Prostate cancer screening practices amongst physicians in the North Simcoe Muskoka Local Health Integration Network.

INTRODUCTION: The prostate-specific antigen (PSA) screening test is controversial and can result in both over-diagnosis and over-treatment. Recently, the Canadian Task Force on Preventive Health Care (CTFPHC) has recommended against routine screening for prostate cancer. We sought to determine how the CTFPHC has impacted the practice patterns among family physicians in the North Simcoe Muskoka (NSM) Local Health Integration Network (LHIN). MATERIALS AND METHODS: We surveyed all 439 family physicians within the NSM LHIN as well as 21 residents of the Family Medical Teaching Unit. Surveys were distributed by either mail or fax. Questions covered three sections: 1) demographics, 2) screening practice, and 3) perceptions of screening efficacy. RESULTS: The overall survey response rate was 33.3%. In all, 39.5% of physicians felt that prostate cancer screening did not provide a survival benefit, and 13.1% did not offer PSA screening. These beliefs were more likely to be held by younger physicians (age < 45), and those with < 10 years of practice (p < 0.05). Interestingly, female physicians were less likely to believe that PSA screening provided a survival benefit (p ≤ 0.01); however, no gender bias for PSA screening practices was observed (p = 0.73). Of the physicians who agreed with CTFPHC's recommendation (31.8%), 6.0% do not offer PSA screening because of the recommendation. The CTFPHC recommendation had no impact on the age at which physicians begin or stop offering PSA screening (p > 0.05). CONCLUSION: Despite the CTFPHC recommendations, prostate cancer screening remains controversial. Practice patterns amongst general practitioners in the NSM LHIN vary considerably, but seem to have been minimally impacted.

A randomized, double-blinded, placebo-controlled trial of intercostal nerve block after percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: The optimal method of pain control after percutaneous nephrolithotomy (PCNL) remains controversial. We sought to determine whether intercostal nerve block with bupivicaine provided superior pain control, when compared with placebo, with a lower need for narcotics and improved health-related quality of life (HRQL) in the immediate postoperative period. PATIENTS AND METHODS: Sixty-three patients were randomized to receive intercostal blockade with either 20 mL of 0.5% bupivacaine with epinephrine or 20 mL physiologic saline. All patients received intravenous narcotic patient-controlled analgesia (PCA) postoperatively. Data were collected on stone parameters, demographics, analgesic usage, length of stay, and HRQL as assessed by the Postoperative Recovery Scale. RESULTS: The mean age was 47.7±1.2 years; mean body mass index was 28.0±5.0 kg/m(2); mean stone diameter was 29.2±15.8 mm. Within the first 3 to 6 hours after surgery, there was a significant reduction in narcotic use for the group receiving intercostal nerve blockade with bupivacaine compared with placebo. At 3 hours, narcotic use was 2.4±3.1 mg vs 4.3±3.8 mg morphine equivalents (P=0.034), and within 6 hours of surgery, narcotic use was 5.9±6.1 mg vs 8.8±7.4 mg (P=0.096). Durable improvement in HRQL was also observed in patients receiving intercostal nerve blockade with bupivacaine compared with placebo (P=0.034). No complications were attributable to the intercostal nerve blocks in either group. CONCLUSIONS: Intercostal blockade with bupivacaine significantly improves both pain control and HRQL in the early postoperative period. The effectiveness of bupivacaine disappears within 6 hours of surgery, after which narcotic use becomes indistinguishable. Intercostal nerve blockade is an easy, safe, and inexpensive method that can be used to optimize pain control after PCNL.

A clinical nomogram to predict the successful shock wave lithotripsy of renal and ureteral calculi.

PURPOSE: Although shock wave lithotripsy is dependent on patient and stone related factors, there are few reliable algorithms predictive of its success. In this study we develop a comprehensive nomogram to predict renal and ureteral stone shock wave lithotripsy outcomes. MATERIALS AND METHODS: During a 5-year period data from patients treated at our lithotripsy unit were reviewed. Analysis was restricted to patients with a solitary renal or ureteral calculus 20 mm or less. Demographic, stone, patient, treatment and 3-month followup data were collected from a prospective database. All patients were treated using the Philips Lithotron® lithotripter. RESULTS: A total of 422 patients (69.7% male) were analyzed. Mean stone size was 52.3±39.3 mm2 for ureteral stones and 78.9±77.3 mm2 for renal stones, with 95 (43.6%) of the renal stones located in the lower pole. The single treatment success rates for ureteral and renal stones were 60.3% and 70.2%, respectively. On univariate analysis predictors of shock wave lithotripsy success, regardless of stone location, were age (p=0.01), body mass index (p=0.01), stone size (p<0.01), mean stone density (p<0.01) and skin to stone distance (p<0.01). By multivariate logistic regression for renal calculi, age, stone area and skin to stone distance were significant predictors with an AUC of 0.75. For ureteral calculi predictive factors included body mass index and stone size (AUC 0.70). CONCLUSIONS: Patient and stone parameters have been identified to create a nomogram that predicts shock wave lithotripsy outcomes using the Lithotron lithotripter, which can facilitate optimal treatment based decisions and provide patients with more accurate single treatment success rates for shock wave lithotripsy tailored to patient specific situations.

Comparison of supracostal versus infracostal percutaneous nephrolithotomy using the novel prone-flexed patient position.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is considered standard therapy for large and complex renal calculi. The optimal patient position and puncture site for collecting system access remains controversial. This purpose of this retrospective review is to analyze our PCNL series with respect to puncture tracts, success, and complications using our novel prone-flexed position. PATIENTS AND METHODS: Perioperative data were collected on consecutive PCNL cases for renal calculi performed in the prone-flexed position from 2004 to 2009. Patient demographic, stone, operative, postoperative, and follow-up data were collected. Successful treatment was defined as stone free or sandlike (≤1 mm) particles visible on CT scan at 3 months. RESULTS: A total of 318 patients, with a mean age of 52.9 years and body mass index of 27.8 kg/m(2), underwent PCNL in the prone-flexed position (57.9% male). Sixteen tracts were above the 11th rib, 138 were above the 12th rib, and 164 were infracostal. Multiple tracts were used in 16 patients. There were no significant differences between patients undergoing supracostal vs infracostal puncture with respect to side, stone area, number of tracts, number of stones, or the presence of staghorn or struvite calculi. Success in the supracostal group (89.8%) was not statistically different from the infracostal group (94.1%), P>0.05. Overall complication rates across groups was low (11.6%), with a significant difference in complications between the supracostal and infracostal puncture groups across Clavien grades, P<0.01. No patients needed blood transfusions or angioembolization. CONCLUSION: Regardless of supracostal or infracostal renal access, our novel prone-flexed position assists with percutaneous renal access and ease of nephrolithotomy, while maintaining excellent success rates and minimizing procedural morbidity.

Shockwave lithotripsy in patients with horseshoe kidney: determinants of success.

BACKGROUND AND PURPOSE: Horseshoe kidney (HSK) is the most common renal fusion anomaly, with a prevalence of ∼1 in 400 and an incidence of urolithiasis between 20% and 60%. The role of shock wave lithotripsy (SWL) in patients with HSK remains poorly studied. METHODS: Data from all patients treated since January 1994 with a known HSK was reviewed. Analysis was restricted to all patients with a minimum follow-up of 2 weeks after SWL. Success was defined as patients who were stone-free or had asymptomatic, clinically insignificant residual fragments ≤ 4 mm. RESULTS: Data from 41 patients with HSK were analyzed (61 calculi). Mean stone size was 91.3 ± 71.6 mm(2); mean body mass index was 27.1 ± 5.3 kg/m(2). At 3 months, the single-treatment success and stone-free rates were 25.0% and 9.1%, respectively. The overall treatment success rate at 3 months was 63.6%, and the stone-free rate was 39.1%. Little incremental benefit was found for more than two SWL treatments per stone. The auxiliary treatment rate was 72.7%, with an efficiency quotient of 10.5%. On multivariate analysis, stone burden (p = 0.074), other calyceal location (p = 0.026), and body mass index (p = 0.013) were found to be prognostic for SWL success. CONCLUSIONS: Patients with HSK appear to have lower success and stone-free rates after SWL than patients with normal kidneys. This likely has to do with factors such as greater skin-to-stone distance (particularly for calyceal stones) and restricted urinary drainage. SWL may be offered to patients with a HSK once limitations in stone clearance have been considered.

Ureteritis cystica: a rare cause of ureteral obstruction.

Ureteritis cystica is a rare, but recognized cause of ureteral obstruction. To our knowledge, we present the first case where obstruction secondary to the cystic component is confirmed with a functional study. Additionally, we present high-quality radiologic and endoscopic images of two cases of ureteritis cystica.

Limitations to ultrasound in the detection and measurement of urinary tract calculi.

OBJECTIVES: To evaluate differences in stone measurement using computed tomography (CT) and ultrasound (US). Axial unenhanced helical CT is the reference-standard imaging modality for the assessment of urinary tract calculi; however, US is also commonly used. Differences in stone measurement using these techniques are poorly described and contributors to measurement error remain unknown. METHODS: All patients at our institution undergoing both abdominal CT and renal US less than 1 month apart since June 2004 were reviewed. Solitary renal calculi were identified on both CT and US in all cases. RESULTS: We identified 71 calculi in 60 patients. Compared with CT, US overestimated stone size, an effect that was more pronounced with smaller calculi. The mean stone measurement on CT was 7.4 +/- 4.4 mm and on US it was 9.2 +/- 4.5 mm (P = .018). For stones

Dong Quai (angelica sinensis) in the treatment of hot flashes for men on androgen deprivation therapy: results of a randomized double-blind placebo controlled trial.

OBJECTIVE: To determine whether Dong Quai, a Chinese herbal compound purported to be efficacious in treating menopausal vasomotor symptoms, has a therapeutic benefit in treating hot flashes among prostate cancer patients receiving androgen deprivation therapy. METHODS: A randomized double-blind placebo controlled trial was conducted involving 22 men receiving luteinizing hormone-releasing hormone agonist therapy for prostate cancer with bothersome hot flashes. After recording a baseline log of the frequency, duration and severity of daily hot flashes, patients were randomly assigned in a 1:1 ratio to receive daily placebo or Dong Quai for 3 months. Vasomotor and adverse events were recorded daily. Blood work including serum prostate-specific antigen (PSA), international normalized ratio of prothrombin time and partial thromoboplastin time were recorded at baseline and at the termination of the study. RESULTS: Seventeen of the 22 patients enrolled completed the trial. Baseline vasomotor duration and severity were equivalent between the groups, however the number of hot flashes were significantly more in the Dong Quai group (p = 0.02). With respect to the change in number of hot flashes per day, there was a slight decrease in the mean number among the Dong Quai group which was insignificant. The absolute change and average percentage change in perceived hot flash severity was similar in both groups. There was no significant decrease in the duration of the hot flashes between the 2 groups. Disease progression based on either PSA increase or change in digital rectal exam was not observed in any patient. CONCLUSION: In this small pilot study, there were no significant differences in the severity, frequency or duration of hot flashes among men receiving placebo or Dong Quai.

Shock wave lithotripsy: a randomized, double-blind trial to compare immediate versus delayed voltage escalation.

OBJECTIVES: To present a randomized trial investigating immediate vs delayed voltage escalation during shock wave lithotripsy (SWL). SWL efficiency is affected by the energy setting of the lithotripter, the consumption level of the electrode, and the rate of shock wave administration. Preliminary data have suggested that delaying voltage escalation for SWL might both improve fragmentation and minimize renal injury. METHODS: A total of 160 patients with previously untreated radiopaque renal calculi were randomized to undergo immediate vs delayed voltage escalation SWL. Success was defined as an asymptomatic patient who was stone free or had adequate fragmentation (sand or fragments < or = 4 mm) at 3 months after treatment. RESULTS: Of the 160 patients, 83 were treated with immediate voltage escalation SWL and 77 patients with delayed escalation. The groups were similar in sex, body mass index, stone area, and stone location. The overall success rate at 3 months was 72.5% for immediate vs 54.5% for delayed SWL (P = .021). After adjusting for body mass index, sex, and stone location, the stone area decreased more rapidly in patients treated with immediate voltage escalation (P = .002). A trend was also seen for immediate voltage escalation to be more effective in the treatment of smaller calculi with a cross-sectional area of < 100 mm(2) (P = .089) compared with calculi with a cross-sectional area of > or = 100 mm(2) (P = .248). No differences were seen in the complications or ancillary procedures between the 2 treatments (P = .667 and P = .355, respectively). No perinephric hematomas were observed in either group. CONCLUSIONS: These results suggest that delayed voltage escalation might not provide superior stone fragmentation compared with conventional, immediate voltage escalation.

The management of treatment-resistant biliary calculi using percutaneous endourologic techniques.

BACKGROUND: Complicated choledocholithiasis cannot always be managed by standard surgical, radiologic or endoscopic methods. One additional approach is to use percutaneous techniques developed by endourologists to treat renal calculi. In this report, we present our experience over the past 10 years with this novel approach. METHODS: We conducted a retrospective review of all patients who underwent percutaneous, endoscopic treatment of biliary calculi at our institution between January 1997 and August 2007. Primary outcomes of interest were symptom- and stone-free rates, length of stay in hospital and complications. RESULTS: Nineteen patients underwent 21 percutaneous treatments for biliary calculi. All were dependent on external drainage for symptom control. The primary indications for treatment were cholangitis, retained stone, biliary colic and jaundice. Seventeen patients (89.5%) had failed prior endoscopic retrograde cholangiopancreatography (ERCP) or open attempts at treatment. The 2 remaining patients (10.5%) were deemed unfit for a general anesthetic. Patients had experienced a mean of 1.8 (standard deviation [SD] 1.0) prior failed attempts at stone removal. We used several treatment modalities, including holmium:yttrium-aluminum-garnet laser (61.9%), electrohydraulic lithotripter (19.0%), ultrasound (9.5%), basket extraction (9.5%) and balloon dilatation of the ampulla (19.0%). Overall, treatment led to successful removal of the biliary drainage tube in 94.7% of patients and 76.2% were stone-free. We performed cholangiograms an average of 21.8 (SD 13.7) days after treatment. The average length of stay in hospital was 1.9 (SD 1.1) days. One patient experienced a perioperative acute coronary syndrome and another experienced prolonged biliary drainage. Both had successful endoscopic treatment of their calculi. There were no cases of treatment-related sepsis, and we observed no other complications. CONCLUSION: Biliary calculi may be successfully treated using standard endourologic methods with high stone-free rates. This technique is generally well-tolerated even among high-risk patients.

Percutaneous nephrolithotomy in the prone and prone-flexed positions: anatomic considerations.

OBJECTIVES: Percutaneous nephrolithotomy is commonly performed in the prone position. Knowledge of renal anatomy and the relationship of adjacent organs is essential to minimize patient morbidity and iatrogenic organ injury. We present the anatomical basis for a prone-flexed modification to patient positioning and review the advantages and disadvantages of alternate positions. METHODS: Triphasic computed tomography was conducted with the patient in supine, prone, and prone-flexed positions, and an anatomical survey was conducted. A 30 degrees angle was used to approximate the plane of nephrostomy access and the risk of organ injury. RESULTS: For upper pole punctures, the liver and spleen were more medially situated, and thus more likely to be injured with supine positioning, compared with either prone or prone-flexed positioning (p < 0.001). In contrast, for lower pole punctures, the colon was more medially situated in the prone and prone-flexed positions compared to supine (p < 0.001). With prone-flexed positioning, the left kidney was displaced lower than the right in 92.3% of cases. The prone-flexed modification increased the distance from the posterior iliac crest to the 12th and 11th ribs by 2.9 and 3.0 cm, respectively (p < 0.001). If access was performed in the most superior calyx, this would have converted an upper pole access above the 11th rib to one above the 12th rib in 5 of 11 patients (45.5%). CONCLUSIONS: Prone-flexed positioning is a simple modification that provides improved access to the upper pole and more mobility for lower pole percutaneous nephrolithotomy. This position is well tolerated and has several advantages over other patient positions, including the supine position.

Percutaneous nephrolithotripsy in patients with diabetes mellitus.

PURPOSE: To compare the surgical outcomes in a cohort of patients with diabetes who were undergoing percutaneous nephrolithotripsy (PCNL) for renal stone disease to a nondiabetic group of patients at a single center. PATIENTS AND METHODS: Between July 1990 and December 2005, all patients scheduled for PCNL were prospectively included in a single-center database. Preoperative, intraoperative, and postoperative data were prospectively collected and analyzed. Primary outcomes evaluated were stone-free rates and complications, including the need for blood transfusion, while the secondary outcome was length of hospital stay. This report specifically reviews these outcomes in patients known to have diabetes at the time of surgery. Both outcomes were compared with those obtained in our nondiabetic patient population. RESULTS: Analysis of the data from 183 (13.7%) patients with diabetes of the 1338 patients undergoing PCNL revealed that patient age (63.1 years), surgical time (90.8 minutes), and complications (major 2.2%), including need for transfusion (0.5%) and stone-free rate (94.5%), were not significantly different from those observed in our nondiabetic patients. The average length of hospital stay was significantly longer in the diabetic group (4.4 days vs 3.9 days, P = 0.022). Uric acid stone composition was found to be the most common stone composition among the patients with diabetes in this study (41%). CONCLUSIONS: PCNL can be performed with excellent stone-free rates and with an acceptable complication risk in the diabetic population. The incidence of uric acid stone disease appears to be significantly higher than previously reported and warrants heightened efforts directed toward stone prevention in this population.