M.P. Laguna

Prognostic Factors and Percutaneous Nephrolithotomy Morbidity: A Multivariate Analysis of a Contemporary Series Using the Clavien Classification

PURPOSE We stratified factors affecting treatment morbidity, compared the outcomes of percutaneous nephrolithotomy procedures from a single department and provided evidence of treatment benefits when percutaneous nephrolithotomy is performed in an expert setting. MATERIALS AND METHODS Since the department became a dedicated endourological center in 2002 we grouped all percutaneous nephrolithotomy procedures into those performed before 2002 (group 1) and after 2002 (group 2). The modified Clavien classification was used to score morbidity. Independent variables with an influence on complications were studied including stone size, operating time, operative complications, dilation device, urine culture, group allocation and lithotripsy device. Contingency and logistic regression were used for univariate and multivariate analysis. RESULTS Of the 244 percutaneous nephrolithotomy procedures 68 comprised group 1 and 176 formed group 2. Statistical preoperative differences were patient age, the use of anticoagulants and positive urinary cultures. Group 1 had a complication rate of 56.8% and group 2 had a complication rate of 37.2%. There were significant differences between the groups (p = 0.007). Almost all complications were grade 1 to 2. On univariate analysis the influence variables were urine culture (OR 1.69), group allocation (OR 2.20), stone size (OR 2.28), dilation device (OR 4.8), lithotripsy device (OR 1.22), perioperative complications (OR 2.83) and surgical time (OR 1.87). On multivariate analysis the independent factors in the complicated outcome were stone size (OR 1.25), type of lithotripsy device (OR 1.35) and incidence of perioperative complications (OR 3.71). CONCLUSIONS The dedicated setting for percutaneous nephrolithotomy at our center resulted in decreased operative time, more uneventful procedures and decreased hospitalization time. The modified Clavien morbidity score is a reliable tool for more objective outcome comparisons after renal stone treatment.

The Role for Active Monitoring in Urinary Stones: A Systematic Review

BACKGROUND AND PURPOSE All urinary stones may not need prompt active treatment. The aim of our study was to identify urinary stones that can be actively monitored safely. MATERIALS AND METHODS We performed a systematic review of the natural history and the role of active monitoring for urinary stones. RESULTS Thirty-seven studies have selected. Of symptomatic ureteral calculi <4 mm, 38% to 71% will pass spontaneously while only 4.8% of stones <2 mm will need intervention during surveillance. Follow-up with history, physical examination, urinalysis, and plain radiography every 2 weeks for 1 month is necessary. If spontaneous passage does not occur within this period, intervention is recommended. When shockwave lithotripsy for caliceal stones is prospectively compared with observation, there is no difference in stone-free rates (28% vs 17%), need for additional treatment (15% vs 21%), or visits to a general practitioner (18.5% vs 20.8%). Patients under observation may need more invasive procedures and may be more commonly left with residual stone fragments >5 mm (58% vs 30%). Isolated, nonuric acid calculi <4 mm may be most amenable to active monitoring. Physical examination, urinalysis, and CT scan performed on an annual basis up to year 2 or 3, followed by intervention, are recommended. Lower pole stones <10 mm could be actively monitored on an annual basis by alternating ultrasonoraphy with CT scan, provided the patients are adequately informed. Up to 58.6% and 43% of patients with residual fragments after shockwave and percutaneous lithotripsy, respectively, may become symptomatic or require intervention during follow-up. Noninfected, asymptomatic fragments, <4 mm postextracorporeal lithotripsy, and <2 mm postpercutaneous surgery could be followed expectantly on an annual basis, in combination with medical therapy. CONCLUSION Active stone monitoring has a certain role in the treatment of patients with urinary stones. The success is largely dependent on the stone size, location, and composition, as well as the time after the diagnosis. Medical therapy is a useful adjunct to observation.

Post-Void Residual Urine Volume is Not a Good Predictor of the Need for Invasive Therapy Among Patients With Benign Prostatic Hyperplasia

PURPOSE We assessed the value of baseline PVR as predictor of the need for invasive therapy during long-term followup of patients with clinical BPH treated initially with alpha1-blockers or WW. MATERIALS AND METHODS The records of a cohort of 942 patients with BPH treated with alpha(1)-blockers or WW were reviewed. Baseline I-PSS scores, PSA, prostate volume, uroflowmetry, pressure flow parameters and followup data were collected prospectively. Correlations between PVR and other baseline parameters were calculated. The 5-year cumulative risks of invasive therapy were calculated with the Kaplan-Meier method. After stratification of PVR by various cutoff levels (50, 100 and 300 ml), rate ratios between large and small PVRs were calculated using proportional hazards analyses. RESULTS PVR has weak (-0.2<R <0.2) correlations with other baseline parameters. With increasing PVR cutoff levels, the 5-year cumulative risk of invasive therapy for the large PVR subgroup, increases from 45% to 64% and from 15% to 21% in the alpha1-blockers and WW group, respectively. Large PVR yields a significant 2-fold up to a 4-fold increased risk of invasive therapy compared to small PVR in both treatment groups. In multivariate models these significant risk differences largely disappear, although a statistically not significant higher risk remains for the large PVR (greater than 300 ml) patients. CONCLUSIONS In general, baseline PVR has little prognostic value for the risk of BPH related invasive therapy in patients on alpha1-blocker and WW. Only patients with large PVR have a 2-fold increased risk of invasive therapy compared to patients with smaller PVR.

Laparoscopic radical prostatectomy: a European virus.

The evolution of prostate cancer treatment has now incorporated the principles of minimally invasive surgery. Laparoscopic radical prostatectomy, just like a virus, infected first Europe and three years ago the United States. This European virus has nowadays a potentially widespread application. Oncological efficacy and ability to preserve and improve continence and potency are the factors that will ultimately determine the role of laparoscopic radical prostatectomy and thus the future of this virus infection. This article reviews the current published experience with minimally invasive prostatectomy and provides comparisons to published data on radical retropubic prostatectomy to increase awareness about viability. Some prospective and retrospective non‐randomized comparative studies of the two approaches are also included in the present review. The current practice patterns regarding urological laparoscopic surgery and the tendency of the urologic community in Europe and in the United States to establish minimally invasive radical prostatectomy in more urological departments are described.

Contrast-enhanced ultrasonography

Ultrasound is the cornerstone for prostatic imaging and covers diagnostics, therapy monitoring, and follow-up. In the aspect of focal therapy, accurate prostate cancer localization is mandatory. Contrast-enhanced ultrasound (CEUS) is a promising imaging technique which has shown to greatly increase the chances to find prostate cancer in biopsies. At the moment, CEUS is only performed in expert centers because of difficult interpretation and steep learning curves. CEUS quantification techniques can make reliable and objective interpretation, with a high sensitivity, possible outside of expert centers. Focal therapy and active surveillance are increasingly used, but require to be supported by proper imaging techniques. CEUS seems a promising technique for real-time monitoring and follow-up of focal therapy treatment. In the near future, the use of targeted contrast agents will be a major breakthrough in the combat against prostate cancer. They show promising results regarding better visualization and longer lasting contrast enhancement of prostate cancer in in-vitro as well as in in-vivo animal experiments.

Avances en el diagnostico ecográfico del cáncer de próstata

OBJETIVO: La biopsia guiada por ecografia posee un papel primordial en el diagnostico del cancer de prostata. Diversos protocolos de biopsia prostatica guiada mediante ultrasonidos se han diseno en un intento de mejorar el diagnostico del cancer de prostata. La incorporacion de los contrastes vasculares permite identificar aquellas zonas hipervasculares compatibles con cancer, mientras que los nuevos modos de ecografia permiten incrementar y diferenciar la senal producida por el contraste, separandola de la senal reflejada por el tejido normal. METODO: Revision no estructurada de la literatura sobre la utilidad de los diversos modos y tipos de ecografia en dirigir la biopsia prostatica.