Two-step minipercutaneous ureterolithotripsy under multimodal analgesia for complicated impacted calculi in proximal ureter.

OBJECTIVE: To suggest minipercutaneous ureterolithotripsy using the mininephroscope as an alternative process for impacted stones of the upper ureter because these stones can be challenging to treat and can produce severe symptoms. MATERIALS AND METHODS: We report our results of cases in which the percutaneous approach using 2-step minipercutaneous ureteroscopy with the mininephroscope was used to achieve relief from the stone, with minimal anesthesia risks. A total of 54 patients (33 men and 21 women) presented with impacted stones in the proximal ureter. The mean stone size was 16.2 mm (range 10-21). All patients were treated with 2-step minipercutaneous antegrade ureterolithotripsy under multimodal analgesia. RESULTS: The mean operative time was 49 minutes (range 40-110). Placement of the percutaneous drainage tube was quick and was performed with the patient under local anesthesia. The minipercutaneous session followed several days later, with the patient under multimodal anesthesia. The initial stone-free rate was 94%. The stone-free rate 2 months after the procedure was 100%. All procedures were well tolerated by the patients (group mean visual analog scale score 3.1 ± 0.7 standard deviation). No severe adverse events were noted. The mean hospital stay was 5.3 days (range 3-12). CONCLUSION: In selected emergency cases of impacted proximal ureteral stones, the approach of the initial insertion of a nephrostomy tube followed by a second session of antegrade ureterolithotripsy using the mininephroscope is a safe and effective alternative treatment, especially, because it can be accomplished with minimal anesthesia requirements.

Safety and outcome of percutaneous nephrolithotomy in the elderly: retrospective comparison to a younger patient group.

AIM: To evaluate whether the overall safety and efficacy profile of percutaneous surgery for urinary stone disease in older (>70 years) patients might influence the decision for the procedure in the elderly. MATERIALS AND METHODS: A large database was created from our patients (n = 1058) who underwent percutaneous surgery for stone disease between 1991 and 2003 in the Scottish Lithotriptor Centre, including clinical and operation details for each case. Only percutaneous nephrolithotomy cases with full details were studied (n = 779) and were grouped into two age groups: (1) between 17 and 69 years and (2) over 70 years. Statistical analysis evaluated differences in terms of operation-related adverse events, stone-free success rates, and clinical success rates (including stone-free cases and cases with residual fragments <4 mm). Further analysis was performed for the same endpoints after stratification of the patients by (1) previous stone procedures and (2) special clinical features. RESULTS: In the overall database, no statistically important differences were found between the two groups in terms of stone burden before surgery, adverse events rates, complete stone-free rates, and clinical success rates. However, a statistical trend toward higher clinical success rates in favor of the younger group was seen (P = 0.051). Stratification of our database according to previous stone disease procedures or special clinical or anatomic characteristics has only shown a statistically important difference for clinical success rates in favor of the older group without special features (P = 0.01). CONCLUSION: In experienced hands, age-related morbidity or age itself should not be a discouraging consideration when deciding on performing percutaneous nephrolithotomy, as the procedure is as equally feasible and safe in the elderly as in the younger patient population.

Ultrasound-guided transrectal placement of a drainage tube as therapeutic management of patients with prostatic abscess.

BACKGROUND AND PURPOSE: A novel approach for continuous drainage of prostatic abscesses is presented and discussed. PATIENTS AND METHODS: We present seven cases diagnosed with prostatic abscess during 2001-2007. The diagnosis was based on either clinical or transrectal ultrasound (TRUS) findings. All patients were initially treated as prostatitis cases by intravenous antibiotics, a1 blockers, and a suprapubic catheter. Those diagnosed with an abscess had a drainage tube placed transrectally under TRUS guidance, and it was left in place for 24-36 hours. RESULTS: Past medical history most often included previous urinary infection (n = 4), bladder outlet obstruction (n = 1), and diabetes mellitus (n = 4). In all patients, prostatic abscess was greater than 1.5 cm, and in two patients the abscess was multifocal. All abscesses were completely resolved by transrectal continuous drainage, and the average hospitalization period was 10 days. No patient required a second intervention. All patients received antibiotics for 1 month following the procedure. CONCLUSION: Although rare, prostatic abscess is a serious condition that needs quick diagnosis and treatment. In our experience, TRUS-guided transrectal placement of a drainage tube is a feasible and safe treatment alternative for prostatic abscess; it is also easy to perform and well tolerated by the patients.

Value of immediate anastomotic biopsy following biochemical failure after radical prostatectomy.

AIMS: To study the value, in diagnostic terms, of performing transrectal ultrasound (TRUS)-guided anastomotic biopsy immediately following the diagnosis of biochemical failure in patients treated by radical retropubic prostatectomy. METHODS: We report on 50 sessions of TRUS-guided biopsy obtained during post-radical retropubic prostatectomy follow-up, immediately after the diagnosis of biochemical failure. No patient had received either adjuvant or further treatment due to biochemical failure status prior to the biopsy session. In each case, tissue sampling involved cores taken by a standard protocol (random) as well as TRUS-guided biopsy to sonographically suspicious areas. Statistical analysis focused on identifying the statistical importance of various pre- and post-treatment variables in predicting biopsy outcome. RESULTS: 10/50 cases with local evidence of malignancy (1 case harboring both benign and malignant glands) were identified and in another 10/50 cases benign prostatic tissue was diagnosed. The remaining (30) cases have shown fibromuscular tissue only. Statistical analysis of various parameters has demonstrated a significant correlation between local evidence of cancer and the finding of sonographically remarkable areas. CONCLUSION: Performing TRUS-guided anastomotic biopsy close to the onset of biochemical failure can frequently identify but also may easily miss the suspected local presence of prostate tissue. We believe that, with minimal risks of morbidity, there is merit in exploring its possibilities to trace local prostatic tissue, since it may provide useful information for further treatment actions also in an earlier time.

Analgesia during extracorporeal shockwave lithotripsy: fentanyl citrate versus parecoxib sodium.

BACKGROUND AND PURPOSE: Shockwave-induced pain may become an important issue during extracorporeal shockwave lithotripsy (SWL), although the new generation of lithotriptors generally produces less pain than previous models. The aim of the study was to compare the analgesic effect of a cyclooxygenase-2-specific inhibitor (parecoxib sodium) with that of our standard method of analgesia (fentanyl citrate) in patients who needed pain relief when undergoing SWL. PATIENTS AND METHODS: Fifty-eight patients who were undergoing SWL for renal calculi were randomized to receive intravenously either fentanyl citrate (group A, n = 30) or parecoxib sodium (group B, n = 28) when they felt that their pain during the session became intolerable. Lithotripsy was recommenced 10 minutes after administration of analgesia. The severity of pain before and after administration of the analgesic regimens was evaluated using a five-level verbal scale. The effectiveness of each drug was evaluated with respect to degree of pain relief and ensuing tolerance of the procedure to completion, as well as the need for supplementary analgesia (half the standard dose of fentanyl citrate). RESULTS: The patients in the two groups were comparable with regard to age, sex, body mass index, and stone size. There was no statistically significant difference in the maximum energy level achieved as well as in the total number of shock waves given in the two groups. Administration of fentanyl citrate resulted in alleviation of pain and completion of SWL in 27 patients (90%), whereas parecoxib sodium was effective in five patients (17.8%) (P < 0.01). The remaining 23 patients in group B received supplementary analgesia, and 22 completed the lithotripsy session. CONCLUSIONS: Parecoxib sodium was not as effective as fentanyl citrate in alleviating pain during SWL. Its use, however, may lower the dose of opioid-based analgesia in this group of patients.

Percutaneous nephrostomy in patients with tumors of advanced stage: treatment dilemmas and impact on clinical course and quality of life.

OBJECTIVES: The purpose of this study was to evaluate the outcome, in respect to safety, survival, and quality of life (QoL), after performance of percutaneous nephrostomy in patients with obstructive nephropathy caused by various types of advanced malignancy. PATIENTS AND METHODS: A cohort of 270 patients with established nephropathy because of advanced pelvic or nonpelvic tumors was evaluated. A decision to obtain percutaneous access was made; primary stenting had either failed or was not feasible because of complicated anatomy. Patients were divided in equal groups by type of malignancy (54 patients each). In addition, each malignancy group was further divided in two equal subgroups by tumor burden (27 patients each). Correlations were made with respect to renal function outcome, overall survival after the procedure, and QoL differences both before and after the procedure. RESULTS: No serious complications, such as severe bleeding or sepsis, were experienced because of the procedure. Statistical analysis showed no significant differences in survival among patients with different types of cancer. Only patients with prostate (P < 0.0365) and colorectal (P < 0.0307) cancer with lower tumor burden had significantly longer survival when compared with patients with large tumor burden. Regarding QoL scores, only patients with prostate cancer in the subgroup with low tumor burden demonstrated a positive statistically significant difference (P < 0.001). CONCLUSIONS: Despite the fact that percutaneous nephrostomy has shown good safety characteristics and beneficial impact on renal function, only patients with specific cancers most likely to respond to ongoing palliative therapy or with cancers that progress slowly by nature may statistically benefit from the procedure. This questions the universal application of this procedure for all types and stages of advanced malignancy.

Sixteen years of experience with stone management in horseshoe kidneys.

INTRODUCTION: Horseshoe kidney is the commonest congenital renal fusion anomaly, and is often complicated by urolithiasis. We focus on our 16 years of experience with stone management in horseshoe kidneys. MATERIALS AND METHODS: We reviewed the progress of 44 patients treated between 1987 and 2002. Shock wave lithotripsy (SWL) was used in 25 patients; the average stone surface area was 91 (range 10-1,600) mm2 and average follow-up was 36.5 (range 1-91) months. 19 patients underwent percutaneous nephrolithotomy (PCNL); the average stone surface area was 197 (range 6-2,400) mm2. Follow-up data are available for 8 patients and the average follow-up was 42.3 (range 3-144) months. RESULTS: In the SWL group the 3-month stone-free rate (SFR) was only 31%. In the PCNL group the SFR was 75% on the postoperative day-1 KUB. Complications occurred in 9 patients. CONCLUSIONS: Stone management in horseshoe kidneys is challenging: PCNL produces a higher SFR with minimal major complications and failed access. PCNL thus appears to be the preferred management option in patients with urolithiasis in horseshoe kidneys.

Progression delay in men with mild symptoms of bladder outlet obstruction: a comparative study of phytotherapy and watchful waiting.

To determine the effect of phytotherapy (Serona repens) on the clinical progression in men with mild symptoms of bladder outlet obstruction (BOO). A total of 189 patients with mild symptoms of BOO, recruited from four different European clinics, were included in the analysis. Age, prostate specific antigen (PSA), international prostate symptom score (IPSS), quality of life (QOL), maximum urinary flow rate (Qmax) and total prostate and transitional zone volume were recorded. Clinical progression was defined as change from the mild-IPSS group into the moderate or severe group or the occurrence of urinary retention and need of surgery. Cumulative progression rate was 1, 7, 9 and 16% at 6, 12, 18 and 24 month, respectively, for the active group (Serona repens) as compared to 6, 13, 15 and 24% for the watchful waiting group. (P=0.03) significant improvements in the Qmax, IPSS and QOL were seen in the group receiving Serona repens. Serona repens significantly reduced the clinical progression rates in men with mild symptoms of BOO. It also led to improvements in urinary symptoms, QOL scores and urinary flow rates.

The Vienna nomogram: validation of a novel biopsy strategy defining the optimal number of cores based on patient age and total prostate volume.

PURPOSE: We conducted a trial in patients with prostate specific antigen (PSA) levels from 2 to 10 ng/ml to validate a newly developed nomogram that defines the optimal number of biopsy cores required for prostate cancer (PCa) detection based on patient age and total prostate volume (Vienna nomogram). MATERIALS AND METHODS: A total of 502 patients underwent transrectal ultrasound guided prostate biopsy using the Vienna nomogram. These results were compared with those of a previous group of 1,051 patients who had standard octant biopsies followed by systematic repeat biopsies after 6 to 8 weeks if the initial biopsy result was negative for PCa. RESULTS: The overall PCa detection rate using the Vienna nomogram was 36.7% compared with 22% on first and 10% on repeat biopsy in the control group. The PCa detection rate using the Vienna nomogram was superior (p=0.002) to the octant biopsy technique, and comparable to a combination of first and repeat biopsy in the control group. Multivariate analysis of the Vienna nomogram showed that only PSA and the number of cores were independent predictors of PCa detection (chi-square = 49, p <0.001). Total prostate volume, transition zone volume and age were not independent predictors of PCa detection. CONCLUSIONS: The Vienna nomogram offers an easy tool to select the optimal number of prostate biopsy cores based on patient age and total prostate volume in PSA range 2 to 10 ng/ml. Cancer detection is significantly improved (66.4%) compared to the control group. The bias factor of larger prostate volume is eliminated by using the Vienna nomogram. Moreover, the Vienna nomogram is advantageous not only in terms of the improved PCa detection rate but also economically makes systematic repeat biopsies unnecessary.

Longitudinal study of men with mild symptoms of bladder outlet obstruction treated with watchful waiting for four years.

OBJECTIVES: To determine the risk of clinical progressions in men with mild lower urinary tract symptoms of bladder outlet obstruction and identify the predictors for progression in this group of men. METHODS: A total of 397 men who presented to the urology clinics with mild symptoms of bladder outlet obstruction (International Prostate Symptom Score less than 8) were analyzed in this longitudinal study conducted during a 4-year period. They began with the watchful waiting protocol and were followed up every 3 months for 48 months. Age, International Prostate Symptom Score (IPSS), divided into obstructive symptom score and irritative symptom score, serum prostate-specific antigen level, total prostate volume, transitional zone volume, urinary flow rates, and postvoid residual urine volume were documented. RESULTS: The cumulative incidence of clinical progression, defined as worsening of the IPSS with migration to the moderate symptom group (IPSS 8 to 18) or severe symptom group (IPSS 19 to 35) and an increase in IPSS of more than 2 points, was 6%, 13%, 15%, 24%, 28%, and 31% at 6, 12, 18, 24, 36, and 48 months, respectively. Nineteen patients (4.9%) developed acute urinary retention within the 48-month follow-up period. Of these 19 patients, only 2 (0.6%) required transurethral resection of the prostate. The variables of importance for disease progression in the artificial neural network analysis were, in order of statistical significance, prostate-specific antigen level, obstructive symptom score, and transitional zone volume. CONCLUSIONS: The risk for men with mild symptoms of bladder outlet obstruction to progress clinically and develop complications such as acute retention of urine is moderate. Prostate-specific antigen, obstructive symptom score, and transitional zone volume were identified as important risk factors.

Management of ureteric stones.

The contemporary management of ureteric stones is reviewed and evidence based recommendations about treatment are made. Stones measuring less than 4mm in diameter have a high chance of spontaneous passage and the main debate for optimum treatment of larger stones centres around the choice of shock wave lithotripsy or endoscopic management combined with laser fragmentation. Treatment recommendations should be based on patient preference, published evidence, local audit (surgeon expertise and availability of equipment) and cost. Artificial Neural Networks could become a useful tool for prediction of treatment outcome for ureteric stones, and further research is needed to clarify this potential. ESWL is less effective than ureteroscopy but it may prevent the need for more invasive treatment in a substantial proportion of patients. It should only be considered as initial treatment in patients with stones less than 10mm in size. The routine use of stents should be avoided as both fragmentation and stone free rates are noticeably lower. For larger stones, initial laser ureteroscopy serves better both for proximal or distal calculi and is more cost-efficient. Provided that no contraindications for general anaesthesia exist, laser ureterolithotripsy should be regarded as an excellent first line treatment modality for ureteric stone especially in greater stone burden. In the best hands, the outcome for endoscopic management of ureteric stone in all sites is better than ESWL and is cheaper, although equipment, expertise and experience are all required to achieve this superior outcome.

An artificial neural network to predict the outcome of repeat prostate biopsies.

OBJECTIVES: To develop an advanced artificial neural network (ANN) to predict the presence of prostate cancer (PCa) and to predict the outcome of repeat prostate biopsies. The predictive accuracy was compared with the accuracy obtained using standard cutoffs for the free/total (f/t) prostate-specific antigen (PSA) ratio, PSA density (PSAD), PSA density of the transition zone (PSA-TZ), and the total and transition zone volumes. Clinical and biochemical diagnostic tests have been shown to improve PCa detection. When these tests are combined using an ANN, significant increases in specificity at high sensitivity are observed. METHODS: The Vienna-based multicenter European referral database for early PCa detection of 820 men with a PSA level between 4 and 10 ng/mL was used. The presence of PCa was determined using transrectal ultrasound-guided octant needle repeat biopsy. Variables in the database consisted of age, PSA, f/t PSA ratio, digital rectal examination findings, PSA velocity, and the transrectal ultrasound-guided variables of prostate volume, transition zone volume, PSAD, and PSA-TZ. The ANN used in the analysis was an advanced multilayer perceptron selected for accuracy by a genetic algorithm. RESULTS: The repeat biopsy PCa detection rate was 10% (n = 83). At 95% sensitivity, the specificity for ANN was 68% compared with 54%, 33.5%, 21.4%, 14.7%, and 8.3% for multivariate logistic regression analysis, f/t PSA ratio, PSA-TZ, PSAD, and total PSA, respectively. The ANN reduced unnecessary repeat biopsies by 68% in this study. The area under the curve was 83% for the ANN versus 79%, 74.5%, 69.1%, 61.8%, and 60.5% for multivariate analysis, f/t PSA ratio, PSA-TZ, PSAD, and total PSA, respectively. CONCLUSIONS: The current ANN found a strong pattern predictive of PCa in patients with a negative initial biopsy. By combining the individual clinical and biochemical markers into the ANN, 68% specificity at 95% sensitivity was achieved. The ANN allows more accurate and individual counseling of patients with a negative initial biopsy.

Artificial neural networks for decision-making in urologic oncology.

The authors are presenting a thorough introduction in Artificial Neural Networks (ANNs) and their contribution to modern Urologic Oncology. The article covers a description of Artificial Neural Network methodology and points out the differences of Artificial Intelligence to traditional statistic models in terms of serving patients and clinicians, in a different way than current statistical analysis. Since Artificial Intelligence is not yet fully understood by many practicing clinicians, the authors have reviewed a careful selection of articles in order to explore the clinical benefit of Artificial Intelligence applications in modern Urology questions and decision-making. The data are from real patients and reflect attempts to achieve more accurate diagnosis and prognosis, especially in prostate cancer that stands as a good example of difficult decision-making in everyday practice. Experience from current use of Artificial Intelligence is also being discussed, and the authors address future developments as well as potential problems such as medical record quality, precautions in using ANNs or resistance to system use, in an attempt to point out future demands and the need for common standards. The authors conclude that both methods should continue to be used in a complementary manner. ANNs still do not prove always better as to replace standard statistical analysis as the method of choice in interpreting medical data.

Artificial neural networks for decision-making in urologic oncology.

Artificial neural networks (ANNs) are computational methodologies that perform multifactorial analyses, inspired by networks of biological neurons. Like neural networks, ANNs contain layers of simple points (nodes) of data that interract through carefully weighted connection lines. ANNs are "trained" and balanced by having been previously fed data, which the ANN uses as the means for adjusting its interconnections. Studies have shown that novel and highly accurate ANNs significantly enhance the ability to detect prostate cancer early (high sensitivity) while avoiding a greater number of unnecessary tissue samplings (high specificity). The use of ANNs in prostate cancer is ideal because of 1) multiple predicting factors that influence outcome; 2) the desire to offer individual consulting based on various tests; 3) the fact that prior logistic regression analysis results have had serious limitations in application; and 4) the need for an up-to-date tool that can apply easily to everyone. An ANN should be seen as an important tool that is complementary to the physician's personal knowledge and judgment in making decisions.