Deborah J. Lightner

Is nephroureterectomy necessary in all cases of upper tract transitional cell carcinoma? Long-term results of conservative endourologic management of upper tract transitional cell carcinoma in individuals with a normal contralateral kidney.

Abstract Objectives. To evaluate the endoscopic management of upper urinary tract transitional cell carcinoma (TCC) as a first-line treatment in patients with a normal contralateral kidney. Methods. During an 11-year period, 21 patients diagnosed with upper tract TCC were treated with conservative endourologic techniques using either neodymium:yttrium-aluminum-garnet laser or electrocautery at our institution. The 21 patients were followed up for a mean of 6.1 years (range 1 to 11.6). Results. A total of 8 renal pelvic tumors and 13 ureteral tumors were found. All tumors were Stage T1 or less and grade 3 or less. All tumors were less than 2 cm in the greatest dimension (range 0.4 to 2). Of the 21 patients, 7 (33%) had one local recurrence and 1 (4.7%) developed two local recurrences. Of the 13 ureteral tumors, 6 (46%) recurred; 1 (12%) of the 8 renal pelvic tumors recurred. No recurrent tumor was shown to have an increase in grade. Of the 21 target renal units, 17 (81%) were preserved; 4 (19%) of 21 patients required nephroureterectomy because of tumor recurrence. Overall, 11 patients in the series died, 10 of non-TCC etiology and 1 secondary to invasive bladder TCC that developed after treatment for upper tract TCC. No patients died as a result of conservative management of their upper tract TCC. Conclusions. Endourologic techniques and conservative treatment of upper tract TCC is an evolving field; however, in properly selected patients, endoscopic treatment can be safely and effectively used as a first-line treatment for upper tract TCC.

COMPLICATIONS OF STERILE ABSCESS FORMATION AND PULMONARY EMBOLISM FOLLOWING PERIURETHRAL BULKING AGENTS

PURPOSE Agents currently used in the treatment of urinary incontinence secondary to intrinsic sphincter deficiency are effective and minimally invasive. Ensuring a lack of sensitivity to the product or use of autologous material, such as fat, minimizes significant problems. However, local and systemic complications can occur with any bulking agent. We describe rare complications of periurethral bulk injections. MATERIALS AND METHODS Three cases of sterile abscess formation and 1 of pulmonary embolism after periurethral bulk injections were reviewed. Two patients with intrinsic sphincter deficiency were treated with transurethral injection of glutaraldehyde cross-linked collagen at the Mayo Clinic, 1 also treated with collagen for intrinsic sphincter deficiency was referred from elsewhere and 1 underwent periurethral injection of autologous fat for intrinsic sphincter deficiency elsewhere. Clinical information and patient followup were obtained from medical records and discussion with treating physicians. RESULTS Three patients treated with collagen presented with sterile abscesses at the injection site after routine transurethral injection. Documentation of the abscesses included cystoscopic findings, magnetic resonance imaging of the pelvis and/or transvaginal ultrasound. Drainage procedures for relief of obstructive and irritative voiding symptoms were required in 2 patients. In 1 of these patients transurethral unroofing failed, and transvaginal incision and drainage were required while the other had slow spontaneous improvement but a mass remained at the injection site 3 months later. Repeat skin testing was negative in 2 of 3 cases. Currently, these 3 patients are asymptomatic except for continued urinary incontinence. Pulmonary embolism was documented in 1 patient who underwent periurethral autologous fat injection. This patient survived without long-term consequences but was maintained on ventilatory support for a short time. CONCLUSIONS In general, periurethral injection of bulk agents is safe and effective. However, injectable bulk agents are not without risk of complications, some of which are life threatening and others of considerable morbidity that may require operative intervention.

Surgical treatment for local control of female urethral carcinoma.

We reviewed 53 patients (mean age 63 years) who underwent partial urethrectomy (n = 26) or radical extirpation (n = 27) for primary female urethral cancer from 1948 through 1999. Clinical stage, histology, high pathologic stage (3 or 4) and grade, tumor location, nodal status, surgery type, adjuvant therapy, and treatment decade were candidate outcome predictors. The predominant carcinomas were squamous cell (n = 21), transitional cell (TCC) (n = 15), and adenocarcinoma (n = 14). For adjuvant therapy, 20 patients had radiation (8 preoperatively), 2 had radiation + chemotherapy, and 1 had chemotherapy alone. During mean follow-up of 12.8 years, 27 patients had recurrence; 15 local only, 2 distant only and 10 local + distant. Of patients undergoing partial urethrectomy for pT1-3 tumors, 6/27 (22%) had urethral recurrence. Overall, there were no bladder recurrences. Recurrence-free survival +/- standard error (SE) at 10 years was 45 + 8%. Those who recurred had a cancer mortality rate of 71% at 5 years postrecurrence. The estimated 10-year cancer-specific survival (CSS) and crude survival (CS) rates were 60 +/- 8% and 42 +/- 7%, respectively. Pathologic stage was predictive for local recurrence (P = 0.02) and CSS (P = 0.01). Positive nodes on pathology were related to local and distant recurrence and CSS (P = 0.01). Upon review, partial urethrectomy resulted in a high urethral recurrence rate (22%) with no bladder recurrences. These patients may be better served with radical urethrectomy and creation of continent catheterizable stoma.

Anticoagulation and antiplatelet therapy in urological practice: ICUD/AUA review paper.

PURPOSE Given the lack of urology specific directives for the periprocedural management of anticoagulant and antiplatelet medications, the AUA (American Urological Association) and ICUD (International Consultation on Urological Disease) named an international multidisciplinary panel to develop consensus based recommendations. MATERIALS AND METHODS A systematic literature review was queried by a methodologist for 3 questions. 1) When and in whom can anticoagulant/antiplatelet prophylaxis be stopped in preparation for surgery? 2) What procedures can be safely performed without discontinuing anticoagulant/antiplatelet prophylaxis? 3) What periprocedural strategies can adequately balance the risk of major surgical bleeding vs the risk of major thrombotic event? Hematology and cardiology guidelines, and 79 articles were selected for full review. RESULTS Multidisciplinary management of anticoagulant/antiplatelet medications for patients with recent thromboembolic events, mechanical cardiac valves, atrial fibrillation and cardiac stents would reduce the high morbidity and mortality of inexpertly discontinuing or modifying these lifesaving therapies. No elective procedures requiring interruption of dual antiplatelet therapies should be performed with a recent bare metal or drug eluting stent. The risk of significant bleeding complications is low for patients who require continuation of aspirin for ureteroscopy, transrectal prostate biopsies, laser prostate outlet procedures and percutaneous renal biopsy. Open extirpative prostate and renal procedures can be performed with a low risk of significant hemorrhage for patients on aspirin and those requiring heparin based bridging strategies. The current literature does not give direction on the timing of the resumption of anticoagulant/antiplatelet prophylaxis other than that it be resumed as soon as the risk of bleeding has decreased. CONCLUSIONS A total of 2,674 nonredundant article abstracts were obtained and assessed for relevance to key questions outlined by the panel. Overall 106 articles were selected for full text review and accepted or rejected based on the relation to the topic, quality of information and key questions. A total of 79 articles were accepted. Reasons for rejection (27 articles) included abstract only (12), insufficient information or unrelated to topic (13) and redundancy (2). We extracted study design, patient population, followup period and results from accepted articles, which serve as the evidence base.

Nocturia is associated with an increased risk of coronary heart disease and death.

Study Type – Prognosis (inception cohort)

Incidence of physician-diagnosed interstitial cystitis in Olmsted County: A community-based study

To obtain community‐based information about the incidence of interstitial cystitis, a chronic disabling condition of the bladder where knowledge is limited because there are no definitive diagnostic criteria.

Randomized Controlled Multisite Trial of Injected Bulking Agents for Women With Intrinsic Sphincter Deficiency: Mid-urethral Injection of Zuidex Via the Implacer Versus Proximal Urethral Injection of Contigen Cystoscopically

OBJECTIVES To determine whether Zuidex using a non-cystoscopy mid-urethral injection technique produces as good a result (i.e. was not inferior) as Contigen injected endoscopically at the bladder neck in the treatment of urinary stress incontinence secondary to intrinsic sphincter deficiency in adult women. METHODS A prospective 2:1 randomized trial of mid-urethral injections of Zuidex-Implacer vs proximal urethral cystoscopic injections of Contigen was performed in 344 women with intrinsic sphincter deficiency at 23 North American sites, and followed up for >1 year from last treatment. RESULTS Outcomes at 12 months from last treatment failed to demonstrate that mid-urethral injected Zuidex was equivalent to cystoscopically injected Contigen in primary and secondary outcome variables. The primary outcome, the proportion of women who achieved a 50% reduction in urinary leakage on provocation testing, was achieved in 84% of Contigen-treated women vs 65% of Zuidex-treated women. CONCLUSIONS Confounding multiple variables inherent in the study design make a detailed analysis of study outcomes difficult.

Female sexual dysfunction.

Female sexual dysfunction (FSD) was recently recognized as arising from multiple organic etiologies; it is not primarily a psychological symptom as believed previously. A symptom-related complex resulting in physiologic changes, FSD can respond to either treatment of the underlying condition or supportive measures. A new diagnostic classification allows physicians to perform a clinical evaluation of women with FSD, and recently validated FSD question naires allow monitoring of treatment efficacy. This article details the clinical evaluation and physical examination of women with FSD and outlines the fledgling research and treatment options.

Cystoscopic Injections of Dextranomer Hyaluronic Acid Into Proximal Urethra for Urethral Incompetence: Efficacy and Adverse Outcomes

OBJECTIVES To determine whether dextranomer/hyaluronic acid would be more efficacious or would produce fewer complications when using the material in a standard proximal-urethra cystoscopically-directed injection technique. Injectable periurethral bulking agents are an alternative to stress incontinence surgery. Dextranomer, a highly hydrophilic dextran polymer, solubilized in a base of nonanimal stabilized hyaluronic acid, has been approved as an injectable agent for the treatment of childhood vesicoureteric reflux (Deflux, Q-Med AB, Uppsala, Sweden), and in Europe for women with stress urinary incontinence (SUI) (Zuidex, Q-Med AB, Uppsala, Sweden). A previous multicenter trial demonstrated nonequivalence compared with bovine glutaraldehyde cross-linked collagen with a high complication rate. We sought to determine whether the failure of the treatment lay in the material itself or the use of a blind, midurethral injection technique. METHODS A retrospective case series of 56 patients undergoing cystoscopically guided bladder neck injections of dextranomer/hyaluronic acid with follow-up in 42, included 35 women with intrinsic sphincter deficiency (ISD), 4 men with postprostatectomy incontinence, 2 men with sphincteric denervation secondary to spinal cord injury, and 1 woman with sphincteric failure after a neobladder. Outcome assessment used gender-appropriate International Consultation on Incontinence Questionnaire, clinical records, and/or urodynamic assessment. RESULTS Of 35 women with ISD, 4 developed pseudoabscess formation with outlet obstruction requiring multiple operative interventions. Patient-defined treatment failure occurred in all 4 carefully selected postprostatectomy incontinent men, and in 23 of 35 females with ISD. CONCLUSIONS Complications with cystoscopically injected dextranomer hyaluronic acid at the bladder neck occurred at a high rate, and using a validated questionnaire, the efficacy of dextranomer hyaluronic acid applied in this manner for ISD was poor.

Efficiency, satisfaction, and costs for remote video visits following radical prostatectomy: a randomized controlled trial.

BACKGROUND Telemedicine in an ambulatory surgical population remains incompletely evaluated. OBJECTIVE To investigate patient encounters in the outpatient setting using video visit (VV) technology compared to traditional office visits (OVs). DESIGN, SETTING, AND PARTICIPANTS From June 2013 to March 2014, 55 prescreened men with a history of prostate cancer were prospectively randomized. VVs, with the patient at home or at work, were included in the outpatient clinic calendar of urologists. INTERVENTION Remote VV versus traditional OV. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS An equivalence analysis was used to assess the primary outcome, visit efficiency as measured by time studies. Secondary outcomes were patient/provider satisfaction and costs. RESULTS AND LIMITATIONS There were 28 VVs and 27 OVs. VVs were equivalent in efficiency to relative to OVs, as measured by patient-provider face time (mean 14.5 vs 14.3min; p=0.96), patient wait time (18.4 vs 13.0min; p=0.20), and total time devoted to care (17.9 vs 17.8min; p=0.97). There were no significant differences in patient perception of visit confidentiality, efficiency, education quality, or overall satisfaction. VVs incurred lower costs, including distance traveled (median 0 vs 95 miles), travel time (0 vs 95min), missed work (0 vs 1 d), and money spent on travel (