Lawrence L. Yeung

A Comparison of Chlorhexidine-Alcohol Versus Povidone-Iodine for Eliminating Skin Flora Before Genitourinary Prosthetic Surgery: A Randomized Controlled Trial

PURPOSE We defined the relevant skin flora during genitourinary prosthetic surgery, evaluated the safety of chlorhexidine-alcohol for use on the male genitalia and compared chlorhexidine-alcohol to povidone-iodine in decreasing the rate of positive bacterial skin cultures at the surgical skin site before prosthetic device implantation. MATERIALS AND METHODS In this single institution, prospective, randomized, controlled study we evaluated 100 consecutive patients undergoing initial genitourinary prosthetic implantation. Patients were randomized to a standard skin preparation with povidone-iodine or chlorhexidine-alcohol. Skin cultures were obtained from the surgical site before and after skin preparation. RESULTS A total of 100 patients were randomized, with 50 in each arm. Pre-preparation cultures were positive in 79% of the patients. Post-preparation cultures were positive in 8% in the chlorhexidine-alcohol group compared to 32% in the povidone-iodine group (p = 0.0091). Coagulase-negative staphylococci were the most commonly isolated organisms in post-preparation cultures in the povidone-iodine group (13 of 16 patients) as opposed to propionibacterium in the chlorhexidine-alcohol group (3 of 4 patients). Clinical complications requiring additional operations or device removal occurred in 6 patients (6%) with no significant difference between the 2 groups. No urethral or genital skin complications occurred in either group. CONCLUSIONS Chlorhexidine-alcohol was superior to povidone-iodine in eradicating skin flora at the surgical skin site before genitourinary prosthetic implantation. There does not appear to be any increased risk of urethral or genital skin irritation with the use of chlorhexidine compared to povidone-iodine. Chlorhexidine-alcohol appears to be the optimal agent for skin preparation before genitourinary prosthetic procedures.

A Critical Review of Clinical Practice Guidelines for the Management of Clinically Localized Prostate Cancer

PURPOSE Increasingly there is a recognized need for the development of high quality, evidenced-based clinical guidelines to assist clinicians and patients in critically important treatment related decision making. We review the different approaches used by leading urological organizations to develop guidelines for the management of clinically localized prostate cancer and their specific recommendations for case management. MATERIALS AND METHODS Guidelines for the management of localized prostate cancer developed by leading professional organizations were identified through the National Guidelines Clearinghouse, PubMed, cited references and personal communication with prostate cancer experts. A structured data abstraction was applied to assess how the guideline was developed, what type of professionals and stakeholders were involved in the development process, how the primary evidence was identified and graded, and what specific final recommendations were reported. RESULTS Clinical practice guidelines on the management of clinically localized prostate cancer demonstrate major differences in their specific recommendations. Few recommendations are based on high level evidence, and there are considerable discrepancies among the systems used to grade the quality of the evidence and the strength of the recommendations. CONCLUSIONS There appears to be a need to standardize the process used by leading urological organizations to develop clinical guidelines for the management of prostate cancer. A unified approach may offer considerable rewards in terms of efficiency, guideline credibility and optimal clinical decision making. Furthermore, increased efforts are indicated to promote studies that yield high quality evidence to guide the management of prostate cancer.

Clinical Practice Guidelines on Prostate Cancer: A Critical Appraisal

PURPOSE Clinical practice guidelines are increasingly being used by leading organizations to promote high quality evidence-based patient care. However, the methodological quality of clinical practice guidelines developed by different organizations varies considerably. We assessed published clinical practice guidelines on the treatment of localized prostate cancer to evaluate the rigor, applicability and transparency of their recommendations. MATERIALS AND METHODS We searched for English based clinical practice guidelines on treatment of localized prostate cancer from leading organizations in the 15-year period from 1999 to 2014. Clinical practice guidelines limited to early detection, screening, staging and/or diagnosis of prostate cancer were excluded from analysis. Four independent reviewers used the validated AGREE II instrument to assess the quality of clinical practice guidelines in 6 domains, including 1) scope and purpose, 2) stakeholder involvement, 3) rigor of development, 4) clarity of presentation, 5) applicability and 6) editorial independence. RESULTS A total of 13 clinical practice guidelines met inclusion criteria. Overall the highest median scores were in the AGREE II domains of clarity of presentation, editorial independence, and scope and purpose. The lowest median score was for applicability (28.1%). Although the median score of editorial independence was high (85.4%), variability was also substantial (IQR 12.5-100). NICE and AUA clinical practice guidelines consistently scored well in most domains. CONCLUSIONS Clinical practice guidelines from different organizations on treatment of localized prostate cancer are of variable quality and fall short of current standards in certain areas, especially in applicability and stakeholder involvement. Improvements in these key domains can enhance the impact and implementation of clinical practice guidelines.

How to Use a Clinical Practice Guideline

PURPOSE Leading organizations increasingly recognize clinical practice guidelines as an important approach in promoting an evidence-based clinical practice of urology. In light of their considerable clinical, economic and medicolegal impact, guideline users should be confident that the guidelines were rigorously developed and address relevant patient questions. In this article we outline a practical approach for critically appraising a clinical practice guideline. MATERIALS AND METHODS We outline a 3-step approach to the assessment of a clinical practice guideline that answers the questions of whether the recommendations are valid, what the recommendations are and whether they will help in the treatment of an individual patient. RESULTS To determine the adequacy of a clinical practice guideline, urologists should carefully review the rigor of the development process and its content. Important questions that relate to the validity of a guideline are whether, for specific questions, all important management options and outcomes were considered, and whether there was an explicit and sensible process to identify, select and combine all relevant evidence. Clinical practice guidelines should formally grade the quality of the available evidence for a given clinical question and outline a formal process of how the recommendations were derived. Value judgments made in the guideline development process about the relative importance of the potential benefits and harms of a given health care intervention should be made transparent to the reader. The recommendations made should be practical and should address important clinical issues. Furthermore, their strength should be graded to reflect the underlying uncertainty about the evidence and the values applied in the guideline development process. CONCLUSIONS The systematic approach presented in this article will allow urologists to critically appraise clinical practice guidelines. Determining the validity of the recommendations, understanding the recommendations and assessing their applicability to patients are 3 fundamental steps toward an evidence-based approach to using clinical practice guidelines.

Contemporary management of renal trauma: differences between urologists and trauma surgeons.

Background: The purpose of this study was to evaluate the contemporary practice patterns of urologists (UR) and trauma surgeons (TS) regarding controversial topics in the management of renal trauma (RT). Methods: We conducted a national survey of all Society of Genitourinary Reconstructive Surgeons members and a random sampling of American Association for the Surgery of Trauma members between October and November 2010 via email, regarding management routines for various stages of blunt and penetrating RT. Results: Response rate was 33%. In all, 21% of TS and 3% of UR (p = 0.005) do not use any tests to confirm the presence of another kidney before exploring an expanding retroperitoneal hematoma, despite lack of preoperative imaging. To confirm the presence of another kidney, UR prefer the “one-shot” intravenous pyelogram (82%), whereas TS prefer palpation (61%; p < 0.001). TS do not obtain primary renal vascular control before opening the retroperitoneal, whereas UR do (21% vs. 71%; p < 0.001). TS utilize early angiography for the control of intravascular contrast extravasation more commonly than UR (88% vs. 55%; p < 0.001). TS overutilize ureteral stenting (50% vs. 24%; p < 0.001) for isolated collecting system injuries compared with UR. Differences in practice patterns between TS and UR tend to follow differences in published guidelines. Conclusion: There is an apparent lack of communication and differing treatment methods for RT. That there are two camps with differing “community standards of practice” indicates that there is a desperate need for reeducation and for large-scale, multi-institutional prospective studies on RT to “standardize” management. Level of Evidence: V, expert opinion.

Evidence-based medicine training in residency: a survey of urology programme directors

To investigate whether and in what format urology residents receive formal training in evidence‐based clinical practice.

Intraoperative Tissue Characterization and Imaging

As surgical operative technology improves, surgeons today have the ability to visualize fine structures and detailed anatomy. There are a number of advances that have been made to optimize patient outcomes with better tissue characterization in urologic procedures. This article focuses on advances in intraoperative imaging and tissue characterization for various urologic procedures. Each modality is presented with its corresponding applications in urology. The following techniques are covered: optical coherence tomography, confocal fluorescent microscopy, near infrared fluorescence imaging, elastography, intraoperative ultrasonography, and a neurovascular bundle surgical mapping aid.

Duplicate Presentations on Prostate Cancer at American Urological Association and European Association of Urology Annual Meetings

PURPOSE We determined the rate of duplicate research presentations at recent American Urological Association and European Urological Association annual meetings. MATERIALS AND METHODS We cross-referenced all clinical research presentations related to prostate cancer presented at the 2006 American Urological Association and European Urological Association annual meetings with those presented at the corresponding annual meetings in 2005, 2006 and 2007 using a defined search strategy based on author names, abstract titles, study design and objectives. All data abstraction was performed in duplicate by 2 independent reviewers to ensure accuracy. RESULTS We identified 282 and 312 abstracts on prostate cancer clinical research at the 2006 European Urological Association and American Urological Association annual meetings, respectively. The overall duplication rate of American Urological Association abstracts was 19.2% (60 of 312). Of duplicated abstracts 80.0% (48 of 60) were presented at the European Urological Association annual meeting the same year. Duplication of European Urological Association abstracts was identified in 20.9% (59 of 282). Authors who presented the same research (71 duplicate abstracts) at the 2 meetings altered the presentations in various ways, including a different study title in 40.8%, a different first and senior author in 14.1% and 18.3%, and increased or decreased sample size in 8.5% and 14.1%, respectively. CONCLUSIONS Approximately a fifth of clinical research abstracts on prostate cancer presented at the American Urological Association annual meeting were also presented at the European Urological Association meeting and vice versa. Inconsistencies between duplicate abstracts raise concerns about the integrity of the underlying studies. Stricter submission guidelines and improved dissemination of research findings from the 2 meetings may help limit this practice.

Development of Squamous Cell Carcinoma of Buccal Mucosa Graft Used for Urethroplasty: A Case Report

Urethroplasty may involve the use of tissue substitution including buccal mucosa graft (BMG), penile fasciocutaneous flaps, or skin grafts. Stricture recurrence and fistula formation are some uncommon complications that can result from surgery. The development of squamous cell carcinoma (SCC) after BMG substitution urethroplasty is a new complication that we encountered that has not been described in the literature. We present the first reported case of a patient who developed SCC of the buccal mucosa graft used to reconstruct the urethra.

Surgical reconstruction and follow-up of penile strangulation injury

Penile strangulation by a foreign body is an uncommon urological emergency.1 Previously reported mechanisms include metallic rings, washers, rubber bands, and hair tourniquets.2e4 These injuries classically lead to progressive edema, ischemia, and tissue necrosis and must be recognized and treated immediately in order to avoid irreversible tissue loss. The current body of literature often documents a detailed mechanism of injury in such cases; however, the progression of the injuries beyond initial presentation to include management and results in longitudinal follow-up are rarely captured.3,4 Our report addresses the full care episode and follow-up of a unique case of penile strangulation injury.