potential adverse effects, clinical appointments for infections, and potential antibiotics received. Results Thirty-two-patients (14%) had FQ-resistant isolates (most Escherichia coli ), and 3 (1.3%) were ESBL-producing isolates. There were no infectious complications identified in this period, (compared with 3 septic complications among 103 biopsies in the 4 months preceding the study). Conclusion Rectal cultures obtained before TRUS biopsy, using selective media to identify FQ-resistant Enterobacteriaceae, facilitate targeted antibiotic prophylaxis, and appear to be highly efficacious in reducing infectious complications.
New-generation flexible ureteroscopes allow the management of proximal ureteral and intrarenal pathology with high success rates, including complete removal of ureteral and renal calculi. One problem ...is that the irrigation pressures generated within the collecting system can be significantly elevated, as evidenced by pyelovenous and pyelolymphatic backflow seen during retrograde pyelography. We sought to determine if the ureteral access sheath (UAS) can offer protection from high intrarenal pressures attained during routine ureteroscopic stone surgery.
Five patients (average age 72.6 years) evaluated in the emergency department for obstructing calculi underwent percutaneous nephrostomy (PCN) tube placement to decompress their collecting systems. The indications for PCN tube placement were obstructive renal failure (N=1), urosepsis (N=2), and obstruction with uncontrolled pain and elevated white blood cell counts (N=2). Flexible ureteroscopy was subsequently performed with and without the aid of the UAS while pressures were measured via the nephrostomy tube connected to a pressure transducer. Pressures were recorded at baseline and in the distal, mid, and proximal ureter and renal pelvis, first without the UAS, and then with the UAS in place.
The average baseline pressure within the collecting system was 13.6 mm Hg. The mean intrarenal pressure with the ureteroscope in the distal ureter without the UAS was 60 mm Hg and with the UAS was 15 mm Hg. With the ureteroscope in the midureter, the pressures were 65.6 and 17.5 mm Hg, respectively; with the ureteroscope in the proximal ureter 79.2 and 24 mm Hg, and with the ureteroscope in the renal pelvis 94.4 and 40.6 mm Hg, respectively. All differences at each location were statistically significant (P<0.008). Compared with baseline, all pressures measured without the UAS were significantly greater, but only pressures recorded in the proximal ureter and renal pelvis after UAS insertion were significantly higher (P<0.03).
The irrigation pressures transmitted to the renal pelvis and subsequently to the parenchyma are significantly greater during routine URS without the use of the UAS. The access sheath is potentially protective against pyelovenous and pyelolymphatic backflow, with clinical implications for the ureteroscopic management of upper-tract transitional cell carcinoma, struvite stones, or calculi associated with urinary tract infection.
The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a ...prospective, randomized, multicenter trial.
A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures.
A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL.
This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.
Controversy exists regarding the need for ureteral stent insertion after routine ureteroscopic stone surgery. We designed a questionnaire to assess and better understand the practice patterns of ...urologists for stent applications.
A 26-question survey was distributed to 570 community and academic urologists. The answers were anonymously tabulated to determine the practice patterns for stent placement.
Of the 173 respondents, 97.7% performed ureteroscopic surgery, with the majority (77%) performing 1 to 10 procedures per month. Sixty-eight percent of urologists considered more than 70% of their ureteroscopic procedures "routine." Only 21% of urologists dilated the ureteral orifice more than 90% of the time. Those who dilated the ureteral orifice used a balloon (43%), ureteral access sheath (13.5%), or both (21%). The use of an access sheath did not change stenting practices for 75% of urologists. Patterns vary with regard to length of indwelling time, with 85% of urologists maintaining the stent for fewer than 7 days. Most urologists use either cystoscopy (42%) or pull-suture in clinic (37%) to remove stents. Patient tolerance is the most significant problem with stents reported by 97.6% of urologists. The respondents were divided into three experience-based groups: group 1, <2 years of experience; group 2, 2 to 10 years; and group 3, >10 years. Using Fisher's exact test, there were no statistically significant differences between the groups.
A wide variability exists among urologists in the practice patterns of stent insertion after routine ureteroscopic surgery. Most consider their procedures routine and are more likely to place stents after ureteral dilation despite growing evidence to the contrary. Knowledge of the varied practices may aid less experienced urologists in their decision to insert a stent after ureteroscopy.
To investigate the impact of statin medications on urinary stone formation in hyperlipidemic patients.
We searched outpatient military electronic health records from the Southwestern United States to ...identify adult patients with hyperlipidemia and urolithiasis. Military facilities serve active duty members, retirees, and their immediate family members. We created two predictor variables - with and without statin. The outcome variable was a diagnosis of urolithiasis.
The inception cohort included 57,232 subjects with hyperlipidemia and 1,904 subjects with nephrolithiasis. Patients taking statin medications had significantly less stone formation compared to patients not taking statin medications (3.1% vs. 3.7%, univariate OR = 0.83, 95% CI 0.76 - 0.91, p < 0.001). Statins patients were significantly older (59 vs. 45 years, p < 0.001), more likely to be female (38% vs. 34%, p < 0.001) and have co-morbidities (obesity, hypertension, diabetes, heart disease; all p < 0.001). Multivariate analysis indicated that statin medications had a protective effect against stone formation (OR = 0.51, 95% CI 0.46 - 0.57, p < 0.001), after adjusting for age, sex, and comorbidities. The risk of nephrolithiasis was not only additive for diabetes mellitus, hypertension, and obesity; more importantly it was attenuated with addition of statin use.
Statin medications are associated with reduced risk of urinary stones. This is the first study to demonstrate the impact of statins on nephrolithiasis. Further prospective studies are necessary to validate these findings that treatment of hyperlipidemia reduces stone risk formation.
BACKGROUND.
Given the limited data regarding the impact of obesity on treatment outcomes after external beam radiation therapy (EBRT) for the definitive treatment of prostate cancer, the authors ...sought to evaluate the effect of obesity as measured by body mass index (BMI) on biochemical disease recurrence (BCR) using the most current 2006 Radiation Therapy Oncology Group‐American Society for Therapeutic Radiation and Oncology (RTOG‐ASTRO) Phoenix consensus definition (prostate‐specific antigen PSA nadir + 2 ng/mL).
METHODS.
A retrospective cohort study identified men who underwent primary EBRT for localized prostate cancer between 1989 and 2003 using the Center for Prostate Disease Research (CPDR) Multi‐center National Database. BMI was calculated (in kg/m2) and the data were analyzed. Univariate and multivariate Cox proportional hazards regression analyses were used to determine whether BMI significantly predicted BCR.
RESULTS.
Of the 1868 eligible patients, 399 (21%) were obese. The median age of the patients and pretreatment PSA level were 70.2 years and 8.2 ng/mL, respectively. Of 1320 patients for whom data were available with which to calculate PSA recurrence (PSA nadir + 2 ng/mL), a total of 554 men (42.0%) experienced BCR. On univariate analysis, BMI was found to be an independent predictor of PSA recurrence (P = .02), as was race, pretreatment PSA level, EBRT dose, clinical T classification, Gleason score, PSA nadir, and the use of androgen‐deprivation therapy (ADT). On multivariate analysis, BMI remained a significant predictor of BCR (P = .008).
CONCLUSIONS.
To the authors' knowledge, this is the first study to report the association between obesity and BCR after EBRT for localized prostate cancer as measured by the updated 2006 RTOG‐ASTRO definition. A higher BMI is associated with greater odds of BCR after undergoing definitive EBRT. Cancer 2007. Published 2007 by the American Cancer Society.
To the authors' knowledge, this is the first study to report the association between obesity and prostate‐specific antigen recurrence after radiation therapy for localized prostate cancer as measured by the updated 2006 Radiation Therapy Oncology Group‐American Society for Therapeutic Radiation and Oncology (RTOG‐ASTRO) Phoenix consensus definition. Higher body mass index is associated with greater odds of biochemical disease recurrence after definitive external beam radiation therapy.
Abstract Purpose The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower ...pole stones in a prospective, randomized, multicenter trial. Materials and Methods A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures. Results A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL. Conclusions This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.
Purpose Extrinsic ureteral obstruction can be a challenging entity for the urologist since half of the ureteral stents placed for malignant obstruction fail. We evaluated the resistance to radial ...compression of various stents. Materials and Methods Silhouette® 4.6Fr, 6Fr and 8Fr, Sof-Curl™ Tecoflex® 6Fr, Resonance® 6Fr, Polaris™ Ultra 6Fr and 7Fr, and Percuflex® 6Fr and 8Fr stents were tested. The force needed to compress the stent to 50% of its original external diameter was measured at 3 locations along the stent length, including proximal, middle and distal. Statistical analysis was performed. Results Statistically greater force was required to compress the Resonance and Silhouette stents compared to all others tested. These results were maintained at all 3 locations along the stent. Only the Polaris 6Fr stent differed in resistance to compression along the stent length. Conclusions The significantly higher forces required to compress the Resonance and Silhouette stents may translate into improved success in patients with malignant ureteral obstruction.
Of all patients who have vasectomies performed in the United States, upwards of 6% will pursue a vasectomy reversal. Currently, the gold-standard reversal procedure is a microscopic vasovasostomy ...utilizing either a one or two-layer vasal anastomosis. Unfortunately, most urologists do not perform these procedures as they require extensive training and experience in microsurgery. The objective of our study was to evaluate the feasibility and success rate of robot-assisted vasovasostomy performed at our institution. We completed a retrospective review of our experience with vasectomy reversal utilizing the da Vinci
®
Surgical System and a single layer vasal anastomosis. A successful reversal was defined as a return of sperm on semen analysis or light microscopy. Since 2009 we have completed 79 robotic vasectomy reversals, 60 of which utilized a single-layer vasal anastomosis. The average obstructive interval was 5.7 ± 2.2 years. Average operative time was 192 min. 42 patients returned for a post-operative semen evaluation at an average time of 4.3 months post-procedure revealing a success rate of 88% (37 out of 42). Post-operative semen parameters were significant for an average sperm density of 31.0 million/mL with an average motility of 29.1%. Robot-assisted vasovasostomy with a single layer anastomosis has overall success rates that are similar to that of reported microscopic vasovasostomy rates. Although more study is warranted with regard to cost, we feel as though our study demonstrates an alternative approach to vasectomy reversal that can be performed successfully by urologists trained in robotic surgery.
Purpose Living in a desert environment has been associated with a higher incidence of kidney stone formation, likely because of concentrated urine output, higher production of vitamin D and genetic ...predisposition. We determined the changes in urinary parameters after a group of United States Marines temporarily transitioned from a temperate environment to a desert environment. Materials and Methods A total of 50 Marines completed a questionnaire and performed 3, 24-hour urine collections before mobilization to the desert, after 30 days in the desert and 2 weeks after returning from the desert. Results Daily urine output decreased 68% to 0.52 L despite marked increased fluid intake (17 L per day). Total daily urinary excretion of calcium, uric acid, sodium, magnesium and potassium in the desert decreased by 70%, 41%, 53%, 22% and 36%, respectively. Urinary pH decreased from 6.1 to 5.6 while in the desert, and citrate and oxalate had minimal changes. After their return from the desert, apart from a decrease of 22% in oxalate, there were no statistically significant differences from baseline. While in the desert, relative supersaturation risks of uric acid and sodium urate were increased 153% and 56%, respectively. Brushite relative supersaturation decreased 24%. After their return there was no statistical difference from baseline. Conclusions Our findings suggest that the kidneys preserved water and electrolytes while the Marines were subjected to the desert environment. Despite this conservation, relative saturations indicate increased risk of stones in healthy men exposed to a desert environment with rapid resolution upon return.
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