Ken Anson

A multicenter, randomized, prospective study of endoscopic laser ablation versus transurethral resection of the prostate

OBJECTIVES To assess the safety and efficacy of endoscopic laser ablation of the prostate (ELAP), performed with the Urolase fiber and the neodymium:yttrium-aluminum-garnet laser, compared to transurethral resection of the prostate (TURP) in patients with bladder outflow obstruction secondary to benign prostatic hyperplasia (BPH). METHODS In this multicenter, prospective, randomized study, a total of 151 patients were treated (ELAP, 76; TURP, 75) of whom 137 completed 1 year follow-up (ELAP, 67; TURP, 70). Safety parameters included measurement of preoperative and 24-hour postoperative sodium, hematocrit, and hemoglobin values and careful monitoring of adverse events. Efficacy was assessed with the American Urological Association symptom score (6), urinary flow rates, and residual urinary volume measurements. RESULTS There was 1 death in each group during the study period unrelated to the treatment procedure. There was a clinically significant improvement in all efficacy parameters in both groups. Between group comparisons favored TURP in maximum flow rate, residual urinary volume, and symptom score. ELAP had a better safety profile than TURP in the defined safety parameters of drop in hemoglobin and hematocrit values. In 16% of patients, a blood transfusion was required after TURP compared with no transfusions in the ELAP group. Urinary tract infections and dysuria were more frequent in the ELAP group. CONCLUSIONS ELAP performed with the Urolase fiber is a useful alternative therapy to TURP in patients presenting with bladder outflow obstruction secondary to BPH.

Acute urinary retention in men: an age old problem.

Acute urinary retention refers to the sudden inability to pass urine. It will often be unexpected, usually inconvenient, and always painful. If a man lives long enough his risk of having an episode of acute urinary retention is remarkably high. Over 1 in 10 men in their 70s will experience acute urinary retention within the next five years.1 The risk for men in their 80s is nearly 1 in 3. Treatment depends largely on where the episode occurred. In some areas men have catheters inserted by their general practitioners (with immediate relief of pain), in others patients have to get to hospital first.2 Once a catheter is inserted treatment depends on local policy. Some men will be sent home with a catheter and collection bag, others will spend a night or two in hospital, and a few will find themselves consenting to prostatectomy the next day.3Those sent home will have to wait to be readmitted for a trial without catheter or prostatectomy, or both (if the trial fails). Our understanding of why men develop acute urinary retention has been limited. Until recently, the only way to deal with the condition was to drain the bladder with a catheter. Over the centuries only the materials, silicone rubber instead of silver and ivory, have changed (1). However, recent developments offer hope of better treatment. Firstly, high quality experimental and community based studies have greatly improved our understanding of the epidemiology and pathogenesis of acute urinary retention. Secondly, recent reports suggest that acute urinary retention might be preventable in some men. Thirdly, development in catheter technology might substantially improve management and make hospital admission unnecessary. #### Summary points

Success and Short-term Complication Rates of Percutaneous Nephrostomy during Pregnancy

Outcome of percutaneous nephrostomy creation during pregnancy was retrospectively studied. Catheter insertion was successful in all cases (N = 8; 3% of all nephrostomies over a 5-year period), with one major complication (sepsis) and three minor complications. Catheters remained in situ for a mean of 9.4 days until the stone passed (n = 1) or was removed on ureteroscopy (n = 2) or a ureteral stent was inserted (n = 5). Maternal outcome was normal in all cases, but there were two premature deliveries. Nephrostomy during pregnancy has acceptable technical and clinical results, but the possibility of an increased risk of septic complications (12.5% in this series) necessitates further study.

Computed Tomography for Percutaneous Renal Access

Abstract Successful percutaneous nephrolithotomy (PCNL) relies on appropriate preoperative planning and optimal percutaneous access. CT has now become the standard imaging tool for PCNL. For percutaneous renal access, CT may be used for planning access, guiding access, and in the follow-up after access. In this review, we discuss the role of each aspect for percutaneous access in PCNL. In particular, we describe the technique for gaining access using CT, a valuable method in the difficult collecting system.

Does endoscopic laser ablation of the prostate stand the test of time? Five-year results from a multicentre randomized controlled trial of endoscopic laser ablation against transurethral resection of the prostate

Objective To determine the long‐term objective and subjective outcome of patients with benign prostatic enlargement (BPE) treated by endoscopic laser ablation of the prostate (ELAP), as part of a multicentre randomized controlled trial of ELAP against TURP.

What radiation exposure can a patient expect during a single stone episode

PURPOSE There is increasing concern about the risks of radiation exposure with the advent of new, more complex imaging modalities. For example, computed tomography (CT), with its obvious advantages, is being more commonly used in the investigation of acute flank pain. The likely radiation exposure a patient can expect during a single complete urinary stone episode was studied. PATIENTS AND METHODS The hospital records of 60 consecutive unselected patients who had become or were rendered stone-free were studied. The effective radiation doses in milliSieverts (mSV) associated with diagnostic imaging modalities such as intravenous urogram studies and CT scans were calculated for St. Georges Hospital. By combining these with the published effective doses for interventional examinations, the total effective dose over an entire stone episode was derived. RESULTS There were a total of 60 patients with 68 stones (15 renal, 9 in the upper, 12 in the middle, and 32 in the lower ureter), with a median stone burden of 4 mm. Thirty-two patients had procedures performed, including extracorporeal shockwave lithotripsy SWL. Total effective doses ranged from 1.18 to 37.66 mSv (median 5.3 mSv; 95% CI of the median 4.13, 7.61). Renal and proximal ureteral stones resulted in the highest radiation exposures. CONCLUSION In this study the median radiation dose per stone episode was calculated at 5.3 mSv, with higher doses in those with renal stones and those who required CT scans and other interventions. Monitoring and reduction of radiation exposure is advised for all patients presenting with urolithiasis.

Portable ultrasonography and bladder volume accuracy--a comparative study using three-dimensional ultrasonography.

OBJECTIVES To compare the ultrasound bladder volume accuracy and level of agreement between two portable bladder scanners (Bladderscan and Bardscan) and a three-dimensional ultrasound (3D-US) system. METHODS A total of 50 healthy volunteers were scanned using the Bladderscan BVI 3000, Bardscan, and 3D-US system (HDI 4000), in random sequence. The BVI3000 is a dedicated bladder volume calculator, and the Bardscan combines real-time ultrasonography with bladder volume calculation. The ultrasound bladder volumes were compared with the voided volume measurements. The volunteers underwent repeat scanning after voiding, and those with a measurable residual volume were excluded from the final analysis. RESULTS A residual volume was detected in 16 subjects (32%). In the remaining 34 subjects, the mean voided volume +/- standard deviation was 252.9 +/- 167.4 mL (range 33 to 709). A significant correlation (P <0.001) was found between the voided and ultrasound volumes with all three methods (Bardscan, r = 0.97; Bladderscan, r = 0.98; and 3D-US system, r = 0.99). No significant differences were found between the voided volumes and the Bladderscan or 3D-US volumes; however, the Bardscan significantly underestimated the voided volume by a mean of 21.4 mL (t = 2.84, P = 0.0076). The Bland-Altman 95% limit of agreement between the voided and calculated volumes was -64.5 to 107.2 mL, -73.7 to 88.4 mL, and -28.9 to 40.0 mL for the Bardscan, Bladderscan, and 3D-US systems, respectively. CONCLUSIONS The results of our study have shown that although the Bardscan has the advantages of real-time scanning with portability and instantaneous volume calculation, it is not as accurate as the Bladderscan. The accuracy and level of clinical agreement was greatest when using the 3D-US system to calculate the bladder volume.

The risk of prostate cancer amongst South Asian men in southern England : the PROCESS cohort study

To reinvestigate whether South Asian men in the UK are at lower risk of being diagnosed with prostate cancer in a UK‐based retrospective cohort study and to examine possible reasons that may explain this.

Percutaneous nephrostomy and ureteric stent insertion for acute renal deobstruction: Consensus based guidance

Objective: Ureteric obstruction can be relieved by either percutaneous nephrostomy (PCN) or retrograde ureteric stenting (RUS). Both are associated with variable technical success, complication rates, availability and quality of life issues. Our aim was to generate guidelines for PCN, RUS and the general approach of renal deobstruction in the UK. Materials and Methods: Subsequent to a pilot study, a formal postal questionnaire regarding the indication and method of renal deobstruction was sent via the BAUS audit office to members of BAUS, BSIR, BSUR. Data from 227 radiologists and urologists were categorised into areas of “clear agreement” (>75% agreement), “broad agreement” (50–75% agreement) and “no broad consensus” (less than 50% agreement) for any particular method of management. Results: In septic patients with renal obstruction, there was “clear agreement” for urgent deobstruction by PCN. If uncorrectable coagulopathy exists then RUS was the preferred option. There was “clear agreement” that patients with acute or chronic renal failure should be deobstructed during working hours if not septic, with “broad agreement” that this should be performed with PCN. Patients with obstruction subsequent to pelvic malignancy and the pregnant patient are discussed. Conclusion: The authors hope that these results and recommendations will aid clinical decision-making and aid the development of local and regional PCN and RUS services.

CURRENT OPINION AMONGST RADIOLOGISTS AND UROLOGISTS IN THE UK ON PERCUTANEOUS NEPHROSTOMY AND URETERIC STENT INSERTION FOR ACUTE RENAL UNOBSTRUCTION: RESULTS OF A POSTAL SURVEY

© 2 0 0 6 T H E A U T H O R S J O U R N A L C O M P I L A T I O N