Paramananthan Mariappan

ONE WEEK OF CIPROFLOXACIN BEFORE PERCUTANEOUS NEPHROLITHOTOMY SIGNIFICANTLY REDUCES UPPER TRACT INFECTION AND UROSEPSIS: A PROSPECTIVE CONTROLLED STUDY

Urosepsis after percutaneous nephrolithotomy (PCNL) is a severe complication, and its avoidance can sometimes be difficult despite antibiotic prophylaxis. Authors from the UK with a considerable experience in this procedure describe a prospective controlled study using ciprofloxacin for 1 week before PCNL, and found that it significantly reduces the risk of urosepsis.

Good quality white‐light transurethral resection of bladder tumours (GQ‐WLTURBT) with experienced surgeons performing complete resections and obtaining detrusor muscle reduces early recurrence in new non‐muscle‐invasive bladder cancer: validation across time and place and recommendation for benchmarking

Study Type – Therapy (cohort)

Prevalence and correlations of lower urinary tract symptoms, erectile dysfunction and incontinence in men from a multiethnic Asian population : results of a regional population-based survey and comparison with industrialized nations

To determine, in a population‐based survey, the prevalence of lower urinary tract symptoms (LUTS), erectile dysfunction (ED) and incontinence in community‐dwelling men in multiethnic Malaysia, as currently available Western demographic data might not be applicable in the Asian population.

Clinical and Cost Effectiveness of Hexaminolevulinate-guided Blue-light Cystoscopy: Evidence Review and Updated Expert Recommendations

CONTEXT Non-muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence risk, partly because of the persistence of lesions following transurethral resection of bladder tumour (TURBT) due to the presence of multiple lesions and the difficulty in identifying the exact extent and location of tumours using standard white-light cystoscopy (WLC). Hexaminolevulinate (HAL) is an optical-imaging agent used with blue-light cystoscopy (BLC) in NMIBC diagnosis. Increasing evidence from long-term follow-up confirms the benefits of BLC over WLC in terms of increased detection and reduced recurrence rates. OBJECTIVE To provide updated expert guidance on the optimal use of HAL-guided cystoscopy in clinical practice to improve management of patients with NMIBC, based on a review of the most recent data on clinical and cost effectiveness and expert input. EVIDENCE ACQUISITION PubMed and conference searches, supplemented by personal experience. EVIDENCE SYNTHESIS Based on published data, it is recommended that BLC be used for all patients at initial TURBT to increase lesion detection and improve resection quality, thereby reducing recurrence and improving outcomes for patients. BLC is particularly useful in patients with abnormal urine cytology but no evidence of lesions on WLC, as it can detect carcinoma in situ that is difficult to visualise on WLC. In addition, personal experience of the authors indicates that HAL-guided BLC can be used as part of routine inpatient cystoscopic assessment following initial TURBT to confirm the efficacy of treatment and to identify any previously missed or recurrent tumours. Health economic modelling indicates that the use of HAL to assist primary TURBT is no more expensive than WLC alone and will result in improved quality-adjusted life-years and reduced costs over time. CONCLUSIONS HAL-guided BLC is a clinically effective and cost-effective tool for improving NMIBC detection and management, thereby reducing the burden of disease for patients and the health care system. PATIENT SUMMARY Blue-light cystoscopy (BLC) helps the urologist identify bladder tumours that may be difficult to see using standard white-light cystoscopy (WLC). As a result, the amount of tumour that is surgically removed is increased, and the risk of tumour recurrence is reduced. Although use of BLC means that the initial operation costs more than it would if only WLC were used, over time the total costs of managing bladder cancer are reduced because patients do not need as many additional operations for recurrent tumours.

Endoscopic stone surgery: minimizing the risk of post-operative sepsis

Purpose of review Urosepsis from manipulation of the urinary tract during stone surgery can be catastrophic despite antibiotic prophylaxis and sterile pre-operative urine. We have reviewed recent literature with regards to pathogenesis, predictors of infected stones and prevention of urosepsis. Recent findings Bladder urine culture has been found to correlate poorly with infection in the upper urinary tract, defined by either stone or pelvic urine culture. This specimen, which has been the cornerstone in pre-operative preparation of patients, does not predict urosepsis. Authors recommending routine stone culture found that the presence of infected stones is highly predictive of potential sepsis. Terminology for systemic infection has been standardized and used in recent literature to define urosepsis. Summary Recent studies have recommended changes in the approach to the peri-operative management of stone surgery. Predictors of potential sepsis have also been identified.

Nocturia, nocturia indices and variables from frequency-volume charts are significantly different in Asian and Caucasian men with lower urinary tract symptoms: a prospective comparison study.

To describe and compare the patterns of nocturia in Asian and Caucasian men presenting with lower urinary tract symptoms (LUTS), and to identify associations or correlations between LUTS and variables from a frequency‐volume chart (FVC), as nocturia is common among men with LUTS, and analysis of FVCs shows nocturnal polyuria and reduced nocturnal bladder capacity (NBC) as the predominant causes in Western patients, but there are few comparisons with other ethnic groups.

Radical cystectomy: Analysis of trends in UK practice 2004–2012, from the British Association of Urological Surgeons’ (BAUS) Section of Oncology Dataset:

Objective: To analyse the British Association of Urological Surgeons’ (BAUS) radical cystectomy (RC) dataset, to examine the trends in patient selection, use of neoadjuvant chemotherapy (NAC) and operative technique. Methods: Data for RC were entered into a database voluntarily, by operating surgeons. A comparison was made to the Hospital Episode Statistics (HES) data, to estimate the proportion of cases captured by the dataset. Results: From 2004 to 2012, data was collected on 5321 patients undergoing RC. This constituted 37.1% of all HES RC cases during the corresponding time period. Notable trends were: An increasing use of NAC, the introduction of minimally-invasive surgery (23.5% in 2012), a dramatic reduction in blood transfusion rates and the increasing yields from lymph node dissection. The ileal conduit urinary diversion predominated as the urinary diversion of choice (80% of cases). Conclusions: This analysis of a large multi-centre dataset provides insight into RC practice in the UK, over 8 years. The major weaknesses of the study were that only one-third of cases were recorded and that outcome data was very limited. Mandatory publication of outcome data from 2016 should increase the recording of cases and provide material for a more complete analysis.

Is there seasonal variation in symptom severity, uroflowmetry and frequency-volume chart parameters in men with lower urinary tract symptoms?

Purpose There is a widely held perception that lower urinary tract symptoms may be exacerbated by cold weather. In this study, we examine the effect of seasonal variation in ambient temperatures on frequency–volume chart derivatives, symptom severity scores and uroflowmetry parameters in men with lower urinary tract symptom. Methods Between January 2000 and April 2004, men presenting with lower urinary tract symptom were prospectively recruited and assessed in Edinburgh, UK (55°52′N) with maritime temperate climates (Köppen classification Cfb). Local monthly temperatures were extracted from national meteorological records. Patients completed the International Prostate Symptom Score and 3-day frequency volume chart before undergoing free uroflowmetry with post-micturition volume measurement. Exclusion criteria were previous bladder outflow surgery and anti-cholinergic medication. Results Data on 296 patients were suitable for analysis. Mean age was 62.3 years (range, 26–90). Over the period of study, the coldest month was January (mean = 4.7℃) and the warmest month was August (mean = 15.8℃). There was no significant variation in either International Prostate Symptom Score symptom scores by season (p > 0.05) or any frequency–volume chart parameters, with the exception on an increase in median actual nightly voids over the summer months (p = 0.021). There was no significant correlation between maximal flow rate and post-micturition residual volumes and mean monthly temperatures (p > 0.05). Conclusions Seasonal variation in nocturia, but not other frequency–volume parameters, symptom severity or uroflowmetry parameters, is significant in men with lower urinary tract symptom. Future work should consider the impact of seasonal variation in lower urinary tract symptoms in both sexes across a wider range of climates.

Could prostate biopsies be avoided in men older than 75 years with raised PSA

Objectives: Our purpose was to review current practice regarding the use of prostate biopsies in men older than 75 years with raised PSA by presenting the results of a retrospective audit and to identify these older men who really benefit from prostate biopsies. Methods: A high-volume tertiary center’s prospectively maintained prostate biopsy database of contemporary biopsies was reviewed. Men were stratified by age and PSA. Logistic regression analysis, Mantel-Haenszel and Fisher’s exact tests were used for statistical analysis. Results: Overall, 1,593 men underwent prostate biopsies between April 2004 and August 2006. Of these, 293 patients (18.4%) with a mean age of 82.62 years and mean PSA of 30.37 ng/ml were eligible for the study with an overall incidence of prostate cancer of 73.7%. Elderly men with PSA >20 ng/ml had a prostate cancer detection rate of 91%. They were more likely to have-high grade disease (OR = 5.4, 95% CI = 2.8–10.8, p < 0.0001) and receive hormone deprivation therapy (RR = 3.0, 95% CI = 2.1–4.3, p < 0.0001). Elderly men with PSA <20 ng/ml had a 3-fold risk of being placed on active monitoring. Almost 20% of them had 1 complication following biopsy, of whom 12 (4.1%) needed hospitalization. Conclusions: Given the high probability of detecting prostate cancer and receiving conservative treatment, prostate biopsies can be omitted in men >75 years with PSA >20 ng/ml. However, they are still useful in fit men >75 and <80 years with PSA <20 ng/ml who can be the potential candidates for treatment with curative intent.

A one-day frequency-volume chart is representative of a 3-day chart in the assessment of lower urinary tract symptoms suggestive of bladder outflow obstruction

Introduction: 24-h frequency-volume (FV) charts are often used to assess patients with lower urinary tract symptoms suggestive of bladder outflow obstruction (LUTS/BOO). There are no clear guidelines regarding the optimum chart duration. We aimed to determine whether a one-day FV chart is representative of a 3-day equivalent. Patients and methods: Men presenting with LUTS (including nocturia) were prospectively recruited and completed a 3-day FV chart. Exclusion criteria were previous bladder outflow surgery and anti-cholinergic medication. Results: 285 patients were recruited (mean age, 67 years; range 26–93 years). There were no significant inter-day differences in 24-h urine volume (24HUV) (p = 0.10) and functional bladder capacity (FBC) (p = 0.19). However, there were significant differences identified between days 1 and 2, and 1 and 3 for both nocturnal urine volume (NUV) (p < 0.001) and actual nocturnal voids (ANV) (p < 0.001) despite significant correlation of these parameters on each day with their respective 3-day means. Conclusion: Our data suggest that a one-day FV chart is representative of a 3-day equivalent for the assessment of 24HUV and FBC in patients with LUTS/BOO. Further studies are required to compare the repeatability and clinical utility of a one-day chart compared with 3- and 7-day charts, particularly in patients with nocturia.