Adjuvant Radiation Therapy Following Radical Prostatectomy for Pathologic T3 or Margin-positive Prostate Cancer: Are the EAU Guidelines Correct?

Objective: To present a critical review of the published data as to whether adjuvant radiation therapy (RT) is the preferred first line of management for pathologic T3 or margin-positive prostate cancer (PCa) after radical prostatectomy (RP), which has level 1B evidence in the European Association of Urology (EAU) guidelines. Methods: Three randomised studies have been published comparing immediate adjuvant RT and salvage treatment in patients with pT3 and/or margin-positive PCa. The concept of these trials was critically evaluated, and the translation of the outcome of these trials to daily clinical practice is discussed. Results: Current evidence is insufficient to subject all patients with pT3 and/or margin-positive PCa to adjuvant RT after RP, and it should be reserved for a subset of patients with adverse prognostic factors after RP, such as seminal vesicle invasion. Conclusions: The data that can be retrieved from the trials exploring the benefit of adjuvant RT following RP cannot be translated to routine clinical urologic practice, because the field of PCa is changing rapidly and the patients present at an earlier stage. A trial evaluating immediate versus salvage RT should answer the question of who needs adjuvant treatment and when. The recommendation concerning adjuvant RT should thus be adapted in the EAU guidelines. (C) 2011 European Association of Urology. Published by Elsevier B.V. All rights reserve

Tubeless percutaneous nephrolithotomy: 3 years of experience with 454 patients

To present our experience with 454 patients who had tubeless percutaneous nephrolithotomy (TPCNL) over last 3 years. From September 2004 to August 2007, all patients aged >14 years and undergoing PCNL were considered for TPCNL. Exclusion criteria were the presence of pyonephrosis, matrix calculi, significant bleeding or residual stone burden and need for three of more percutaneous accesses. These patients had a nephrostomy tube placed after PCNL (control group). The remaining patients undergoing TPCNL (study group) had antegrade ureteric stenting. Demographic and perioperative data were compared retrospectively. Of 840 patients who had PCNL during the study period, 454 had TPCNL. The two groups had comparable demographic data except for a smaller stone burden (322.8 vs 832.2 mm(2)) and fewer staghorn calculi (94 vs 154) in patients undergoing TPCNL (P < 0.001). The mean number of tracts per renal unit and operative duration were statistically higher in patients undergoing standard PCNL (1.5 vs 1.1, and 68.8 vs 52.2 min, respectively). The decrease in haemoglobin, complication and stone-free rates were comparable. TPCNL was associated with less postoperative pain, analgesia requirement and earlier discharge (P < 0.001). TPCNL can be used with a favourable outcome and no increase in complications in selected patients, with the potential advantages of decreased postoperative pain, analgesia requirement and hospital stay. Its application can be extended to patients with a solitary kidney, previous ipsilateral open surgery, raised serum creatinine level, in the presence of three renal accesses or supracostal access, and in patients undergoing bilateral synchronous PCNL or contralateral endourological stone treatment

A Randomized Control Trial Evaluating Efficacy of Nephrostomy Tract Infiltration with Bupivacaine After Tubeless Percutaneous Nephrolithotomy

Purpose: We conducted a randomized controlled trial to assess the efficacy of nephrostomy tract infiltration with bupivacaine in tubeless percutaneous nephrolithotomy (PCNL). Patients and Methods: All adult patients undergoing unilateral tubeless PCNL from July 1, 2007 to October 31, 2007 were included in the study. Patients were randomized to receive infiltration of bupivacaine in the nephrostomy tract at the end of the procedure or not to receive bupivacaine. To show a 10% difference in postoperative pain, a sample size of 30 persons per group would be needed. Postoperatively, the pain score were obtained at 4 and 24 hours by a nurse who was blinded to the protocol. The perioperative outcome of these patients (study group) was compared with those undergoing tubeless PCNL without nephrostomy tract infiltration of bupivacaine (control group). Results: Patient demographics and intraoperative parameters in both groups were comparable. Supracostal access was needed in 65.7% and 72.7% patients in the study and control group, respectively. The nephrostomy tract were infiltrated with bupivacaine in 31 patients. The visual analogue pain score at 4 hours and 24 hours for the study group was 2.66±1.07 & 2.23±0.50 respectively, while in control group was 5.15±1.52 and 3.22±1.11, respectively ( P =0.000). There was a trend toward lesser analgesia requirement in the study group (94.8 vs 124.2 mg of diclofenac sodium). There was no difference in the duration of postoperative catheterization, hospital stay, stone-free rates, and complication between both groups. Conclusions: Nephrostomy tract infiltration of bupivacaine in tubeless PCNL is associated with less postoperative pain and analgesia requirement

A Plea for Centralized Care for Ureteroscopy: Results from a Comparative Study Under Different Conditions Within the Same Center

Purpose: We stratified factors that affect treatment morbidity, compared the outcomes of ureteroscopy procedures from a single department under different conditions, and provided evidence of treatment benefits when ureteroscopy is performed in an expert setting. Patients and Methods: Since the department became a dedicated endourologic center in 2002, we grouped all ureteroscopy procedures into those performed before 2002 (group A) and after 2002 (group B). The modified Clavien classification was used to score morbidity. Independent variables with an influence on postoperative outcomes were studied, including operative time, intraoperative and postoperative complications, and hospitalization time. Results: Of the 248 ureteroscopy procedures performed, 62 comprised group A and 186 comprised group B. Statistical preoperative differences were in the American Society of Anesthesiologists score, patients with diabetes mellitus, cardiovascular disease, and the use of anticoagulants; and the perioperative differences were seen in operative time, hospital stay, and the number of eventful procedures. Group A had a significantly longer operative time and a longer hospital stay compared with group B. The number of failed and eventful procedures are also higher in group A compared with group B. Stone-free rates were similar in both groups. Conclusions: The dedicated setting for ureteroscopy 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 comparisons of morbidity after ureteroscopic stone treatmen

Endoscopic management of adult orthotopic ureterocele and associated calculi with holmium laser: Experience with 16 patients over 4 years and review of literature

Purpose: To retrospectively evaluate the safety and effectiveness of holmium laser endoscopic incision and laser lithotripsy in adults with orthotopic ureterocele and associated calculi. Patients and Methods: From May 2003 to August 2007 at our center, 16 adults underwent transurethral incision of an ureterocele and intracorporeal holmium laser lithotripsy for associated calculi. The perioperative data of these patients were retrospectively analyzed. The literature was reviewed to identify all the reported options for management of this relatively rare condition. Results: Ureterocele was associated with a single system in 13 patients. Two patients had bilateral ureteroceles. Four patients had associated upper tract stones. The procedure was uneventful in all patients. The average postoperative hospital stay was 19.3 hours. All patients were stone free after the procedure. Eleven patients were available for follow-up at 3 and 6 months. None of these patients had any evidence of residual ureterocele and/or hydronephrosis when evaluated with intravenous urography at 3 months. Micturating cystourethrography (MCU) at 3 months revealed low-grade vesicoureteral reflux (VUR) in four patients; no reflux was found with MCU at 6 months. Conclusions: Laser endoscopic management of adult orthotopic ureterocele and associated calculi effectively decompressed ureterocele and removed stones in all patients without any significant postoperative morbidity. Low-grade VUR that may occur postoperatively resolved at 6 months. A literature review suggests that the ability of the holmium laser to manage both ureterocele and calculi simultaneously should make holmium laser management a procedure of choice at centers that possess the equipment

Splenic injury: rare complication of percutaneous nephrolithotomy: report of two cases with review of literature

Splenic injury is an uncommon complication of percutaneous nephrolithotomy (PCNL). We report herewith two cases of splenic injury that occurred during puncture of the 10th intercostal-space for PCNL. One of these patients presented with hypotension on day 5 after discharge from the hospital. Both patients needed emergency laparotomy, and one of them required splenectomy for management of the injury. We reviewed the literature to determine the risk factors and management of splenic injury during PCNL

The management of renal matrix calculi: a single-centre experience over 5 years

To define incidence of renal matrix calculi in patients undergoing percutaneous nephrolithotomy (PCNL), and describe its clinical, laboratory and radiological features; we also studied the efficacy of PCNL in managing this rare entity. We retrospectively reviewed the records of 1368 PCNLs performed from April 2003 to March 2008, and identified 17 patients (mean age 44.3 years; 11 women and six men) having matrix calculi. The patients' clinical, laboratory and radiological features were studied, and the perioperative outcome and follow-up data analysed. Flank pain was commonest mode of presentation (15) followed by recurrent urinary tract infection (five). Pyuria was present in 14 patients and urine culture showed significant growth in 10. A plain X-ray showed a small radio-opaque calculus (10 renal units) and faint laminated calcification (four). Intravenous urography showed a filling defect and non-visualized system in nine and five patients, respectively. Non-contrast computed tomography and magnetic resonance urography diagnosed calculi in two and one patient, respectively, on haemodialysis. PCNL was abandoned initially in four patients due to pyonephrosis. The mean hospital stay was 3.4 days and decrease in haemoglobin was 0.89 g/dL. One patient developed sepsis. Of 11 stones analysed, two were composed entirely of proteins and the remaining nine had crystalline components. At a mean follow-up of 12.6 months, no patients had recurrence of stone. Matrix calculi occurred in 1.24% of patients undergoing PCNL. Although considered radiolucent, plain X-ray showed a small radio-opaque calculi or faint laminated calcifications in 10 of 17 patients. PCNL rendered patients stone-free with minimum morbidity

A randomized trial evaluating type of nephrostomy drainage after percutaneous nephrolithotomy: Small bore v tubeless

Purpose: To compare the outcome of tubeless percutaneous nephrolithotomy (PCNL) with small-bore nephrostomy drainage after PCNL. Patients and Methods: We tested the hypothesis that tubeless PCNL is superior to small-bore nephrostomy drainage after PCNL in terms of postoperative pain, analgesic requirement, and hospital stay. To show a 10% difference in these parameters, a sample size of 30 persons per group would be needed. All patients undergoing PCNL from September 2005 to May 2006 were included in the study. Patients meeting the inclusion and exclusion criteria were then randomized to either a tubeless approach with insertion of a ureteral stent or placement of an 8F nephrostomy tube without insertion of a ureteral stent. The perioperative outcomes of patients in the two groups were compared. Results: Tubeless PCNL was performed in 33 patients, and an 8F nephrostomy tube was placed in 32 patients. The two groups had comparable demographic data. The hemoglobin drop and complication rate between the two groups were comparable. Patients undergoing tubeless PCNL experienced less postoperative pain (P = 0.001), needed less analgesia (P = 0.006), and were discharged 9 hours earlier than patients in the other group. Complete stone clearance was achieved in 87.87% patients in the tubeless group and 87.5% patients in the nephrostomy group. In the tubeless group, 39.4% of patients had bothersome stent-related symptoms, of whom 61.5% needed analgesics and/or antispasmodic agents. Conclusions: Tubeless PCNL offers the potential advantages of decreased postoperative pain, analgesic requirement, and hospital stay without increasing the complications. It was associated with stent-related discomfort in 39% of patients