Comparison of patients undergoing laser vaporization of the prostate versus TURP using the ACS-NSQIP database.

BACKGROUND: The introduction of laser therapies for the management of bladder outlet obstruction in men with BPH has challenged the gold standard treatment, TURP. We sought to compare the changing clinical characteristics of patients undergoing TURP and laser vaporization of the prostate (LVP) over time. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for men who underwent TURP and LVP from 2007 to 2012. Patient demographics, clinical and intraoperative characteristics and 30-day postoperative outcomes were analyzed. RESULTS: In all, 12,645 men met inclusion criteria, of whom 65% underwent TURP and 35% underwent LVP. Overall, men undergoing TURP were more likely to be scheduled as an emergency (3% vs. 1%, P<0.001), have shorter operative times (53 vs. 56 min, P<0.001), longer hospital stays (2.4 vs 1.0 days, P<0.001), more frequent blood transfusions (2.1% vs. 0.6%, P<0.001) and more postoperative complications including: pneumonia (0.5% vs. 0.3%, P=0.02), septic shock (0.3% vs. 0.1%, P=0.045), and reoperation within 30 days (2.2% vs. 1.4%, P=0.06). However, between 2007 and 2012, there was a significant trend for men undergoing TURP to have increased functional independence (93-96%, P<0.01) and American Society of Anesthesiology (ASA) Physical Class I categorization (0.6-5.1%, P<0.001). In contrast, over the same time period, there was a trend for men undergoing LVP to be significantly older (71-73 years, P<0.001) and have an increased hospital stay (0.50 days to 1.30 days, P=0.03). CONCLUSIONS: Statistically significant differences in clinical characteristics of patients undergoing TURP and LVP have historically existed. However, since 2007, the characteristics of patients undergoing LVP and TURP have changed significantly. Further studies are required to compare these patient characteristics with specific urologic variables and to evaluate clinically significant changes in these cohorts.

Long-term results of antegrade endoureterotomy using the holmium laser in patients with ureterointestinal strictures.

OBJECTIVES: To investigate the effectiveness and morbidity of percutaneous laser endoureterotomy in the management of ureterointestinal anastomotic strictures after radical cystectomy and urinary diversion. METHODS: Between May 1997 and August 2000, 19 percutaneous endoureterotomy incisions, including 3 repeated incisions, were performed on 15 patients with a mean age of 61 years (range 41 to 80) to treat ureterointestinal strictures. A total of 16 renal units were treated (9 left, 7 right), including one bilateral procedure. All procedures were performed using a 200-micrometer holmium laser fiber in antegrade fashion with a 7.5F flexible ureteroscope. A nephroureteral stent was left in place for 4 to 6 weeks postoperatively. Success was defined as radiologic improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes. RESULTS: With a median follow-up of 20.5 months (range 9 to 41), the overall success rate was 57% (8 of 14 renal units). Two patients were lost to follow-up. The mean operative time was 91 minutes, and no perioperative complications occurred. Three patients required repeated endoureterotomies, with two requiring open reimplantation. Overall, the endoureterotomy failed in 6 patients in the series, with five of the six failures involving left-sided strictures. CONCLUSIONS: Percutaneous endoureterotomy is an effective, minimally invasive treatment option for patients with ureterointestinal strictures after urinary diversion. Better visualization and a more precise incision may make the holmium laser a safer cutting modality than alternative methods in patients with ureteroenteric strictures. Patients with left-sided ureterointestinal strictures should be cautioned that endourologic management might have a lower success rate.

Randomized, double-blind, placebo-controlled trial of saw palmetto in men with lower urinary tract symptoms.

OBJECTIVES: To assess the effects of saw palmetto on urinary symptoms, sexual function, and urinary flow rate in men with lower urinary tract symptoms using a double-blind, randomized, placebo-controlled trial. METHODS: The eligible patients were 45 years of age or older and had an International Prostate Symptom Score of 8 or greater. After a 1-month placebo run-in period, 85 men were randomized to receive saw palmetto or placebo for 6 months. Patients were evaluated using the International Prostate Symptom Score, a sexual function questionnaire, and by measurement of the urinary flow rate. RESULTS: The mean symptom score decreased from 16.7 to 12.3 in the saw palmetto group compared with 15.8 to 13.6 in the placebo group (P = 0.038). The quality-of-life score improved to a greater degree in the saw palmetto group, but this difference was not statistically significant. No change occurred in the sexual function questionnaire results in either group. The peak flow rate increased by 1.0 mL/s and 1.4 mL/s in the saw palmetto and placebo groups, respectively (P = 0.73). CONCLUSIONS: Saw palmetto led to a statistically significant improvement in urinary symptoms in men with lower urinary tract symptoms compared with placebo. Saw palmetto had no measurable effect on the urinary flow rates. The mechanism by which saw palmetto improves urinary symptoms remains unknown.

High-grade prostatic intraepithelial neoplasia with adjacent atypia is associated with a higher incidence of cancer on subsequent needle biopsy than high-grade prostatic intraepithelial neoplasia alone.

OBJECTIVES: High-grade prostatic intraepithelial neoplasia (HGPIN) is often considered a premalignant lesion of the prostate. Its incidence ranges from 0.7% to 20% in all prostate biopsies, and patients with HGPIN on initial biopsy are reportedly found to have a higher risk of cancer on subsequent biopsy. The purpose of our study was to determine the incidence of HGPIN in our patients who underwent prostate biopsy and to determine whether a further pathologic subclassification of HGPIN between HGPIN alone and HGPIN with adjacent atypical glands has any prognostic value in predicting the rate of prostate cancer on subsequent prostate biopsy. METHODS: A total of 485 patients who underwent prostate biopsy between January 1998 and October 1999 were included in the study. Each set of slides was reviewed by a single urologic pathologist to determine the presence of HGPIN alone or HGPIN with adjacent atypical glands. If any HGPIN was identified, a repeat biopsy was performed, and the presence of cancer was recorded. RESULTS: The overall incidence of HGPIN alone and HGPIN with adjacent atypical glands on initial biopsy was 33 (6.8%) of 485. Of these 33 patients, 21 (64%) had HGPIN alone and 12 (36%) had HGPIN with adjacent atypical glands. Three (14%) of 21 patients with HGPIN alone were found to have cancer on subsequent biopsy compared to 9 (75%) of 12 patients with HGPIN with adjacent atypia on initial biopsy. This difference is statistically significant (P <0.005). CONCLUSIONS: The incidence of HGPIN alone in our experience is 4.3% (21 of 485). Patients with HGPIN with adjacent atypical glands suspicious for cancer have a significantly higher incidence of cancer on subsequent biopsy than patients with HGPIN alone.

Dual stent placement for the treatment of a persistent urine leak after partial nephrectomy.

Persistent urine leak is a known complication after partial nephrectomy. In the present case, a partial nephrectomy was performed to remove a large, centrally located, renal mass in an elderly man with a solitary functioning kidney. A persistent urine leak refractory to single stent drainage was successfully treated after two stents were placed in the ipsilateral renal unit such that the upper and lower calices were drained by separate stents.

Practice patterns in the treatment of female urinary incontinence: a postal and internet survey.

OBJECTIVES: To survey American urologists to assess practice patterns in treating female incontinence. Advances in the treatment of female incontinence have changed the way urologists practice. METHODS: Postal and e-mail surveys were sent to 2502 members of the American Urological Association. RESULTS: From the postal group (n = 1000), 419 (42%) responses were obtained; from the e-mail group (n = 1502), 160 (11%) responses were obtained. For types I, II, and III stress urinary incontinence (SUI), 239 (44%) of 546, 388 (68%) of 570, and 512 (94%) of 547 urologists, respectively, recommended a sling procedure. For type I SUI, 75 (53%) of the 143 respondents in practice for less than 10 years recommended a sling procedure. The sling was recommended by 62 (35%) of the 176 respondents in practice for longer than 20 years (P <0.001). Most urologists (75%, 358 of 480) referred patients with significant vaginal prolapse to a gynecologist; however, urologists in full-time academic practice were more likely to offer surgical treatment (56%, 29 of 52). Most urologists recommended medical treatment for urge incontinence (94%, 461 of 491), and the medications most commonly selected were tolterodine (41%, 202 of 491), oxybutynin (26%, 129 of 491), and extended-release oxybutynin (25%, 125 of 491). CONCLUSIONS: Overall, a sling procedure was the most commonly recommended surgical procedure for all types of SUI. Most urologists referred patients with significant vaginal prolapse to a gynecologist. For type I SUI, older urologists were more likely than younger urologists to perform needle bladder neck suspension.

Comparative viewing modalities for CT cystography.

BACKGROUND: To define the speed and accuracy of two different reconstructive techniques using computed tomography (CT) cystography for the detection and measurement of urinary bladder masses and determine the overall ease of use. METHODS: Ten patients scheduled for cystoscopy for the evaluation of hematuria or bladder masses were studied by means of thin-section CT of the air-distended bladder. Two techniques were employed by two radiologists to blindly interpret the data: conventional two-dimensional data with interactive three-dimensional problem solving (2D3DPS) and surface-shaded display (SSD) three-dimensional images. The results were compared with the data from cystoscopy. RESULTS: Twenty-two (100%) of 22 masses detected on cystoscopy were visualized using the reconstructive techniques. Both modalities were shown to have high accuracy, but only the 2D3DPS had a sensitivity and specificity of 100% for both observers at the patient-level diagnosis. The sensitivities for detecting individual masses for the two observers were 100% and 64% for 2D3DPS and 64% and 70% for SSD. CONCLUSION: Both methods used to display the CT data had a high sensitivity and specificity for masses, but only the 2D3DPS had a sensitivity and specificity of 100% at the patient-level diagnosis, thus making it a feasible imaging modality for cystography. It was also preferred overall for ease of use, high accuracy, and relative low cost.

Results of treatment with tamsulosin in men with acute urinary retention.

PURPOSE: The aim of this study was to prospectively assess the outcome in men treated with temporary catheter drainage and tamsulosin after an episode of acute urinary retention (AUR). MATERIALS AND METHODS: Thirty-three consecutive men with AUR were treated with tamsulosin 0.4 mg daily for at least 4 days before a trial of voiding. Those men who were able to void adequately continued taking tamsulosin and were evaluated at 2-week and 3-month follow-up. After 3 months, additional follow-up was obtained at regular intervals as determined by the treating physician. RESULTS: Median follow-up was 6.5 months. Mean urine volume at the time of initial bladder drainage was 790 mL. Eighty-eight percent (29/33) of men were able to void initially. Transurethral prostatectomy or intermittent catheterization were necessary in 9 (27%) of 33 patients during the follow-up period. A poor quality-of-life score on the initial International Prostate Symptom Score (p = .038) and a high postvoid residual volume 2 weeks after catheter removal (p = .013) correlated with failure of medical therapy. Patients with AUR after nonurologic surgery had a significantly better outcome than those with AUR that did not occur postoperatively. Mean symptom score, quality-of-life score, and postvoid residual urine volume were 12.9, 2.7, and 111 mL, respectively, at 2-week follow-up and were 11.9, 2.8, and 61.7 mL, respectively, at 3-month follow-up. Mean peak urinary flow rate at 3 months was 7.7 mL/s. CONCLUSIONS: Tamsulosin appears to be helpful in the management of men with AUR. The majority of men were able to avoid surgery after temporary catheter drainage.

Should laparoscopy be the standard approach used for pelvic lymph node dissection?

Involvement of the pelvic lymph nodes in patients with prostate cancer worsens the overall prognosis of this common disease entity. Prior radiographic staging techniques, including fine-needle aspiration, are limited by a poor sensitivity and are not reliable. The gold standard for the evaluation of pelvic lymph nodes in men with prostate cancer involves performing a lymphadenectomy. Historically, this procedure was performed using an open surgical technique. Unfortunately, this invasive procedure is associated with significant morbidity. In response, modern surgical technology has provided newer, less invasive techniques, including laparoscopic pelvic lymphadenectomy (LPLND). Improved detection of localized prostate cancer through the institution of screening protocols and early detection programs has decreased the number of patients presenting with lymph node involvement. Various clinical indicators, including prostate-specific antigen, grade, and stage, have been used to improve the selection of "high-risk" patients that are appropriate candidates for pelvic lymph node dissection. The technique of LPLND is a valid option in the armamentarium for staging of prostate cancer. The laparoscopic approach provides the same staging accuracy as the open surgical technique and is superior with respect to morbidity. LPLND is limited to patients who present with a high risk of advanced prostate cancer. In addition, the urologist must accept the additional training, financial expense, and "learning curve" associated with this technique.

Use of new technology in endourology and laparoscopy by american urologists: internet and postal survey.

OBJECTIVES: To assess the use of new technology by American urologists. METHODS: Using the American Urological Association directory, surveys were sent via the U.S. postal service to 1000 randomly selected American urologists and 3065 urologists who had an Internet address listed in the directory. RESULTS: Responses were received from 601 urologists (415 postal, 186 Internet). Overall, 81% of survey respondents reported performing fewer or the same number of percutaneous procedures as compared with 3 to 4 years ago and 84% reported carrying out more or the same number of ureteroscopic procedures in the treatment of patients with stone disease. Open dismembered pyeloplasty (43%) and Acucise endopyelotomy (42%) were most frequently reported as the preferred treatment for adult patients with symptomatic ureteropelvic junction obstruction. Although 60% of respondents reported that they have taken a laparoscopy course, 67% currently do not perform any laparoscopy in their practice. In addition, only 7% of urologists stated that laparoscopy comprises more than 5% of their practice. When stratified by the number of years in practice, those in practice less than 10 years were more likely than those in practice 10 to 20 years and those in practice longer than 20 years to have performed an endopyelotomy (77%, 60%, and 48%, respectively, P <0.001) and to be currently performing laparoscopy (49%, 36%, and 18%, respectively, P <0.001). CONCLUSIONS: Compared with 3 to 4 years ago, American urologists are performing more ureteroscopy and fewer percutaneous stone procedures. Although most urologists have taken laparoscopy courses, this modality has not been widely incorporated into their practices at present.

Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy.

OBJECTIVES: To determine whether preoperative biofeedback training improves urinary continence overall or the rate of return of continence in men undergoing radical prostatectomy. METHODS: One hundred men scheduled to undergo radical prostatectomy were randomized to receive graded pelvic muscle exercise training with biofeedback 2 to 4 weeks before surgery or to a control group performing pelvic muscle exercises without biofeedback. The biofeedback group was instructed to continue exercises four times per day until surgery and to resume exercises when the urethral catheter was removed following surgery. The control group received written and brief verbal instructions in pelvic muscle exercises before surgery and again after catheter removal. Urinary continence was assessed by personal or phone interviews. RESULTS: Six months following surgery, the continence rates, as defined by the use of one pad or less per day, were 94% (44 of 47) and 96% (48 of 50) in the biofeedback and control groups, respectively (P = 0.596). Also, the rate of return as determined at time points 1, 2, 3, and 4 months after surgery was not significantly different between the two groups. CONCLUSIONS: Preoperative biofeedback training did not improve the outcome of pelvic muscle exercises on overall continence or the rate of return of urinary control in men undergoing radical prostatectomy.

Role of transurethral biopsy sampling of the prostate to diagnose prostate cancer in men undergoing surgical intervention for benign prostatic hyperplasia.

PURPOSE: Newer minimally invasive surgical procedures are being used to treat men with significant benign prostatic hyperplasia (BPH). These modalities do not allow retrieval of prostate tissue for histologic review. The goal of our study was to assess the value of transurethral biopsies in detecting prostate cancer in men who would undergo surgical intervention for BPH. MATERIALS AND METHODS: Between September 1997 and January 1999, 422 men undergoing transurethral resection of the prostate (TURP) had transurethral biopsies obtained before completing the TURP. Pathology reports as well as prostate-specific antigen (PSA) results were reviewed and analyzed to determine when cancer was present. RESULTS: Pathological examination revealed that cancer was found in 53 men (12.5%). The transurethral biopsies detected cancer in 32 of 53 (60.4%). No cancers were found in the transurethral biopsy specimen only. Of the 21 cancers missed by transurethral biopsy, 7 were stage T1b. PSA level >10 ng/mL increased the likelihood of finding cancer. CONCLUSIONS: Transurethral biopsy sampling is unreliable for detecting prostate cancer in men with clinically significant BPH. Significant cancers are missed if transurethral biopsies are used to determine the presence of carcinoma before minimally invasive surgical therapy for BPH.

Management of entrapped ureteral stone baskets.

Entrapped stone baskets can occur and can lead to significant ureteral injury and long-term morbidity. We describe two patients in whom semirigid ureteroscopy was used to facilitate safe removal of impacted baskets from the ureter.

Internet and postal survey of endourologic practice patterns among American urologists.

PURPOSE: We determine endourological practice patterns among American urologists for the management of distal ureteral calculi, ureteropelvic junction obstruction, staghorn calculi and the use of ureteral stents with extracorporeal shock wave lithotripsy (ESWLdagger). MATERIALS AND METHODS: Surveys were mailed by the United States postal service to 1,000 American urologists selected randomly from the American Urological Association membership roster. The same survey was sent via the Internet to 3,065 American urologists with an electronic mail address listed in the roster. RESULTS: Responses were received from 1,029 urologists (postal 601, Internet 428). Ureteroscopy was the preferred treatment for all distal ureteral calculi less than or equal to 10 mm. Acucisedouble dagger endopyelotomy was the most frequently selected therapy for adults with ureteropelvic junction obstruction (50.3%, 514 of 1,022). Open pyeloplasty was recommended by a significantly greater percentage of urologists in practice longer than 15 years compared with the remaining survey respondents (166 of 485, 34.2% versus 92 of 427, 21.5%). For patients with renal pelvic stones 10, 15 or 20 mm. who are treated with ESWL routine stent placement was preferred by 25.3% (259 of 1,022), 57.1% (584 of 1,022) and 87.1% (888 of 1, 019) of urologists, respectively. Percutaneous nephrolithotomy was preferred for patients with staghorn calculi by 80.5% (828 of 1,028) of survey respondents. CONCLUSIONS: Most urologists follow the American Urological Association practice guidelines for patients with distal ureteral calculi and staghorn stones. There is a significant difference of opinion regarding the use of stents with ESWL. No clear consensus has been reached concerning the management of adults with ureteropelvic junction obstruction. These data may be useful in designing physician education programs and/or future investigations to help define standard treatment practices for urological diseases.

Retrograde ureteroscopic incision for the treatment of nonureteroenteric ureteral strictures.

A variety of methods are available for the management of patients with ureteral strictures. Ureteroscopic, retrograde incision using the holmium laser was performed on an outpatient basis or with hospitalization for <24 hours in three patients with strictures of varying etiologies. With follow-up of 4 to 12 months, all patients have remained asymptomatic without radiographic evidence of recurrent strictures. Retrograde ureteroscopic incision is an effective, minimally invasive option for patients with benign ureteral strictures.

Retrograde ureteroscopic endopyelotomy for the treatment of primary and secondary ureteropelvic junction obstruction in children.

The use of endopyelotomy in children with ureteropelvic junction (UPJ) obstruction remains controversial. Although most investigators reported good results with percutaneous or retrograde balloon cautery incision, there are distinct advantages associated with a ureteroscopic approach. Three male children, ages 11, 12 and 17 years, underwent ureteroscopic endopyelotomy for treatment of UPJ obstruction (one primary and two secondary). The procedures were performed using 6F to 8.5F semirigid instruments and the holmium laser. All three patients underwent endopyelotomy without complication. The mean operative time was 80 minutes. Two patients were discharged home the day of the procedure, and the third patient was hospitalized for less than 24 hours postoperatively. With follow-up of 6 to 11 months, two patients are asymptomatic, with no radiographic evidence of obstruction. The 12-year-old boy had continued obstruction following endopyelotomy. At the time of open pyeloplasty, a large crossing vessel was noted, which appeared to be the source of obstruction. Ureteroscopic endopyelotomy can be performed with minimal morbidity and hospitalization in children. Further clinical experience is needed to assess the relative efficacy of this procedure in comparison with other forms of endopyelotomy in children.

Transdermal estrogen in the treatment of hot flushes in men with prostate cancer.

OBJECTIVES: To assess the effectiveness and tolerability of transdermal estrogen in men with hot flushes after hormonal therapy for prostate cancer. METHODS: Twelve men with moderate to severe hot flushes were randomized to receive either low-dose (0.05 mg) or high-dose (0.10 mg) estrogen patches applied twice weekly for 4 weeks. After a 4-week washout period in which no treatment was given, each patient received the alternative dose for 4 weeks. Treatment response was assessed by daily logs and questionnaires completed every 4 weeks that included a visual analog assessment. Serum luteinizing hormone, follicle-stimulating hormone, testosterone, and estradiol levels were also measured every 4 weeks during the study. RESULTS: There was a significant reduction in the overall severity of the hot flushes seen in patients with both the low and high-dose estrogen patch. A significant reduction in the daily frequency of the hot flushes was seen with the high-dose patch only. Overall, 10 (83%) of 12 men reported either mild, moderate, or major improvement in symptoms with either the low or high-dose patch. Mild, painless breast swelling or nipple tenderness was noted in 2 (17%) and 5 (42%) of 12 men treated with the low and high-dose estrogen patch, respectively. FSH levels decreased significantly with both the low and high-dose patch. Estradiol levels increased from 12.1 to 16.4 pg/mL and 26.9 pg/mL with the low and high-dose patch, respectively. There was no significant change in serum testosterone or luteinizing hormone levels. CONCLUSIONS: Transdermal estrogen appears to be a promising, well-tolerated therapy for men with hot flushes after endocrine treatment for prostate cancer. Further study in larger groups of patients is necessary to assess the relative effectiveness and morbidity of this treatment.

Use of ureteroscopy and holmium:yttrium-aluminum-garnet laser in the treatment of an infundibular stenosis.

An infundibular stenosis is defined by a dilated calyx draining through a narrowed infundibulum into a nondistended renal pelvis. We describe the use of ureteroscopy and the holmium:yttrium-aluminum-garnet (YAG) laser to successfully treat an infundibular stenosis in a 27-year-old woman who presented with left flank pain. The holmium:YAG laser is well suited for this application. It can be applied with precise control of the direction and depth of the cut. The retrograde approach avoids the morbidity of a percutaneous nephrostomy and is well suited for treating an anterior infundibular stenosis.

Double-blind randomized comparison of single-dose ciprofloxacin versus intravenous cefazolin in patients undergoing outpatient endourologic surgery.

OBJECTIVES: To compare the efficacy of single-dose oral ciprofloxacin with intravenous cefazolin as a prophylactic agent in patients undergoing outpatient endourologic surgery. METHODS: One hundred patients were enrolled in a double-blind, randomized study to receive either ciprofloxacin (500 mg) or cefazolin (1 g) before surgery. A postoperative clinical evaluation and urine cultures were performed 5 to 10 days after surgery. Patients undergoing ureteral stent insertion or exchange, ureteroscopy, bladder biopsy, retrograde pyelography, collagen injection, and internal urethrotomy were included. RESULTS: Postoperative urinary tract infection occurred in 7 (9.1%) of 77 patients, including 3 (8.1%) of 37 and 4 (10.0%) of 40 of those who received ciprofloxacin and cefazolin, respectively (P = 0.77). There were no episodes of sepsis, and no patient with infection required hospitalization. The total cost associated with the administration of prophylactic antibiotics in the study population was $3657 less in those 50 patients who received ciprofloxacin than in the 50 patients who received cefazolin. CONCLUSIONS: A single oral dose of ciprofloxacin in patients undergoing outpatient endourologic surgery was equally effective as cefazolin in preventing postoperative urinary tract infection, but was associated with markedly lower overall costs.