Andreas Bourdoumis

Hexaminolevulinate-induced fluorescence versus white light during transurethral resection of noninvasive bladder tumor: does it reduce recurrences?

OBJECTIVE To evaluate the effect of hexaminolevulinate (HAL)-induced fluorescence during resection of noninvasive bladder cancer on tumor recurrence compared with resection under white light. METHODS Between 2008 and 2010, 102 consecutive patients with suspected bladder cancer were randomized to undergo transurethral resection with either conventional white light or combination of white light and HAL-induced fluorescence. Difference in tumor recurrence rate and recurrence-free survival between the 2 groups was evaluated. Subgroup analysis on recurrence-free survival was performed for different tumor parameters. RESULTS Cystoscopy at 3 months revealed tumor recurrence in 6 of 45 (13.3%) patients of the white light group compared with only 1 of 41 patients of the HAL group (2.4%) (P < .001). The recurrence-free rates in white light patients at 12 and 18 months were 56.3% and 50.6%, respectively, compared with 91% and 82.5% in HAL patients (P = .0006). In subgroup analyses, recurrence-free survival was similar between the 2 groups when solitary tumors were treated (P = .3525). However, the HAL group had a favorable recurrence-free survival compared with the white light group when multifocal tumors (P < .001), primary tumors (P = .0237), recurrent tumors (P = .0189), nonaggressive (papillary urothelial neoplasm of low malignant potential and low grade) tumors (P = .0204), or aggressive (high grade and carcinoma in situ) tumors (P = .0134) were treated. CONCLUSION HAL significantly aids resection of non-muscle-invasive bladder cancer with the result of reduction in tumor recurrence rates.

The novel prostate cancer antigen 3 (PCA3) biomarker

PCA3 is a prostate specific, nonprotein coding RNA that is significantly over expressed in prostate cancer, without any correlation to prostatic volume and/or other prostatic diseases (e.g. prostatitis). It can now easily be measured in urine with a novel transcription-mediated amplification based test. Quantification of PCA3 mRNA levels can predict the outcome of prostatic biopsies with a higher specificity rate in comparison to PSA. Several studies have demonstrated that PCA3 can be used as a prognostic marker of prostate cancer, especially in conjunction with other predictive markers. Novel PCA3-based nomograms have already been introduced into clinical practice. PCA3 test may be of valuable help in several PSA quandary situations such as negative prostatic biopsies, concomitant prostatic diseases, and active surveillance. Results from relevant clinical studies, comparative with PSA, are warranted in order to confirm the perspective of PCA3 to substitute PSA.

Use of a Virtual Reality Simulator to Improve Percutaneous Renal Access Skills: A Prospective Study in Urology Trainees

Objectives: This study aims to assess the impact of a virtual reality trainer in improving percutaneous renal access skills of urological trainees. Methods: A total of 36 urology trainees participated in this prospective study. Initially, they were taken through the exercise of gaining access to the lower pole calyceal system and introducing a guidewire down the ureter. Trainees’ performance was then assessed by virtual reality-derived parameters of the simulator at baseline and after 2 h of training. Results: Participants who underwent training with the simulator demonstrated significant improvement in several parameters compared to their baseline performance. There was a statistically significant correlation between total time to perform the procedure and time of radiation exposure, radiation dose and correct calyx puncture (p < 0.01). Trainees needed a mean of 15.8 min from skin puncture to correct guidewire placement into the pelvicalyceal system before and 6.49 min following training. Conclusions: We found percutaneous renal access skills of trainees improve significantly on a number of parameters as a result of training on the PERC Mentor TM VR simulator. Such simulated training has the potential to decrease the risks and complications associated with the early stages of the learning curve when training for percutaneous renal access in patients.

Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery

With populations ageing and active treatment of urinary stones increasingly in demand, more patients with stones are presenting with an underlying bleeding disorder or need for regular thromboprophylaxis, by means of antiplatelet and other medication. A practical guide to thromboprophylaxis in the treatment of urinary tract lithiasis has not yet been established. Patients can be stratified according to levels of risk of arterial and venous thromboembolism, which influence the requirements for antiplatelet and anticoagulant medications, respectively. Patients should also be stratified according to their risk of bleeding. Consideration of the combined risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. The choice of shockwave lithotripsy, percutaneous nephrolithotomy or ureteroscopy with laser lithotripsy for treatment of lithiasis should be determined with regard to these risks. Although ureteroscopy is the preferred method in high-risk patients, shockwave lithotripsy and percutaneous nephrolithotomy can be chosen when indicated, if appropriate guidelines are strictly followed.

Laparoscopic Varicocelectomy in the Management of Chronic Scrotal Pain

Background and Objectives: To evaluate the usefulness of laparoscopic varicocelectomy in the management of chronic scrotal pain. Methods: Between 2009 and 2011, 48 patients in total were treated with laparoscopic varicocelectomy for dull scrotal pain that worsened with physical activity and was attributed to varicoceles. All patients were followed up at 3 and 6 months and biannually thereafter with a physical examination, visual analog scale score, and ultrasonographic scan in selected cases. Results: The mean age was 38.2 years (range, 23–54 years). The mean follow-up period was 19.6 months (range, 6–26 months). Bilateral varicoceles were present in 7 patients (14.6%), and a unilateral varicocele was present in 41 (85.4%). The varicocele was grade 3 in 27 patients (56.3%), grade 2 in 20 (41.6%), and grade 1 in 1 (2.1%). The mean preoperative visual analog scale score was 4.8 on a scale from 0 to 10. The mean postoperative visual analog scale score at 3 months was 0.8. After the procedure, 42 patients (87.5%) had a significant improvement in the visual analog scale score (P < .001); 5 (10.4%) had symptom improvement, although it was not statistically significant; and 1 (2.1%) remained unchanged. During follow-up, we observed 5 recurrences (10.4%) whereas de novo hydrocele formation was identified in 4 individuals (8.3%). Conclusion: Laparoscopic varicocelectomy is efficient in the treatment of symptomatic varicoceles with a low complication rate. However, careful patient selection is necessary because it appears that individuals presenting with sharp, radiating testicular pain and/or a low-grade varicocele are less likely to benefit from this procedure.

Impact of Thermo-Expandable Memokath Ureteral Stent on Renal Function in the Management of Ureteroileal Anastomotic Stricture

Purpose: The study aimed to assess the impact of the Memokath 051 stent (MK) on glomerular filtration rate (GFR) and split renal function in the management of ureteroileal anastomotic strictures. Materials and Methods: We treated 6 patients in the ages of 66–77 years, 2 of whom had bilateral strictures, with a total of 8 ureteroileal strictures using the MK stent. Five patients had chronic kidney disease (CKD) prior to MK insertion. Mean time between conduit surgery and MK insertion was 28.4 months. Serum creatinine, GFR, and MAG-3 renography were determined before stent insertion and postoperatively at 3 months. Results: Postoperative complications at 3-month follow-up included migration in 2 patients, occlusion in 2 patients, and urinary tract infection in 4 patients. The mean stent indwelling time was 353.4 ± 169.3 days. Mean preoperative creatinine, GFR, right, and left split renal function were 158.3 ± 76.3 μmol/L, 43.6 ± 32.9 mL/min/1.73 m2, 52.8 ± 22.2%, and 47.1 ± 22.2%, respectively. Mean postoperative values were 168.1 ± 84 μmol/L (p = 0.84), 40.8 ± 28.4 mL/min/1.73 m2 (p = 0.56), 51.1 ± 18.3% (p = 1), and 48.8 ± 18.3% (p = 1), respectively. Conclusion: MK stent is a safe and efficient minimally invasive long-term treatment option to preserve GFR in patients who develop CKD through ureteroileal anastomotic stricture. In spite of MK stent insertion and alleviation of obstruction, it was presumably inserted too late to improve renal function.

Is it the End for Urologic Pelvic Laparoscopic Surgery

Aim: To scrutinize the rapid development of robotic versus traditional laparoscopic technique in pelvic urologic surgery. Introduction: In the last few decades, advances in research and development have led to tremendous progress in medical diagnostics and treatment of disease. Minimally invasive surgery has moved from experimental to becoming the dominant form of surgical management across the surgical specialties. Laparoscopy is nowadays used widely in abdominal surgery, from simple diagnostic laparoscopy to complex colorectal and gynecologic cancer procedures. Methods: A literature search of electronic databases (PubMed, Medscape, Embase) using the key words: “pelvic laparoscopy, urologic oncology, robotic surgery, minimally invasive access” was performed for all relevant articles in the English language. Data were extrapolated from the abstracts alone to avoid subjective bias in drawing conclusions. Results: Telemedicine and telesurgery, the diagnostic and operative process is conducted from a distance. The surgeon uses computer-assisted surgery away from the bedside via a robotic system and performs the surgical task at hand. In pelvic urological cancer surgery the use of robotic technique expands to female and reconstructive procedures as well. The leap forward is so massive, that traditional laparoscopic surgery is starting to be considered less, with a growing number of organizations being now more interested in developing a robotic service. Minimally invasive surgical techniques aim to improve surgical outcome in conjunction with delivery of high-quality patient care. Quality studies demonstrating superiority and cost effectiveness are lacking, however. Conclusions: Although tremendous accomplishments took place over a few years, there is still a lot of ground to be covered in standardizing the learning process and evaluating the outcome from the application of new technologies in the field of robotic pelvic surgery.

Re: Antiplatelet and Anticoagulative Medication During Shockwave Lithotripsy: (From: Schnabel MJ, Gierth M, Bründl J, et al. J Endourol 2014;28:1034–1039)

It is with great interest that we read the article by Schnabel and associates in the September issue of the Journal of Endourology concerning antiplatelet and anticoagulation treatment in shockwave lithotripsy (SWL). While the authors venture in a structured and detailed summary of the relevant literature in the absence of well-designed trials and quality evidence, the main issue of finding the balance between the risk of bleeding from the procedure against risk of thromboembolic events from stopping medication is not addressed. We agree that SWL is a procedure of low to intermediate rather than high risk of significant hemorrhage, because it can cause visible hematuria and renal hematoma that resolve with conservative management in the majority of cases and do not necessitate transfusion. It is also important to point out that SWL carries a very low risk of deep vein thrombosis/pulmonary embolism because it avoids prolonged immobilization and use of anesthetic. We believe, however, that the most critical step is to integrate the individual thromboembolic risk in the management plan and consent process of SWL in particular. The American College of Chest Physicians has published guidelines for the perioperative management of antithrombotic therapy that can serve as a guide for risk stratification of thromboembolic events. According to the consensus, patients at low risk can safely stop high-dose aspirin and clopidogrel for 3 to 7 days and anticoagulants for 5 days without bridging and resume 48 to 72 hours post-treatment. Low-dose aspirin prophylaxis (75 mg) is no longer considered a factor for bleeding during major surgery, and discontinuation is not necessary. On the other hand, patients in the intermediate and high-risk groups pose a different challenge. Patients receiving warfarin or dabigatran (a thrombin inhibitor) can be safely bridged with low molecular weight heparin when surgical intervention is needed. Ureteroscopy is preferable in patients at high risk. If SWL is considered, power ramping with the use of the lowest energy possible for fragmentation is recommended. The biggest problem arises with new generation antiplatelets (clopidogrel, prasugrel, ticagrelor) and combination regimens (dual antiplatelet treatment) after coronary artery stent placement, especially with drug eluting stents. Because SWL is minimally invasive, it is an appealing solution for patients with comorbidities in general. In the case of complex cardiac disease, however, we advise that withholding antiplatelets be directed by specialist review and in accordance to strict subspecialist guidelines, because the consequences can be severe. Another option is to defer treatment and consider expectant management until such time that it would be safe to modify the antiplatelet regime. As the authors rightfully point out, special antiplatelet bridging agents are still investigational; again, ureterorenoscopy can be considered if stone removal is absolutely necessary, with respect to anesthetic tolerance. Taking the above into consideration, we believe there is a need for a collaborative effort that includes endourology, anesthetics, and cardiology specialists to design appropriate prospective studies that will yield high quality evidence and work toward a consensus for perioperative antithrombotic planning in minimally invasive stone surgery for all patient risk groups.

Re: Antiplatelet and Anticoagulative Medication During Shockwave Lithotripsy.

It is with great interest that we read the article by Schnabel and associates in the September issue of the Journal of Endourology concerning antiplatelet and anticoagulation treatment in shockwave lithotripsy (SWL). While the authors venture in a structured and detailed summary of the relevant literature in the absence of well-designed trials and quality evidence, the main issue of finding the balance between the risk of bleeding from the procedure against risk of thromboembolic events from stopping medication is not addressed. We agree that SWL is a procedure of low to intermediate rather than high risk of significant hemorrhage, because it can cause visible hematuria and renal hematoma that resolve with conservative management in the majority of cases and do not necessitate transfusion. It is also important to point out that SWL carries a very low risk of deep vein thrombosis/pulmonary embolism because it avoids prolonged immobilization and use of anesthetic. We believe, however, that the most critical step is to integrate the individual thromboembolic risk in the management plan and consent process of SWL in particular. The American College of Chest Physicians has published guidelines for the perioperative management of antithrombotic therapy that can serve as a guide for risk stratification of thromboembolic events. According to the consensus, patients at low risk can safely stop high-dose aspirin and clopidogrel for 3 to 7 days and anticoagulants for 5 days without bridging and resume 48 to 72 hours post-treatment. Low-dose aspirin prophylaxis (75 mg) is no longer considered a factor for bleeding during major surgery, and discontinuation is not necessary. On the other hand, patients in the intermediate and high-risk groups pose a different challenge. Patients receiving warfarin or dabigatran (a thrombin inhibitor) can be safely bridged with low molecular weight heparin when surgical intervention is needed. Ureteroscopy is preferable in patients at high risk. If SWL is considered, power ramping with the use of the lowest energy possible for fragmentation is recommended. The biggest problem arises with new generation antiplatelets (clopidogrel, prasugrel, ticagrelor) and combination regimens (dual antiplatelet treatment) after coronary artery stent placement, especially with drug eluting stents. Because SWL is minimally invasive, it is an appealing solution for patients with comorbidities in general. In the case of complex cardiac disease, however, we advise that withholding antiplatelets be directed by specialist review and in accordance to strict subspecialist guidelines, because the consequences can be severe. Another option is to defer treatment and consider expectant management until such time that it would be safe to modify the antiplatelet regime. As the authors rightfully point out, special antiplatelet bridging agents are still investigational; again, ureterorenoscopy can be considered if stone removal is absolutely necessary, with respect to anesthetic tolerance. Taking the above into consideration, we believe there is a need for a collaborative effort that includes endourology, anesthetics, and cardiology specialists to design appropriate prospective studies that will yield high quality evidence and work toward a consensus for perioperative antithrombotic planning in minimally invasive stone surgery for all patient risk groups.

A Comparative in Vitro Study of Power Output Deterioration over Time Between Ho:YAG Laser Fibers from Different Manufacturers as a Function of Deflection and Power Input.

Objectives: To investigate the performance of laser fibers from 6 major manufacturers in vitro and to identify the effect of time and angulations (180° and 0°) on fiber power output. Materials and Methods: Overall, 36 single-use fibers were used. Each was tested with an energy input of 0.8, 1.4 and 2.0 Joules. A power detector measured power output after 1, 5, 10 and 15 minutes for three 15-minute cycles of continuous use. For the first 2 cycles, the fiber was bent to 180° with the use of a pre fabricated mould. Analysis of the data was performed by ANOVA and Tukeys test when the results were significant amongst groups. Statistical significance was deemed p < 0.05. Results: No fiber fracture occurred. There was no significant difference in output at 15 minutes of continuous use at 0° and 180°. The reduction in energy output at the 15th minute of continuous use at 180° was not significant for any fiber type or initial input. Only output differences between the fibers proved to be significant (p = 0.001). Conclusion: Fiber fracture and decline in performance is not due to deflection and continuous use. Frictional forces that occur between the fiber tip and the stone fragments may be responsible.