M S Khan

Robotic technology in urology.

Urology has increasingly become a technology-driven specialty. The advent of robotic surgical systems in the past 10 years has led to urologists becoming the world leaders in the use of such technology. In this paper, we review the history and current status of robotic technology in urology. From the earliest uses of robots for transurethral resection of the prostate, to robotic devices for manipulating laparoscopes and to the current crop of master–slave devices for robotic-assisted laparoscopic surgery, the evolution of robotics in the urology operating theatre is presented. Future possibilities, including the prospects for nanotechnology in urology, are awaited.

Eosinophilic cystitis and its management

Eosinophilic cystitis (EC) is a rare clinicopathological condition characterized by transmural inflammation of the bladder predominantly with eosinophils, associated with fibrosis with or without muscle necrosis. The cause of EC remains unclear, although it has been associated with various aetiological factors, such as allergy, bladder tumour, bladder trauma, parasitic infections and chemotherapeutic agents. EC is, probably, caused by the antigen–antibody reaction. This leads to the production of various immunoglobulins, which, in turn, cause the activation of eosinophils and initiates the inflammatory process. The most common symptom complex consists of frequency, haematuria, dysuria and suprapubic pain. Cystoscopy and biopsy are the gold standard for diagnosis. Additional laboratory evidence supporting the diagnosis includes proteinuria, microscopic haematuria and peripheral eosinophilia, the last one occurring in few patients. There is no curative treatment for this condition. Current treatment modalities include transurethral resection of the bladder lesion along with non‐specific medical therapy, such as non‐steroidal anti‐inflammatory agents or steroids. Because the lesion tends to recur in spite of the above therapy, long‐term follow‐up is mandatory.

Influence of Number of Retransplants on Renal Graft Outcome

BACKGROUND To assess the influence of number of transplants on the renal graft outcome. METHODS Retrospective analysis of various factors that could influence the outcome of kidney retransplantation in patients receiving more than one allograft between 1993 and 2005 at our center. RESULTS During the 12-year period (1993-2005), 196 patients received more than one renal transplant. Of these, 163 had two (group 1) and 33 had more than two transplants (group II). In group II, 24 patients had three, eight had four, and one had five consecutive allografts. The control group comprised of 100 randomly selected patients receiving a first graft during the same period. In group I, 53 (32.5%) grafts failed. Eighteen (11.0%) patients died with functioning grafts. In group II, 14 (41.2%) grafts failed while four patients (11.8%) died with functioning grafts. In group I, actuarial graft survival rates at 1, 2, 3, and 4 years were 82.3%, 67.3%, 55.97%, and 42.14%, respectively. In group II, the respective figures were 84.85%, 66.67%, 60.61%, and 51.52%. The difference was not statistically significant (P = .96). In the control group, 1-, 2-, 3-, and 4-year survival rates were 92%, 84, 74%, and 60%, respectively. The difference between the control and study groups was statistically significant (P = .0002). CONCLUSION Graft survival after retransplantation is relatively inferior when compared to the primary graft but still remains fairly high. Therefore, previous graft failure should not be considered as a relative contraindication for retransplantation.

Evolution of transdermal oxybutynin in the treatment of overactive bladder.

Overactive bladder (OAB) syndrome affects millions of people worldwide. In addition to adversely affecting quality of life, the direct and indirect costs in managing patients with OAB incur a substantial financial burden on health services. Among the approved anticholinergics for treating OAB, oxybutynin is the most extensively studied drug in clinical trials. The principle metabolite of oxybutynin has a higher affinity for muscarinic receptors in salivary glands which lead to significantly high dry mouth rates. This prompted the development of alternative formulations of oxybutynin aiming to achieve better tolerability whilst sustaining efficacy. This editorial examines the efficacy and tolerability of transdermal oxybutynin (OXY‐TD) in treating OAB. Articles were retrieved from PubMed between 2000 to the present day relating to OXY‐TD. Data is presented from phase I–IV trials. The results from placebo‐controlled trials indicate that OXY‐TD is efficacious in treating patients with OAB associated with urge urinary or mixed incontinence. Systemic side effects most notably dry mouth, appear to be less with this formulation compared with oral anticholinergics. However, further study is required in different OAB populations. The main limitation appears to be related to application site adverse events such as pruritis and erythema. OXY‐TD is likely to find its place as first‐line pharmacotherapy in the clinicians’ armamentarium in treating OAB.

COMING FULL CIRCLE IN ROBOTIC UROLOGY

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Development, validation and clinical application of Pelvic Lymphadenectomy Assessment and Completion Evaluation: intraoperative assessment of lymph node dissection after robot-assisted radical cystectomy for bladder cancer

To develop a scoring tool, Pelvic Lymphadenectomy Appropriateness and Completion Evaluation (PLACE), to assess the intraoperative completeness and appropriateness of pelvic lymph node dissection (PLND) following robot‐assisted radical cystectomy (RARC).

Improving bladder cancer outcomes: The impact of initiating a phase IV randomised controlled clinical trial

Objective: The aim of this study was to determine if patients newly diagnosed with bladder cancer and included in a clinical trial had better outcomes than similar patients treated in the same department before initiation of the trial. Methods: Forty patients presenting with bladder cancer in 2005 and recruited into a randomised trial of photodynamic-assisted tumour resection were compared with a cohort of 40 non-trial patients from 2004. Quality of care was measured by assessing near-miss criteria. Results: There were fewer near-misses in the Trial Group (TG) than in the Control Group (CG) (52 versus 151) (p< 0.001). There were 15 surgical near-misses in the TG compared with 90 in the CG (p=0.025). Adjuvant intravesical chemotherapy was given within 6 h of resection in 26/31(84%) of the TG and 1/23(4%) of the CG. There were 37 process near-misses in the TG compared with 61 in the CG (p=0.002). The times to first outpatient appointment, diagnostic flexible cystoscopy, and outpatient follow-up were shorter in the TG (median 10.5/25/17.5 days) than the CG (median 17/32.5/26 days). Conclusions: Patients in the trial had better outcomes than non-trial patients the previous year. The recruitment of patients into trials is a valuable driver of quality improvement.