Shawn Dason

Guidelines for the diagnosis and management of recurrent urinary tract infection in women

Recurrent uncomplicated urinary tract infection (UTI) is a common presentation to urologists and family doctors. Survey data suggest that 1 in 3 women will have had a diagnosed and treated UTI by age 24 and more than half will be affected in their lifetime.1 In a 6-month study of college-aged women, 27% of these UTIs were found to recur once and 3% a second time.2 The following topics are reviewed in this guideline. We also include a summary of recommendations (Text box 1). Text box 1. Summary of recommendations Definition of recurrent uncomplicated UTI An uncomplicated UTI is one that occurs in a healthy host in the absence of structural or functional abnormalities of the urinary tract. Recurrent uncomplicated UTI may be defined as 3 or more uncomplicated UTIs in 12 months (Level 4 evidence, Grade C recommendation). Recurrent UTIs occur due to bacterial reinfection or bacterial persistence. Persistence involves the same bacteria not being eradicated in the urine 2 weeks after sensitivity-adjusted treatment. A reinfection is a recurrence with a different organism, the same organism in more than 2 weeks, or a sterile intervening culture (Level 4 evidence, Grade C recommendation). Diagnosis of recurrent uncomplicated UTI Clinical diagnosis of each UTI episode is supported by symptoms of dysuria, frequency, urgency, hematuria, back pain, self-diagnosis of UTI, nocturia, costovertebral tenderness and the absence of vaginal discharge or irritation (Level 1 evidence, Grade A recommendation). Complicated causes of UTI may also be ruled out on history and physical examination (Table 1). Uroflowmetry and determining post void residual are optional tests in post-menopausal women to exclude complicated causes of UTI (Level 3 evidence, Grade C recommendation). Culture and sensitivity analysis should be performed when symptomatic and in 2 weeks from sensitivity-adjusted treatment to confirm UTI, guide further treatment and exclude persistence. (Level 4 evidence, Grade C recommendation) Investigation of recurrent uncomplicated UTI Cystoscopy and imaging are not routinely necessary in all women with recurrent UTI (Level 2 evidence, Grade B recommendation). Women with risk factors (Table 2) for a complicated cause for recurrent urinary tract infection should be evaluated by cystoscopy and imaging. Women suspected of having a complicated UTI (Table 2) without knowledge of a specific abnormality (Table 1) should receive a CT urogram or abdominopelvic ultrasound +/− abdominal x-ray. Women suspected of having a specific cause of UTI (Table 1) should be imaged in consultation with a radiologist or the 2011 ACR guidelines (Level 4 evidence, Grade C Recommendation). Indications for specialist referral Specialist referral is recommended for investigation of women with risk factors for complicated UTI (Table 2), surgical correction of a cause of UTI (Table 1), or when the diagnosis of recurrent uncomplicated UTI is uncertain (Level 4 evidence, Grade C Recommendation). Prophylactic measures against recurrent uncomplicated UTI Conservative measures including limiting spermicide use and postcoital voiding lack evidence for their efficacy but are unlikely to be harmful (Level 4 evidence, Grade C recommendation). Cranberry products have conflicting evidence for their efficacy (Level 1 evidence, Grade D recommendation). Continuous antibiotic prophylaxis (Table 3) is effective at preventing UTI. (Level 1 evidence, Grade A recommendation). Postcoital antibiotic prophylaxis (Table 3) within 2 hours of coitus is also effective at preventing UTI (Level 1 evidence, Grade A recommendation). Self-start antibiotic therapy with a 3-day treatment dose antibiotic at the onset of symptoms is another safe option for the treatment of recurrent uncomplicated UTI (Level 1 evidence, Grade A recommendation). Vaginal estrogen creams or rings may also reduce the risk of clinical UTI relative to placebo or no treatment in postmenopausal women (Level 1 evidence, Grade A recommendation). Due to a lack of comparative evidence, the decision to begin therapy, choice of therapy and duration should be based on patient preference, allergies, local resistance patterns, prior susceptibility, cost and side effects (Level 4 evidence, Grade C recommendation). View it in a separate window UTI: urinary tract infection; ACR: American College of Radiology.

Defining a new testosterone threshold for medical castration: Results from a prospective cohort series

BACKGROUND We seek to determine if testosterone levels below the accepted castration threshold (50 ng/dL) have an impact on time to progression to castrate-resistant prostate cancer (CRPC). METHODS This is a prospective cohort series of patients undergoing androgen deprivation therapy (ADT) with luteinizing hormone-releasing hormone agonist or antagonist at a tertiary centre from 2006 to 2011. Serum testosterone level was assessed every 3 months. Patients with any testosterone >50 ng/dL were excluded. Patients were stratified into groups based on those achieving mean testosterone levels <20 ng/dL and <32 ng/dL. Progression to CRPC was assessed with the Kaplan-Meier method and compared with the log-rank test. RESULTS A total of 32 patients were included in this study. Mean patient follow-up was 25.7 months. Patients with a 9-month serum testosterone <32 ng/dL had a significantly increased time to CRPC compared to patients with testosterone 32 to 50 ng/dL (p = 0.001, median progression-free survival (PFS) 33.1 months [<32 ng/dL] vs. 12.5 months [>32 ng/dL]). Patients with first year mean testosterone <32 ng/dL also had a significantly increased time to CRPC compared to 32 to 50 ng/dL (p = 0.05, median PFS 33.1 months [<32 ng/dL] vs. 12.5 months [32-50 ng/dL]). A testosterone <20 ng/dL compared to 20 to 50 ng/dL did not significantly predict with time to CRPC. CONCLUSION This study supports a lower testosterone threshold to define optimal medical castration (T <32 ng/dL) than the previously accepted standard of 50 ng/dL. Testosterone levels during ADT serve as an early predictor of disease progression and thus should be measured in conjunction with prostate-specific antigen.

The impact of method of distal ureter management during radical nephroureterectomy on tumour recurrence.

INTRODUCTON Radical nephroureterectomy for upper tract urothelial carcinoma (UTUC) must include some form of distal ureter management to avoid high rates of tumour recurrence. It is uncertain which distal ureter management technique has the best oncologic outcomes. To determine which distal ureter management technique resulted in the lowest tumour recurrence rate, we analyzed a multi-institutional Canadian radical nephroureterectomy database. METHODS We retrospectively analyzed patients who underwent radical nephroureterectomy with distal ureter management for UTUC between January 1990 and June 2010 at 10 Canadian tertiary hospitals. Distal ureter management approaches were divided into 3 categories: (1) extravesical tenting for ureteric excision without cystotomy (EXTRAVESICAL); (2) open cystotomy with intravesical bladder cuff excision (INTRAVESICAL); and (3) extravesical excision with endoscopic management of ureteric orifice (ENDOSCOPIC). Data available for each patient included demographic details, distal ureter management approach, pathology and operative details, as well as the presence and location of local or distant recurrence. Clinical outcomes included overall recurrence-free survival and intravesical recurrence-free survival. Survival analysis was performed with the Kaplan-Meier method. Multivariable Cox regression analysis was also performed. RESULTS A total of 820 patients underwent radical nephroureterectomy with a specified distal ureter management approach at 10 Canadian academic institutions. The mean patient age was 69.6 years and the median follow-up was 24.6 months. Of the 820 patients, 406 (49.5%) underwent INTRAVESICAL, 316 (38.5%) underwent EXTRAVESICAL, and 98 (11.9%) underwent ENDOSOPIC distal ureter management. Groups differed significantly in their proportion of females, proportion of laparoscopic cases, presence of carcinoma in situ and pathological tumour stage (p < 0.05). Recurrence-free survival at 5 years was 46.3%, 35.6%, and 30.1% for INTRAVESICAL, EXTRAVESICAL and ENDOSCOPIC, respectively (p < 0.05). Multivariable Cox regression analysis confirmed that INTRAVESICAL resulted in a lower hazard of recurrence compared to EXTRAVESICAL and ENDOSCOPIC. When looking only at intravesical recurrence-free survival (iRFS), a similar trend held up with INTRAVESICAL having the highest iRFS, followed by ENDOSCOPIC and then EXTRAVESICAL management (p < 0.05). At last follow-up, 406 (49.5%) patients were alive and free of disease. CONCLUSION Open intravesical excision of the distal ureter (INTRAVESICAL) during radical nephroureterectomy was associated with improved overall and intravesical recurrence-free survival compared with extravesical and endoscopic approaches. These findings suggest that INTRAVESICAL should be considered the gold standard oncologic approach to distal ureter management during radical nephroureterectomy. Limitations of this study include its retrospective design, heterogeneous cohort, and limited follow-up.

The contemporary role of 1 vs. 2-stage repair for proximal hypospadias

This review discusses the most commonly employed techniques in the repair of proximal hypospadias, highlighting the advantages and disadvantages of single versus staged surgical techniques. Hypospadias can have a spectrum of severity with a urethral meatus ranging from the perineum to the glans. Associated abnormalities are commonly found with proximal hypospadias and encompass a large spectrum, including ventral curvature (VC) up to 50 degrees or more, ventral skin deficiency, a flattened glans, penile torsion and penoscrotal transposition. Our contemporary understanding of hypospadiology is comprised of a foundation built by experts who have described a number of techniques and their outcomes, combined with survey data detailing practice patterns. The two largest components of hypospadias repair include repair of VC and urethroplasty. VC greater than 20 degrees is considered clinically relevant to warrant surgical correction. To repair VC, the penis is first degloved—a procedure that may reduce or remove curvature by itself in some cases. Residual curvature is then repaired with dorsal plication techniques, transection of the urethral plate, and/or ventral lengthening techniques. Urethroplasty takes the form of 1- or 2-stage repairs. One-stage options include the tubularized incised urethroplasty (TIP) or various graft or flap-based techniques. Two-stage options also include grafts or flaps, including oral mucosal and preputial skin grafting. One stage repairs are an attractive option in that they may reduce cost, hospital stay, anesthetic risks, and time to the final result. The downside is that these repairs require mastery of multiple techniques may be more complex, and—depending on technique—have higher complication rates. Two-stage repairs are preferred by the majority of surveyed hypospadiologists. The 2-stage repair is versatile and has satisfactory outcomes, but necessitates a second procedure. Given the lack of clear high-quality evidence supporting the superiority of one approach over the others, hypospadiologists should develop their own algorithm, which gives them the best outcomes.

Impact of resident involvement in endoscopic bladder cancer surgery on pathological outcomes

Abstract Objective: Transurethral resection of bladder tumor (TURBT) pathology specimens which lack muscle are associated with clinical upstaging and may necessitate repeat resections, potentially delaying curative treatment. This study evaluated whether resident involvement in TURBT is associated with suboptimal perioperative outcomes. Materials and methods: All TURBTs performed at a Canadian healthcare institution from November 2011 to June 2014 were reviewed. Multivariable logistic regression models assessed associations between intraoperative resident involvement and TURBT muscle presence. Among high-risk patients (high grade, ≥ T1 or carcinoma in situ) who underwent cystectomy, time from TURBT to cystectomy was compared between resident and attending urologists with the log-rank test. Results: In total, 463 TURBTs were identified. In multivariable analyses, residents were less likely to obtain muscle in specimens for all TURBTs [adjusted odds ratio (aOR) 0.59, p = 0.03] and the subset of 275 high-risk TURBTs (aOR 0.41, p = 0.006). Among patients who underwent cystectomy, time to cystectomy was delayed by a median of 23 days when residents were involved in the initial high-risk TURBT compared with attending urologists only (p = 0.024). Conclusions: In this single academic center series, intraoperative resident involvement was associated with a decreased rate of muscle presence in TURBT specimens and a prolonged time to cystectomy.

Testosterone suppression: Impact of testosterone level on disease progression in advanced prostate cancer.

46 Background: In patients with advanced prostate cancer, medical castration remains a mainstay of treatment. A testosterone level below 50 ng/dL has been previously accepted as an adequate level of androgen suppression and remains the benchmark level for clinical trials. However, there is mounting evidence that lower testosterone levels may be associated with improved clinical outcomes. We evaluated our cohort of patients with advanced prostate cancer to assess the impact of testosterone suppression on progression to castrate resistant prostate cancer (CRPC). METHODS Patient data was obtained from a prospective database of patients undergoing androgen deprivation therapy (ADT) at a tertiary centre from 2006-2011. A total of 39 patients were eligible for inclusion with at least 12 months follow-up. Patients were administered LHRH agonists or antagonist with testosterone and PSA assessments every 3 months. Patients were considered to have progressed to CRPC when there were at least 2 consecutive rises in PSA above nadir, clinical progression, or death from disease. Patients were stratified into two risk groups based on 6-month absolute and 1-year mean testosterone levels following initiation of ADT. Baseline characteristics between risk groups were compared using the Students t-test and chi-squared test. Probability of disease progression was assessed using the Kaplan-Meier method and compared using the log-rank test. RESULTS Median patient follow up was 2.3 years with 38% free of disease at last follow up. Patients with 6-month absolute testosterone less than 32 ng/dL had an increased time to CRPC (log rank p=0.06). Patients with 1-year mean testosterone less than 32 ng/dl had a significantly increased time to CRPC (log rank p=0.005). Patients did not differ significantly in their baseline characteristics. CONCLUSIONS Adequate testosterone suppression during ADT may play a clinically significant role in delaying CRPC. While PSA levels are often used to assess for response to ADT, the current study suggests testosterone level in the first year following initiation of ADT may serve as an early predictor of disease progression.

Can it wait? A systematic review of immediate vs. delayed surgical repair of penile fractures

INTRODUCTION Penile fractures have classically been thought to require immediate surgical intervention; however, recent series have described acceptable outcomes with delayed repair. In this systematic review, we compared complication rates between immediate and delayed repair of penile fractures. METHODS A systematic search of MEDLINE, Embase, CENTRAL, and Web of Science was performed with predefined search terms between 1974 and 2015. Titles and abstracts were screened prior to full-text review and quality appraisal by two independent investigators. Abstracted outcomes included postoperative erectile dysfunction (ED), tunical scar formation, and penile curvature. Only studies reporting a direct comparison of complications following immediate (<24 hours from injury to presentation/surgery) and delayed (>24 hours) repair of penile fractures were included. RESULTS A total of 12 studies met inclusion criteria. All were retrospective, observational studies of low or moderate methodological quality. Of the reported 502 patients, 391 underwent immediate repair and 111 delayed repair. In the immediate repair group, the percent of patients with postoperative ED, tunical scars, and curvature were 6.6%, 5.4%, and 1.8%, respectively, while in the delayed group, the rates of ED, tunical scars, and curvature were 4.5% across the board. Rates of ED and tunical scar formation following immediate compared to delayed repair trended towards favouring immediate repair, but did not differ significantly, while rates of curvature significantly favoured immediate repair. However, cases of curvature were typically reported as mild and none affected sexual functioning. CONCLUSIONS In this systematic review, we demonstrated that ED and tunical scar formation rates between immediate and delayed repair of penile fractures were statistically similar, while immediate repair had a lower rate of penile curvature. Although this suggests that a brief delay in repair may be acceptable in select patients, the results should be interpreted with caution, as the included studies were of low or moderate methodological quality. Most importantly, this review highlights the deficiencies in the current penile fracture literature, setting the stage to improve the quality of future studies.

Pure laparoscopic unilateral nephrectomy for a patient with a polycystic horseshoe kidney

A 45-year-old female patient with autosomal dominant polycystic kidney disease (ADPKD) and a horseshoe kidney underwent right laparoscopic nephrectomy. The indication for nephrectomy was to create space within the right iliac fossa for renal transplantation. The operation proceeded as routine for laparoscopic nephrectomy for ADPKD, but was uniquely challenging due to the large size and extensive vasculature of the polycystic horseshoe kidney. In addition to documenting the feasibility of the pure laparoscopic approach for nephrectomy in patients with ADPKD and horseshoe kidney, this case highlights the abnormal location and vasculature encountered when operating on horseshoe kidneys.

Urothelial carcinoma involving the distal penis

Urothelial carcinoma (UC) rarely metastasizes to the penis and skin. We report the case of a 73-year-old man with UC metastases to the corpus spongiosum and dermis of the distal penis. We also review the clinicopathologic characteristics and management options for UC metastasizing to the penis. The patient presented with priapism and edema of the genital region. This follows a 5-year history of urothelial carcinoma in situ that progressed to invasive cancer despite intravesical immunotherapy. Seventeen months prior to presentation, the patient underwent a radical cystectomy with adjuvant chemotherapy. The cystectomy specimen demonstrated a pT4a N2 M0 G3 UC and margins were positive for carcinoma in situ. Follow-up had been negative for recurrence until his presentation with priapism. Incisional biopsy of the glans revealed UC and radical penectomy was performed with negative margins. The penile specimen demonstrated extensive involvement of the corpus spongiosum by UC with lymphovascular invasion and subepidermal involvement. Three months after penectomy, the patient presented with inguinal nodal recurrence. Palliative radiotherapy was administered and the patient passed away eight months after surgery.

Management of pelvic fracture-associated urethral injuries: A survey of Canadian urologists

INTRODUCTION The management of pelvic fracture-associated urethral injuries (PFUI) is not standardized and optimal management is controversial. We surveyed Canadian urologists about their experiences and opinions regarding optimal management of PFUI. METHODS Canadian urologists were surveyed via an anonymous, bilingual, web-based, 12-item questionnaire. A total of 735 Canadian urologists were invited to participate via email distributed by the Canadian Urological Association. RESULTS Of the 146 urologists who participated (19.9% response rate), the majority practice at a trauma centre (53.2%), but manage only 1-5 PFUI/year (71.5%). Most participants (82.6%) favour primary realignment compared to suprapubic (SP) tube with delayed repair (15.3%) and immediate reconstruction (2.1%). Compared to SP diversion and delayed repair, the majority of participants believe primary realignment is associated with equivocal incontinence (61.2%) and erectile dysfunction rates (75.8%), but has lower stricture rates (73.0%). Among respondents who perform primary realignment, 45.4% concurrently place a SP tube, while 54.6% do not. While 91% believe SP tubes do not increase the risk of pelvic hardware infections, 31.6% report that orthopedic surgeons alter their management of pelvic fractures in the presence of a SP tube. CONCLUSIONS Most Canadian urologist respondents - even those practicing at trauma centres - manage very few PFUIs/year. There is reasonable consensus among respondents that primary realignment is favourable to delayed or immediate reconstruction, but discordance on whether or not to place concurrent SP tubes. The urological and orthopedic consequences of SP tubes in the management of traumatic urological injuries warrant further investigation.