Michael E. Chua

Hormonal therapy using gonadotropin releasing hormone for improvement of fertility index among children with cryptorchidism: a meta-analysis and systematic review

BACKGROUND/PURPOSE Gonadotropin releasing hormone(GnRH) as an adjunct to orchidopexy for the treatment of cryptorchidism is still controversial. Present evidences were studied through a meta-analysis of comparative clinical trials. METHOD Systematic literature search was done up to September 30, 2013. Studies were independently appraised by two reviewers. Continuous data of fertility indices were extracted as weighted mean difference (WMD) and standard deviation (SD); while nominal data of fertility indices were extracted as relative risk (RR). Random effects model was used to analyze the pooled effect estimates. Inter-study heterogeneity and publication bias were assessed. PROSPERO Protocol registration (CRD42013004922). RESULTS Ten eligible studies were included. The pooled effect estimates showed that cryptorchid children treated with GnRH when compared with controls, have significantly increased germ cell per tubule (WMD: 0.35; 95% CI 0.07-0.62, P=0.01) and increased RR to have normal value of germ cell per tubule (RR: 2.86; 95% CI 1.73-4.71, P<0.0001). Inter-study heterogeneity was noted, source identified with subgroup analysis. Publication bias was not evident. No GnRH related adverse events were reported in all studies. CONCLUSION Evidence suggests that a subset of boys with cryptorchidism may benefit from GnRH as adjunctive to orchidopexy in improving the fertility index. However, future studies are recommended to specifically identify subgroup characteristics of cryptorchidism that will clearly benefit from the treatment.

Desmopressin Withdrawal Strategy for Pediatric Enuresis: A Meta-analysis

CONTEXT: A high relapse rate after discontinuation of desmopressin treatment of pediatric enuresis is consistently reported. Structured withdrawal strategies have been used to prevent relapse. OBJECTIVE: To assess the efficacy of a structured withdrawal strategy of desmopressin on the relapse-free rate for desmopressin responder pediatric enuresis. DATA SOURCES: Systematic literature search up to November 2015 on Medline, Embase, Ovid, Science Direct, Google Scholar, Wiley Online Library databases, and related references without language restriction. STUDY SELECTION: Related clinical trials were summarized for systematic review. Randomized controlled trials on the efficacy of structured versus abrupt withdrawal of desmopressin in sustaining relapse-free status in pediatric enuresis were included for meta-analysis. DATA EXTRACTION: Eligible studies were evaluated according to Cochrane Collaboration recommendations. Relapse-free rate was extracted for relative risk (RR) and 95% confidence interval (CI). Effect estimates were pooled via the Mantel–Haenszel method with random effect model. RESULTS: Six hundred one abstracts were reviewed. Four randomized controlled trials (total 500 subjects) of adequate methodological quality were included for meta-analysis. Pooled effect estimates compared with the abrupt withdrawal, structured withdrawal results to a significantly better relapse-free rate (pooled RR: 1.38; 95% CI, 1.17–1.63; P = .0001). Subgroup analysis for a dose-dependent structured withdrawal regimen showed a significantly better relapse-free rate (pooled RR: 1.48; 95% CI, 1.21–1.80; P = .0001). LIMITATIONS: The small number of studies included in meta-analysis represents a major limitation. CONCLUSIONS: Structured withdrawal of desmopressin results in better relapse-free rates. Specifically, the dose-dependent structured withdrawal regimen showed significantly better outcomes.

Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children’s Continence Society

BackgroundWe present a consensus view from the International Children’s Continence Society (ICCS) on the evaluation and management of bladder bowel dysfunction (BBD) in children with urinary tract infection (UTI). The statement aims to highlight the importance of BBD in the development and recurrence of childhood UTI and its management to reduce its associated morbidity and sequelae.MethodsA systematic literature search was done on PubMed, Embase, and Scopus databases until August 15, 2016. Relevant publications concerning BBD and its relationship with UTI among children were reviewed and aggregated for statements of recommendation. Discussion by the ICCS Board and a multi-disciplinary core group of authors resulted in a document available on its website for all ICCS members to review. Insights and feedback were considered with consensus and agreement reached to finalize this position statement.ResultsBBD in children with UTI is summarized. Details regarding epidemiology, pathophysiology, and recommendations for general and family practitioners and pediatricians relating to the evaluation and management of this condition are presented.ConclusionsThis document serves as the position statement from ICCS, based on literature review and expert opinion providing our current understanding of BBD in children with UTI.

Efficacy and Safety of Gabapentin in Comparison to Solifenacin Succinate in Adult Overactive Bladder Treatment: Gabapentin for Overactive Bladder

To evaluate the efficacy and safety of gabapentin in comparison to solifenacin succinate and placebo for the treatment of adult patients with overactive bladder (OAB).

Neurostimulation Therapy for Non-neurogenic Overactive Bladder in Children: A Meta-analysis

OBJECTIVE To assess the efficacy and safety of neurostimulation for non-neurogenic overactive bladder in children, we conducted a meta-analysis of randomized controlled trials (RCTs). MATERIALS AND METHODS A systematic literature search was performed on August 2016. RCTs were evaluated according to the Cochrane Collaboration risk of bias assessment. Number of patients with post-treatment partial response (PR) (50%-89%), complete response (CR) (≥90%), and full response (FR) (100%) were extracted for relative risk (RR) and 95% confidence interval (CI). Effect estimates were pooled using the Mantel-Haenszel method with random effect model if significant inter-study heterogeneity (P <.1) was noted. Subgroup analysis was performed according to each treatment setting (PROSPERO CRD42016043502). RESULTS Five eligible studies (245 patients) were included. Overall effect estimates showed that compared with standard urotherapy, neurostimulation demonstrated significantly better ≥50% (PR + CR + FR) response (RR = 2.8, 95% CI 1.1-7.2), but not ≥90% (CR + FR) response (RR = 8.28, 95% CI 0.65-105.92). Clinic-based neurostimulation had significantly better treatment outcomes for both ≥50% (PR + CR + FR) and ≥90% (CR + FR) responses (RR = 3.24, 95% CI 1.89-5.57; RR = 20.81, 95% CI 2.97-145.59, respectively), whereas a self-administered regimen showed no differences for both ≥50% (PR + CR + FR) and ≥90% (CR + FR) response rates between treatment groups (RR = 2.61, 95% CI 0.48-14.15; RR = 3.55, 95% CI 0.19-67.82, respectively). No serious adverse events were reported. CONCLUSION Neurostimulation therapy may lead to better partial improvement of non-neurogenic overactive bladder; however, it may not render a definitive complete response. Office-based neurostimulation seems more efficacious than self-administered neurostimulation. Further RCTs are needed to compare outcomes of the 2 regimens.

2013 Annual National Digital Rectal Exam Day: impact on prostate health awareness and disease detection

Purpose: “Mag-paDRE” is a yearly prostate health public awareness program initiated by the Philippine Urological Association. This study aimed to describe the demographic and clinical data of the participants in the 2013 “Mag-paDRE” program and to identify factors that will further improve prostate health public awareness. Methods: A descriptive cross-sectional study undertaken to collect and assess the demographic data, International Prostate Symptom Score (IPSS) and digital rectal examination findings of the participants in the “Mag-paDRE” conducted in the 10 Philippine Board of Urology (PBU) different accredited training institutions. Descriptive statistics was used to report the proportion of Filipino men aged 40 or older who presented for their first prostate health evaluation. Clinical profile were reviewed and summarized. The study protocol was registered in the Clinicaltrial.gov under Identifier NCT01886547. Results: A total of 925 participants from the 10 PBU accredited training institutions were assessed. Among the 10 training institutions the large tertiary government owned medical center had the highest number of participants and target participants recruited; while the private sectors owned tertiary hospitals have the highest proportion of target participants and cases. According to the predetermined definition of this study, 614 (66%) were considered the target population for the “Mag-paDRE” program. The mean age of the target participants was 58.9±9.9. Only 360 of 614 (59%) were new case, 118 (32.7%) had severe lower urinary tract symptoms (LUTS), 223 (62%) had moderate LUTS, 19 (5.3%) were asymptomatic but with hard prostates, palpable prostate nodules or prostate tenderness. The most bothersome symptoms were incomplete bladder emptying (30.2%), and frequency (22.9%). Conclusions: Overall, the 2013 “Mag-paDRE” among the 10 training institutions was effective in promoting prostate health awareness. A need to modify the preactivity information dissemination by these institutions can be done to further increase the attendance of targeted population of the prostate health awareness program.

Impact of smartphone digital photography, email, and media communication on emergency room visits post-hypospadias repair

INTRODUCTION Advances in communication technology are shaping our medical practice. To date, there is no clear evidence that this mode of communication will have any effect on unnecessary postoperative emergency room (ER) visits. We aim to evaluate the effect of email and media communication with application of smartphone digital photography on post-hypospadias repair ER visit rates. METHODS This prospective cohort study included all patients who underwent hypospadias repair performed by a single surgeon from October 2014 to November 2015. Patients were categorized into two groups: Group A consented for smartphone photography and email communication and Group B declined. Reason for ER visits within 30 days postoperatively was assessed by another physician, who was blinded of patient group assignment. The reasons were categorized as: unnecessary ER visit, indicated ER visit, or visit unrelated to hypospadias surgery. Chi-square test and T-test were used for statistical analysis. Relative risk (RR) and corresponding 95% confidence interval (CI) were also calculated. Statistical significance was set at p<0.05. RESULTS Over a 14-month period, 96 patients underwent hypospadias repair (81 in Group A, 15 in Group B 5). No significant difference was noted between groups for overall ER return rate (RR 0.46, 95% CI 0.21, 1.0). However, the number of ER visits for wound check not requiring intervention was significantly lower in Group A than in Group B (RR 0.14, 95% CI 0.035, 0.56); likewise, a higher number of ER visits requiring intervention was noted in Group A compared with Group B, although statistically this was not significant (RR 1.67, 95% CI 0.23, 12.21). CONCLUSIONS Email communication with the use of smartphone digital photography significantly reduced the number of unnecessary ER visits for post-hypospadias wound checks.

Prevalence and factor association of premature ejaculation among adult Asian males with lower urinary tract symptoms

Purpose To determine the prevalence of premature ejaculation (PE) among adult Asian males presented with lower urinary tract symptoms (LUTS) and characterize its association with other clinical factors. Methods A cross-sectional study was conducted at a tertiary medical center to determine the prevalence of PE among adult male participants with LUTS during the Annual National Prostate Health Awareness Day. Basic demographic data of the participants were collected. All participants were assessed for the presence and severity of LUTS using the International Prostate Symptom Score (IPSS), and for the presence of PE using the PE diagnostic tool. Digital rectal examination was performed by urologists to obtain prostate size. LUTS was further categorized into severity, storage symptoms (frequency, urgency, and nocturia), and voiding symptoms (weak stream, intermittency, straining, and incomplete emptying) to determine their association with PE. Data were analyzed by comparing the participants with PE (PE diagnostic tool score ≥11) versus those without PE, using the independent t test for continuous data, Mann–Whitney U test for ordinal data, and Chi-square test for nominal data. The statistical significance was set at P < 0.05. Results A total of 101 male participants with a mean ± standard deviation age of 60.75 ± 10.32 years were included. Among the participants, 33% had moderate LUTS, and 7% severe LUTS. The most common LUTS was nocturia (33%). The overall prevalence of PE was 27%. There was no significant difference among participants with PE versus those without PE in terms of age, marital status, prostate size, or total IPSS score. However, significant difference between groups was noted on the level of education (Mann–Whitney U, z = −1.993, P = 0.046) where high educational status was noted among participants with PE. Likewise, participants with PE were noted to have more prominent weak stream (Mann–Whitney U, z = −2.126, P = 0.033). Conclusions Among the participants consulted with LUTS, 27% have concomitant PE. Educational status seems to have an impact in the self-reporting of PE, which may be due to a higher awareness of participants with higher educational attainment. A significant association between PE and weak stream that was not related to prostate size suggests a neuropathologic association.

Configuration and validation of a novel prostate disease nomogram predicting prostate biopsy outcome: A prospective study correlating clinical indicators among Filipino adult males with elevated PSA level

Objective To configure and validate a novel prostate disease nomogram providing prostate biopsy outcome probabilities from a prospective study correlating clinical indicators and diagnostic parameters among Filipino adult male with elevated serum total prostate specific antigen (PSA) level. Methods All men with an elevated serum total PSA underwent initial prostate biopsy at our institution from January 2011 to August 2014 were included. Clinical indicators, diagnostic parameters, which include PSA level and PSA-derivatives, were collected as predictive factors for biopsy outcome. Multiple logistic-regression analysis involving a backward elimination selection procedure was used to select independent predictors. A nomogram was developed to calculate the probability of the biopsy outcomes. External validation of the nomogram was performed using separate data set from another center for determination of sensitivity and specificity. A receiver-operating characteristic (ROC) curve was used to assess the accuracy in predicting differential biopsy outcome. Results Total of 552 patients was included. One hundred and ninety-one (34.6%) patients had benign prostatic hyperplasia, and 165 (29.9%) had chronic prostatitis. The remaining 196 (35.5%) patients had prostate adenocarcinoma. The significant independent variables used to predict biopsy outcome were age, family history of prostate cancer, prior antibiotic intake, PSA level, PSA-density, PSA-velocity, echogenic findings on ultrasound, and DRE status. The areas under the receiver-operating characteristic curve for prostate cancer using PSA alone and the nomogram were 0.688 and 0.804, respectively. Conclusion The nomogram configured based on routinely available clinical parameters, provides high predictive accuracy with good performance characteristics in predicting the prostate biopsy outcome such as presence of prostate cancer, high Gleason prostate cancer, benign prostatic hyperplasia, and chronic prostatitis.

Tissue Bulking Agent-Polyacrylate Polyalcohol Copolymer for Endoscopic Correction of Vesicoureteral Reflux in Children: A Comparative Study

Objective: To evaluate the treatment outcome of single session endoscopic treatment using Polyacrylate Polyalcohol Copolymer (PPC) (Vantris ®) compared with conservative Continuous Antibiotic Prophylaxis (CAP) and open surgical treatment among children with Vesico-Ureteral Reflux (VUR). Methods: A retrospective cohort was undertaken in a single institution to evaluate children diagnosed with primary VUR grade 2-4 from 2006-2012 treated by a single urologist with different treatment modalities- conservative continuous antibiotic prophylaxis, endoscopic correction with PPC and open ureteral re-implantation with Cohen technique. Included patients for the study were only those who had 1-3 months and >1 year post-treatment follow- up study with Voiding Cystourethrogram (VCUG), kidney ultrasound, Dimercaptosuccinic Acid (DMSA) renal scan, and urine culture. Comparative analysis was made to evaluate the rate of VUR resolution, reflux recurrence, renal scaring and VUR treatment related hospital stay. Results: Twenty-five children (12 girl and 13 boys) with a mean age of 3 ± 1.4 years were included. Twelve children had bilateral VUR and thirteen had unilateral VUR, a total of thirty-seven Refluxing Renal Units (RRU) were being analyzed (12 CAP, 11 endoscopic corrections and 14 open re-implantation surgery). On initial 3 months post-treatment follow-up, RRU VUR resolution observed for CAP, PPC and open surgery were 33% (4/12), 91% (10/11) and 100% (14/14), respectively. At >1 year post treatment follow-up, VUR resolution were noted in 50% (6/12) treated with CAP. For PPC treated group, 27% (3/11) had reflux recurrence or persistence and 14% (2/14) of open surgery group had ureteral obstruction with hydronephrosis. Renal scarring detected among CAP, PPC and surgery group at >1 year follow-up were 42% (5/12), 18% (2/11) and 14% (2/14), respectively. VUR treatment related mean hospital day per year was highest among the CAP group (6.25 ± 2.6 days/year) and lowest among PPC group (3.27 ± 1.2 days/year). Conclusion: Endoscopic correction of VUR with PPC resulted to better treatment outcome when compared to CAP and was comparable to open surgical management with shorter treatment related hospital stay.