Virtual reality for pain control during shock wave lithotripsy: a randomized controlled study.

PURPOSE: Although external shock wave lithotripsy (SWL) is an outpatient procedure generally not requiring anesthesia or sedation, patients may experience pain during the procedure. The aim of this study is to evaluate whether a virtual reality device is effective in reducing patient-reported pain during the procedure, consequently leading to exposure to higher energy levels and better clinical outcomes. METHODS: Inclusion criteria for SWL were according to the latest EAU guidelines on urolithiasis. Patients were randomized 1:1 in two groups (SWL with VR and SWL without VR). The primary outcome of this randomized, controlled study (RCT) was an overall difference in pain levels determined by VAS-scores. Secondary outcomes were differences in comfort levels, determined by Likert-scale scores, clinical success and total delivered energy. RESULTS: Between January 2019 and September 2021, we enrolled 166 patients; 84 were randomized to the control arm and 82 to the VR arm. Patients without VR experienced significantly more pain compared to the VR group (mean VAS-score = 4.94 vs 4.01; p = 0.011). The mean total delivered energy was significantly higher in the VR group compared to the control group (55.2 J vs. 48.8 J; p = 0'037). No significant differences in comfort levels and clinical success were found. CONCLUSION: This study supports the use of VR as a method of pain relief during shock wave lithotripsy. Higher energy levels can be achieved during the treatment while comfort levels remained equal; this however did not lead to improved clinical success. REGISTRATION NUMBER AND NAME OF TRIAL REGISTRY: Clinicaltrials.gov: NCT05183269. Virtual reality for pain control during extracorporeal shock wave lithotripsy: prospective, comparative, randomized study at a single institution. https://clinicaltrials.gov/ct2/show/NCT05183269?term=shock+wave+lithotripsy&cond=virtual+reality&cntry=BE&draw=2&rank=1 .

Mirabegron for the Treatment of Ureteral Stent-related Symptoms: A Systematic Review and Meta-analysis.

CONTEXT: Ureteral stent-related symptoms (SRSs) are very common and may potentially influence the quality of life and functional capacity of patients. It remains unclear whether mirabegron has a place in the treatment of SRSs. OBJECTIVE: To summarize the evidence of mirabegron for the treatment for SRSs in adult patients. EVIDENCE ACQUISITION: A systematic review of literature was performed using the PubMed, Embase, and Google Scholar databases. Studies published up to June 2021 that met the search terms ("mirabegron" OR "B3-agonist") AND ("stent-related symptoms" OR "stent-related discomfort" OR "stent") were considered. References from relevant sources were examined to identify additional sources for this review. Relevant studies were selected according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The revised Cochrane tool "RoB 2" was used to assess the quality of included randomized clinical trials. EVIDENCE SYNTHESIS: Eight studies were selected for final quantitative and qualitative synthesis. The Ureteral Stent Symptom Questionnaire (USSQ) body pain score was significantly improved by mirabegron in five studies, although a pooled data analysis did not reveal any significant changes. The USSQ urinary symptom score was significantly improved by mirabegron in four independent studies as well as in the corresponding meta-analysis, while no changes were found in two studies. International Prostate Symptom Score was improved significantly by mirabegron in three independent studies as well as in the corresponding meta-analysis. The USSQ general health and the quality of life score were improved significantly by mirabegron on meta-analysis. CONCLUSIONS: Mirabegron may have a beneficial effect on pain and urinary symptoms due to ureteral stents, although the evidence is based on low-quality studies. PATIENT SUMMARY: In this report, we looked at the evidence of mirabegron for the treatment of ureteral stent-related symptoms. We found that mirabegron can potentially alleviate pain and bothersome urinary symptoms due to ureteral stents.

Which clinical and radiological characteristics can predict clinically significant prostate cancer in PI-RADS 3 lesions? A retrospective study in a high-volume academic center.

OBJECTIVE: To investigate which clinical and radiological characteristics can predict clinically significant prostate cancer (csPCa) in PI-RADS 3 lesions. To investigate which clinical and radiological characteristics influence the clinician to biopsy a PI-RADS 3 lesion. MATERIALS AND METHODS: mpMRI PI-RADS 3 lesions scored by 1 out of 3 highly specialized radiologists in a single high-volume center during the period March 2015 to August 2017 were investigated. This score was based on T2 weighted and diffusion weighted imaging (DWI) sequences. Clinical characteristics of all patients with PI-RADS 3 lesions were collected from medical records. Radiological characteristics were collected from radiology reports. Some radiological characteristics such as apparent diffusion coefficient (ADC) in a region of interest at the tumor site and ADC at a site contralateral to the tumor site were calculated on DWI sequences. Cox regression analysis was performed to identify which characteristics could predict csPCa in PI-RADS 3 lesions and which characteristics could influence the behavior of a clinician whether or not to biopsy a PI-RADS 3 lesion. RESULTS: csPCa could be detected in 31 out of 131 patients with PI-RADS 3 lesions (22.9%). A lower median prostate volume (p = 0.015) and a lower ratio of ADC of the tumor on ADC of the contralateral prostate (ADCT/ADCCLP) (p < 0.001) significantly predisposed for csPCa in multivariate logistic regression. For peripheral zone lesions, a diagnostic model with biopsy of only those PI-RADS 3 lesions with a prostate volume <44 cc and a ratio of ADCT/ADCCLP < 70% showed a sensitivity for detection of csPCa of 59% with a specificity of 88%. (area under the curve 0.780) A suspicious rectal examination (p = 0.011) and the mentioning of prostatitis on the MRI report (p = 0.020) influenced clinicians to biopsy a PI-RADS 3 lesion positively and negatively respectively. For transition zone lesions, previous negative biopsies (p = 0.044) predisposed for csPCa. CONCLUSION: Prostate volume and the ratio of ADC tumor on ADC of the contralateral prostate have the potential to predict csPCa in PI-RADS 3 lesions with a sensitivity of 59% and specificity of 88%. A suspicious rectal examination and the mentioning of prostatitis on the MRI report influenced the decision of clinicians to biopsy a PI-RADS 3 lesion.

Resident burnout in USA and European urology residents: an international concern.

OBJECTIVE: To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood. SUBJECTS AND METHODS: An anonymous 32-question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts. RESULTS: Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work-life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non-medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on-call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047). CONCLUSION: In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.

Abiraterone and spironolactone in prostate cancer: a combination to avoid.

Objectives: Disease progression in metastatic castration-resistant prostate cancer (mCRPC) is dependent on androgen signaling. This case describes the complex adaptive androgen signaling mechanisms in mCRPC and illustrates that caution should be exercised when treating these patients with drugs influencing the androgen axis.Methods: Single case report and review of the literature.Results: We report the case of an 86-year-old man with mCRPC, treated with the secondary antihormonal agent abiraterone acetate. Following association of spironolactone to deal with symptoms related to mineralocorticoid excess, biochemical and radiographic disease progression occurred. Spironolactone was discontinued and 8 months after withdrawal, the patient continues to show a biochemical response to abiraterone.Conclusions: Although spironolactone generally exerts anti-androgenic effects, experimental evidence exists that it acts as an androgen receptor agonist in an androgen-depleted environment, capable of inducing prostate cancer proliferation. This is supported by the observations described in this case report. Therefore, spironolactone should be avoided in prostate cancer patients suffering from treatment-associated side effects of abiraterone.

Use of fosfomycin as targeted antibiotic prophylaxis before prostate biopsy: A prospective randomized study.

OBJECTIVES: To investigate whether switching ciprofloxacin to fosfomycin in the case of fluoroquinolone-resistant rectal bacteria influences the incidence of infectious complications after transrectal prostate biopsy. METHODS: From December 2015 until December 2017, patients undergoing prostate biopsy were randomly assigned to a control group or an intervention group in a prospective, open-label fashion at three different centers. The presence of fluoroquinolone-resistant organisms was detected by rectal swabs. Patients in the control group received ciprofloxacin. Patients in the intervention group received fosfomycin instead of ciprofloxacin in the case of fluoroquinolone-resistant bacteria on rectal swab culture. The primary end-point was the difference in occurrence of major (febrile) and minor (afebrile) infections between both groups. RESULTS: A total of 102 patients were randomized to the control group, and 102 patients to the intervention group. In the control group, nine complications occurred, of which five were major febrile complications. In the intervention group, six complications occurred, of which four were major febrile complications. The total number of complications (major and minor) did not differ between both groups (P = 0.59). A subgroup analysis of patients with fluoroquinolone-resistant bacteria on rectal swab showed five complications in the control group and one complication in the intervention group (P = 0.09). CONCLUSIONS: This represents the first prospective randomized study using rectal cultures for targeted antibiotic prophylaxis. Study findings show promising results for use of fosfomycin in patients with fluoroquinolone resistance.

Robot-assisted Kidney Autotransplantation: A Minimally Invasive Way to Salvage Kidneys.

BACKGROUND: Kidney autotransplantation (KAT) is the ultimate way to salvage kidneys with complex renovascular, ureteral, or malignant pathologies that are not amenable to in situ reconstruction. A minimally invasive approach could broaden its adoption. OBJECTIVE: To describe operative technique, perioperative complications, and early functional outcomes of robot-assisted kidney autotransplantation (RAKAT). DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of prospectively collected data regarding consecutive patients undergoing RAKAT between March 2017 and February 2018 at two university hospitals. INTERVENTION: RAKAT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Technical feasibility, perioperative complications, and early functional results. RESULTS AND LIMITATIONS: Seven patients underwent RAKAT (three male and four female; five left and two right; one totally intracorporeal) for complex ureteral strictures (n=5), severe left renal vein nutcracker (n=1), and loin pain hematuria syndrome (n=1). Two patients underwent bench vascular reconstruction and one patient underwent ex vivo flexible ureterorenoscopy. No patient needed open conversion. Median operative and console time was 370 and 255min, respectively, with median vascular and ureteral anastomosis time of 28 and 23min, respectively. Median warm, cold, and rewarming ischemia time was 2, 178, and 44min, respectively. One major postoperative complication occurred-wound dehiscence needing wound revision (grade 3b). Median hospital stay was 5 d. At 3 mo, all patients were free of indwelling stents, pain, or hematuria. Median serum creatinine at 3 mo was 0.80mg/dl and median calculated autotransplant glomerular filtration rate did not drop significantly. CONCLUSIONS: RAKAT is feasible, safe, and results in good functioning of the autotransplant in selected patients with complex ureteral strictures, loin pain hematuria, or severe nutcracker syndrome. Larger studies with longer follow-up are needed to confirm these findings and to test whether RAKAT is feasible for other KAT indications. PATIENT SUMMARY: We describe the first series worldwide of a minimally invasive technique for kidney autotransplantation. Robot-assisted kidney autotransplantation is a safe and feasible approach to prevent nephrectomy for intractable symptoms in selected patients with complex ureteral or renal pathology.

Ultrasonography Is Not Inferior to Fluoroscopy to Guide Extracorporeal Shock Waves during Treatment of Renal and Upper Ureteric Calculi: A Randomized Prospective Study.

OBJECTIVE: To investigate whether the visualization modality (ultrasound or fluoroscopy) used during shockwave lithotripsy (SWL) affects the clinical outcome in those instances where both imaging modalities are optional. METHODS: Between November 2014 and July 2016, 114 patients with radiopaque upper urinary tract calculi were randomly assigned to an ultrasound- or fluoroscopy-guided SWL group in a prospective, open-label, single-center study. A standardized SWL protocol was used. The stone-free rate and the positive outcome rate (stone-free or asymptomatic residual fragments ≤ 4 mm) were compared. RESULTS: The stone-free rate was 52% in the ultrasound-guided group compared to 42% in the fluoroscopy-guided group (p = 0.06) and the positive outcome rate was 79% in the ultrasound-guided group compared to 70% in the fluoroscopy-guided group (p = 0.28). These results were not significantly different but proved to be noninferior based on a Wilson confidence interval of independent proportions (noninferiority limit 10%). The mean number of SWL sessions was not significantly different (p = 0.4). CONCLUSION: Our study demonstrated that the clinical results of ultrasound-guided SWL were not inferior to the results of fluoroscopy-guided SWL, while no ionizing radiation is needed.

Central mesh failure after laparoscopic IPOM procedure.

Central mesh failure after laparoscopic repair of a ventral hernia is a rare finding. We present a case of a 42-year-old man with clear umbilical hernia recurrence 4 years after IPOM procedure with an oxidized cellulose composite polypropylene mesh, using the double crown technique. Laparoscopy showed that a segment of small intestine herniated through a central defect in the prosthesis. A primary repair of the umbilical hernia recurrence was performed through a small transverse infraumbilical incision suturing both the fascia and mesh with interrupted non-resorbable monofilament sutures. A plausible explanation for this type of recurrence might be that the center of the mesh was further torn after an initial (micro) trauma induced by the tackers used for fixation.