Oral fosfomycin for the treatment of chronic bacterial prostatitis.

BACKGROUND: Chronic bacterial prostatitis (CBP) is a difficult-to-treat infection as only a few antibiotics achieve therapeutic concentrations in the prostate. Data on the efficacy and safety of oral fosfomycin for the treatment of CBP are limited. OBJECTIVES: To analyse the efficacy and safety of fosfomycin in CBP due to MDR pathogens. METHODS: In a prospective observational study, an oral regimen of 3 g of fosfomycin q24h for 1 week followed by 3 g q48h for a treatment duration of 6-12 weeks was administered. The outcome was clinical and microbiological cure rate at the end of treatment (EOT) and rate of relapse at 3 and 6 months. RESULTS: The study included 44 patients. The most common pathogen was Escherichia coli (66%), followed by Klebsiella spp. (14%) and Enterococcus faecalis (14%). Most strains were MDR (59%) and 23% had an ESBL phenotype; 33 of 44 strains were resistant to fluoroquinolones, but all were susceptible to fosfomycin (median MIC for Gram-negative pathogens 1.5 mg/L). In 25 patients, treatment was administered for 6 weeks, whereas in the remaining 19 patients it was prolonged to 12 weeks based on the presence of calcifications in the prostate. Cure rate was 82% at EOT and 80% and 73% at 3 and 6 months accordingly. Microbiological eradication was achieved in 86% and 77% at EOT and at 6 months, respectively. Failure was observed in 12 patients. The most common adverse event was diarrhoea (18%). CONCLUSIONS: Oral fosfomycin, particularly in the era of MDR prevalence, represents an attractive, safe and effective alternative to fluoroquinolones for the treatment of CBP.

Clinical Research Office of the Endourological Society Global GreenLight Laser Study: Outcomes from a contemporary series of 713 patients.

OBJECTIVE: To evaluate the outcome in patients undergoing photoselective vaporization of the prostate for benign prostatic obstruction as part of the Clinical Research Office of the Endourological Society Global GreenLight Laser Study. METHODS: Data were collected on 713 patients with lower urinary tract symptoms suggestive of benign prostatic obstruction undergoing photoselective vaporization of the prostate at 25 centers worldwide, between April 2010 and April 2012. Three types of GreenLight laser powers were used: 80 W, 120 W or 180 W. Intraoperative and postoperative complications were recorded. Outcome parameters measured at baseline, 6-12 weeks, 6 months and 12 months were: uroflow measurements, International Prostate Symptom Score; prostate-specific antigen and International Index of Erectile Function. RESULTS: Operating time was shortest with the 180-W laser at 53.8 min. Intraoperatively, bleeding occurred in 3.1% of patients. Statistically significant changes were reported in maximum flow rate, postvoid residual urine, International Prostate Symptom Score, quality of life score and prostate-specific antigen (P < 0.01) at each time-point assessed for the 80- and 120-W lasers as well as for the 180-W laser, with the exception of prostate-specific antigen at 6 months and 12 months. There were 14 Clavien-Dindo grade III-A complications and two grade III-B. The incontinence rate at 12 months was 6.3%, 4.5%, and 2.6% for the 80, 120 and 180 W lasers, respectively. The overall blood transfusion rate was 0.4%. CONCLUSIONS: Objective and subjective improvement after GreenLight laser treatment worldwide was significant at 1-year follow up. Morbidity and complications were low. Although not a randomized control study, the data can provide an indication of the outcome of the different GreenLight laser powers.

Is photodynamic diagnosis ready for introduction in urological clinical practice?

The aim of this review is to provide an up-to-date review of the available literature on photodynamic diagnosis (PDD) for nonmuscle-invasive bladder cancer, to present the technique in a comprehensive approach and, finally, to discuss the relevance of PDD in clinical practice in terms of indications, outcomes and its development trend. A literature search was conducted up to July 2012, using MEDLINE and EMBASE via Ovid databases to identify published studies on PDD for nonmuscle-invasive bladder cancer. Only English-language and human-based full manuscripts that reported on case series and studies with >40 participants, concerning clinical evidence of the technique, its efficacy and safety data were included. Evidence showed that PDD significantly improves detection of bladder cancer compared with standard white-light cystoscopy, having proven to be more effective for the diagnosis of carcinoma in situ. This condition seems to facilitate more complete resections, resulting in a lower residual tumor rate, which, in turn consecutively leads to higher recurrence-free survival rates. The literature search demonstrated that for mid- and long-term follow-up, PDD showed acceptable outcomes in terms of tumor detection, as well as lower residual tumor and lower recurrence rates compared with white-light cystoscopy. It has proven to be safe and well tolerated; the major limitations of PDD are its low specificity and elevated costs.

Bipolar vs monopolar transurethral resection of the prostate: evaluation of the impact on overall sexual function in an international randomized controlled trial setting.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The effect of TURP on overall sexual function and particularly erectile function (EF) is controversial with conflicting results based on a low level of evidence. The effects of monopolar and bipolar TURP (M-TURP and B-TURP, respectively) on EF are similar, as has been shown in a few non-focused randomized control trials (RCTs). For the first time, the present study offers focused results of a comparative evaluation of the effects of B-TURP and M-TURP on overall sexual function, as quantified with the International Index of Erectile Function Questionnaire (IIEF-15) in an international, multicentre, double-blind RCT setting. OBJECTIVE: To compare monopolar and bipolar transurethral resection of the prostate (M-TURP and B-TURP, respectively) using a true bipolar system, for the first time in an international multicentre double-blind randomized controlled trial focusing on the overall sexual function quantified with the International Index of Erectile Function Questionnaire (IIEF-15). Other baseline/perioperative parameters potentially influencing erectile function (EF) after TURP were secondarily investigated. MATERIALS AND METHODS: From July 2006 to June 2009, consecutive TURP candidates with benign prostatic obstruction were prospectively recruited in four academic urological centres, randomized 1:1 into M-TURP/B-TURP arms and followed up at 6 weeks, 6 and 12 months after surgery. In all, 295 eligible patients were enrolled. Overall sexual function was quantified using self-administered IIEF-15 at baseline and at each subsequent visit. Total IIEF/domain scores were calculated and EF score classified erectile dysfunction severity. Differences in erectile dysfunction severity at each visit compared with baseline (EF evolution), classified patients into 'improved', 'stable' or 'deteriorated'. Pre-postoperative IIEF/domain scores and differences in the distribution of EF evolution were compared between arms throughout follow-up. RESULTS: In all, 279 patients received the allocated intervention; 218/279 patients (78.1%) provided complete IIEF-15 data at baseline and were considered in sexual function analysis. Complete IIEF-15 data were available from 193/218 (88.5%), 186/218 (85.3%) and 179/218 (82.1%) patients at 6 weeks, 6 months and 12 months, respectively. Sexual function did not differ significantly between arms during follow-up (scores: IIEF, P = 0.750; EF, P = 0.636; orgasmic function, P = 0.868; sexual desire, P = 0.735; intercourse satisfaction, P = 0.917; overall satisfaction, P = 0.927). Resection type was not a predictor of any sexual function changes observed. Distribution of EF evolution did not differ between arms at any time (M-TURP vs B-TURP at 12 months: improved, 23/87 [26.4%] vs 18/92 [19.6%]; stable, 53/87 [60.9%] vs 56/92 [60.8%]; deteriorated, 11/87 [12.7%] vs 18/92 [19.6%]; P = 0.323). CONCLUSION: There were no differences between M-TURP/B-TURP in any aspect of sexual function.

Sequential robotic-assisted bladder diverticulectomy and radical prostatectomy. Technique and review of the literature.

INTRODUCTION: Acquired bladder diverticula (BD) in men over the age of 60 are usually due to bladder outlet obstruction (BOO) secondary to prostatic enlargement. In cases of clinical significant BD with persistent symptoms or complications surgical excision should be considered. In the treatment of BD it is important to address the BOO with a bladder outlet procedure either simultaneously or in a staged fashion. PRESENTATION OF CASE: We present to the best of our knowledge, the first case of sequential robotic-assisted bladder diverticulectomy (RABD) combined with robotic-assisted radical prostatectomy (RARP) in a patient with large diverticula and malignant prostate enlargement as the cause of BOO. DISCUSSION: Concomitant open radical prostatectomy and bladder diverticulectomy series have been described, while minimal invasive procedures combining BD excision with relive of BOO especially due to benign prostatic enlargement have been reported to be safe and effective. CONCLUSION: Concomitant RABD with RARP is a safe and effective procedure with excellent oncological and functional results.

Midterm results from an international multicentre randomised controlled trial comparing bipolar with monopolar transurethral resection of the prostate.

BACKGROUND: Pooled data from randomised controlled trials (RCTs) with short-term follow-up have shown a safety advantage for bipolar transurethral resection of the prostate (B-TURP) compared with monopolar TURP (M-TURP). However, RCTs with follow-up >12 mo are scarce. OBJECTIVE: To compare the midterm safety/efficacy of B-TURP versus M-TURP. DESIGN, SETTING, AND PARTICIPANTS: From July 2006 to June 2009, TURP candidates with benign prostatic obstruction were consecutively recruited in four centres, randomised 1:1 into the M-TURP or the B-TURP arm and regularly followed up to 36 mo postoperatively. A total of 295 patients were enrolled. INTERVENTION: M-TURP or B-TURP using the AUTOCON II 400 electrosurgical unit. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Safety was estimated by complication rates with a special emphasis on urethral strictures (US) and bladder neck contractures (BNCs) recorded during the short-term (up to 12 mo) and midterm (up to 36 mo) follow-up. Efficacy quantified by changes in maximum urine flow rate, postvoid residual urine volume, and International Prostate Symptom Score was compared with baseline, and reintervention rates in each arm were also evaluated. RESULTS AND LIMITATIONS: A total of 279 patients received treatment after allocation. Mean follow-up was 28.8 mo. A total of 186 of 279 patients (66.7%) completed the 36-mo follow-up. Posttreatment withdrawal rates did not differ significantly between arms. Safety was assessed in 230 patients (82.4%) at a mean follow-up of 33.4 mo. Ten US cases were seen in each arm (M-TURP vs B-TURP: 9.3% vs 8.2%; p=0.959); two versus eight BNC cases (M-TURP vs B-TURP: 1.9% vs 6.6%; p=0.108) were collectively detected at the midterm follow-up. Resection type was not a significant predictor of the risk of US/BNC formation. Efficacy was similar between arms and durable. A total of 10 of 230 patients (4.3%) experienced failure to cure and needed reintervention without significant differences between arms. High overall reintervention rates, withdrawal rates, and sample size determination not based on US/BNC rates represent potential limitations. CONCLUSIONS: The midterm safety and efficacy of B-TURP and M-TURP are comparable. TRIAL REGISTRATION: Netherlands Trial Register, NTR703 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=703).

Follow-up procedures for non-muscle-invasive bladder cancer: an update.

Bladder carcinoma is the most common malignancy of the urinary tract. Approximately 75-85% of patients present with a disease that is confined to the mucosa (stage Ta, carcinoma in situ) or submucosa (stage T1). The stratification of patients to low-, intermediate- and high-risk groups represents the cornerstone for the indication of adjuvant and follow-up treatment. Owing to the high recurrence rate of bladder tumors, a surveillance protocol is recommended to all patients. Currently, the combination of cystoscopy, imaging and urinary cytology represent the follow-up. A systematic review of the recent English literature on follow-up procedures of non-muscle-invasive bladder cancer is performed. The authors review the existing follow-up procedures, with a focus on novel molecular-targeted approaches. At the present time, the additional use and utility of urine-based molecular markers in the follow-up of patients remains unclear and we have to rely on cystoscopic evaluation adapted to risk group classification.

Results from an international multicentre double-blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs monopolar transurethral resection of the prostate.

OBJECTIVE: To compare the perioperative efficacy and safety of bipolar (B-) and monopolar transurethral resection of the prostate (M-TURP) in an international multicentre double-blind randomized controlled trial using the bipolar system AUTOCON(®) II 400 ESU for the first time. PATIENTS AND METHODS: From July 2006 to June 2009, consecutive transurethral resection of the prostate (TURP) candidates with benign prostatic obstruction were prospectively recruited in four academic urological centres, randomized 1:1 into an M-TURP or B-TURP arm and followed up for 6 weeks after surgery. A total of 295 eligible patients were enrolled. Of these, 279 patients received treatment (M-TURP, n= 138; B-TURP, n= 141) and were analysed for immediate postoperative outcomes and perioperative safety. In all, 268 patients (M-TURP, n= 129; B-TURP, n= 139) were analysed for efficacy, which was quantified using changes in maximum urinary flow rate, postvoid residual urine volume and International Prostate Symptom Score at 6 weeks compared with baseline. Safety was estimated using sodium and haemoglobin level changes immediately after surgery and perioperative complication occurrence graded according to the modified Clavien classification system. Secondary outcomes included operation-resection time, resection rate, capsular perforation and catheterization time. RESULTS: No significant differences were detected between each study arm except that postoperative decreases in sodium levels favoured B-TURP (-0.8 vs -2.5 mmol/L, for B-TURP and M-TURP, respectively; P= 0.003). The lowest values were 131 mmol/L (B-TURP) and 106 mmol/L (M-TURP). Nine patients ranged between 125 and 130 mmol/L and the values for three patients were <125 mmol/L after M-TURP. The greatest decrease was 9 mmol/L after B-TURP (two patients). In nine patients (M-TURP) the decrease was between 9 and 34 mmol/L. These results were not translated into a significant difference in TUR-syndrome rates (1/138: 0.7% vs 0/141: 0.0%, for M-TURP and B-TURP, respectively; P= 0.495). CONCLUSIONS: In contrast to the previous available evidence, no clinical advantage for B-TURP was shown. Perioperative efficacy, safety and secondary outcomes were comparable between study arms. The potentially improved safety of B-TURP that is attributed to the elimination of dilutional hyponatraemia risk, a risk still present with M-TURP, did not translate into a significant clinical benefit in experienced hands.

GreenLight™ laser in the treatment of lower urinary tract symptoms due to benign prostatic enlargement.

For more than a decade, laser technology has facilitated a minimally invasive surgical method to treat patients with bladder outlet obstruction caused by benign prostatic hyperplasia. This article critically assesses the features of the GreenLight™ laser and its potential use in the treatment of lower urinary tract symptoms in benign prostatic hyperplasia patients. Recently, a significant body of evidence in the literature on good clinical outcomes in 1-year follow-up periods has been enriched with the findings from a few randomized trials, in which this device is compared with other minimally invasive or standard approaches. In turn, very few patients in the GreenLight laser study groups reach the end point of a 3- or 5-year follow-up time. However, most patients who underwent GreenLight laser treatment were treated successfully with a good clinical outcome and a minor rate of peri- and post-operative complications. Furthermore, it can be implemented in high-risk patients who are undergoing anticoagulation therapy. Bearing in mind the inherent characteristics of using a laser for treatment, one obvious consequence is that no pathological specimen remains for further study. This implies the necessity of suitable patient selection in whom the risk of prostate cancer should be minimal. In terms of cost-effectiveness, one should consider applying this method when dealing with patients who have a moderately enlarged prostate volume.

Postradical cystectomy bowel perforation caused by a drainage tube: a case report.

INTRODUCTION: Open drains are frequently placed in the abdominal cavity to prevent the collection of fluid or blood following major surgery. CASE PRESENTATION: We describe a case of perforation of the large bowel caused by the drain tube placed in a 74-year-old patient who had undergone radical cystectomy for invasive bladder cancer.

Eighteen-month results of a randomized prospective study comparing transurethral photoselective vaporization with transvesical open enucleation for prostatic adenomas greater than 80 cc.

CONFLICT OF INTEREST: None Take Home Message: This is a prospective randomized study showing that for large prostatic adenomas, photoselective vaporization of the prostate requires less blood transfusions, shorter catheterization time and shorter hospital stay compared to open prostatectomy, while achieving similar functional results at the same time. AIM: The effectiveness and the safety of photoselective vaporization of the prostate (PVP) was compared to that of open prostatectomy (OP) for the surgical treatment of large prostatic adenomas. METHODS: 125 patients with prostate glands>80 ml, were randomly allocated to PVP (n=65) or OP (n=60) and prospectively evaluated at 1, 3, 6, 12, and 18 months postoperatively. International prostate symptom score (IPSS) and peak urinary flow rate (Qmax) were chosen as primary treatment-related endpoints. RESULTS: Longer length of operation time, shorter length of catheterization and hospital stay were experienced by patients who underwent PVP. Although patients who underwent OP showed a higher transfusion rate, adverse events in general were minor and of similar profile in both groups. All functional parameters improved significantly compared to baseline values in both groups. There was no difference in IPSS between the two groups at 3, 6, 12, and 18 months postoperatively. Patients who underwent OP scored better in the IPSS-Quality of life score at 18 months postoperatively. At 18 months there were no significant differences between the two groups in the Qmax, post void residual urine volume and in the International Index for Erectile function-5 questionnaire. At three months prostate volume was significantly lower in the OP group and remained as such throughout follow-up. CONCLUSIONS: Our results indicate that for an 18 month period photoselective vaporization of the prostate is a highly acceptable treatment alternative to open prostatectomy.

Greenlight laser in benign prostatic hyperplasia: turning green into gold.

PURPOSE OF REVIEW: The purpose of this review is to present recent clinical data published upon the photoselective vaporization of the prostate procedure and introduce new ideas about the future influence of this new technology upon the treatment of benign prostatic hyperplasia. RECENT FINDINGS: Published studies have provided significant evidence that the photoselective vaporization of the prostate laser procedure is efficient, safe, easy to learn and early results show that it can compete with transurethral resection of the prostate. The major advantages of this technique are that it is a bloodless procedure, the patient goes home after a few hours and it can be applied to all patient categories. The cost of the photoselective vaporization of the prostate procedure is being investigated and a few studies addressing this issue seem to conclude that this surgical option is a cost effective decision. Lately, thoughts about early surgical intervention with the photoselective vaporization of the prostate laser are being expressed but properly designed studies are needed. SUMMARY: The photoselective vaporization of the prostate laser procedure is getting worldwide fast recognition and it is the first time that transurethral resection of the prostate and open prostatectomy are being threatened. The cost of this procedure is being examined but it is difficult to draw solid conclusions since reimbursement strategies differ between various countries.

Transurethral photoselective vaporization versus transvesical open enucleation for prostatic adenomas >80ml: 12-mo results of a randomized prospective study.

OBJECTIVES: To compare the effectiveness and the safety of photoselective vaporization of the prostate (PVP) to open prostatectomy (OP) for the surgical treatment of large prostatic adenomas. METHODS: A total of 125 patients with prostate glands >80ml were randomly allocated to PVP (n=65) or OP (n=60) and prospectively evaluated at 1, 3, 6, and 12 mo postoperatively. International Prostate Symptom Score (IPSS) and peak urinary flow rate (Q(max)) were chosen as primary treatment-related end points. RESULTS: The patients who underwent PVP experienced a longer length of operation time, shorter time of catheterization, and shorter hospital stay. Adverse events were minor and of similar profiles in both groups, although patients who underwent OP showed a higher transfusion rate. All functional parameters improved significantly compared to baseline values in both groups. The IPSS did not differ between the two groups at 3, 6, and 12 mo postoperatively. Patients who underwent OP scored better in the IPSS quality of life score at 6 and 12 mo postoperatively. No significant differences between the two groups in the Q(max), postvoid residual urine volume, and International Index for Erectile Function-5 questionnaire were detected. At 3 mo prostate volume was significantly lower in the OP group compared to the PVP group (median value 10ml vs. 50ml; p<0.001) and remained as such throughout follow-up, whereas prostate-specific antigen values reached statistical difference at 6 mo (median value 2ng/ml vs. 2.4ng/ml; p=0.028). CONCLUSIONS: Our results indicate that for a 12-mo period PVP is a highly acceptable treatment alternative to OP.

Ureteroscopic removal of mildly migrated stents using local anesthesia only.

PURPOSE: In the outpatient office setting we evaluated the feasibility and efficacy of ureteroscopic removal of upward migrated ureteral stents using local or no anesthesia. MATERIALS AND METHODS: Prospectively 37 patients with mild upward stent migration underwent ureteroscopic stent removal under local or no anesthesia. Stent migration was always below the pelvic brim. It was diagnosed by plain x-ray of the kidneys, ureters and bladder, and flexible cystoscopy. Semirigid ureteroscopy was performed in the office outpatient setting. After each procedure patients graded the discomfort and/or pain level experienced by completing 2 separate 5-scale visual analog pain scores, including 1 for flexible cystoscopy and 1 for the ureteroscopic procedure. Pain scores were compared between the 2 procedures. RESULTS: Stent removal was successful in 34 of 37 patients (91.9%). Successful procedures were never interrupted due to pain intolerance. No complications occurred. The mean visual analog pain score for ureteroscopic stent removal was 1.73 and it was similar in men and women (p = 0.199). The mean visual analog pain score for flexible cystoscopy was 1.27. This procedure was significantly more painful in men than in women (p = 0.018). Ureteroscopic stent removal was more painful than flexible cystoscopy overall and in women (each p <0.01) but not in men (p = 0.3). All patients were discharged home within 1 hour after the procedure and no patient required hospital admission or a new hospital visit. CONCLUSIONS: Ureteroscopic removal of a migrated stent using local anesthesia is effective, safe and tolerable in select patients. Preventing the complications and costs associated with general or spinal anesthesia makes this option appealing to patients and it should be offered when possible.

A review on follow-up strategies for renal cell carcinoma after nephrectomy.

OBJECTIVES: To provide a comprehensive review of the evidence supporting the necessity for follow-up after nephrectomy for renal cell carcinoma. METHODS: We searched the Medline, MeSH, EMBASE, and Cochrane databases using the terms "renal cell cancer," "kidney neoplasm," "follow-up," "surveillance," "prognosis," and "staging" to look for human/English language/Randomized Controlled Trials/Clinical trials/Review articles/Meta-analysis/Practiced Guidelines, and Editorials. RESULTS: No consensus currently exists on surveillance guidelines after radical or partial nephrectomy for renal cell carcinoma. The rationale for follow-up strategies is to detect local recurrence or metastatic disease and to allow appropriate treatment. Most of the surveillance protocols recommend various follow-up strategies for all tumour stages. The emphasis on follow-up should be during the first 3-5 yr after nephrectomy. There is no consensus about which investigations should be performed and at what intervals. Most surgeons rely on symptom enquiry, physical examination, chest x-ray, and computed tomography scanning. A protocol based on the stage of the initial tumour is adapted by the majority of the investigators. Patients should be followed similarly after radical or partial nephrectomy on the basis of stage-oriented protocols. The combination of various prognostic factors requires further validation over stage-based protocols. There is a paucity of guidelines in the literature regarding follow-up for patients with hereditary forms of renal cell carcinoma. CONCLUSIONS: Current guidelines for follow-up are based on observational and case studies. While this fact precludes a high level of evidence-based guidelines, we have to conclude that this is the best available evidence to date.

Ultrasound-guided percutaneous nephrostomy performed by urologists: 10-year experience.

OBJECTIVES: To assess the safety, feasibility, and effectiveness of percutaneous nephrostomy tube (PNT) insertion performed solely by a urologist on an outpatient basis. We present our relevant 10-year experience. METHODS: From 1996 to 2005, 650 PNT insertions were performed in 530 patients (356 men and 174 women), aged 39 to 94 years (mean 67.4). All patients were referred to our outpatient department. PNT placement was performed under local anesthesia by a consultant urologist or registrar during regular work hours or during on-call duty. Early complications within 30 days of PNT insertion were recorded. RESULTS: Primary successful PNT insertion was recorded in 615 (94.6%) of the 650 procedures. Follow-up data up to 30 days were available for 545 PNT placements (83.8%). Of the 650 PNT insertions, 22 (3.3%) major immediate complications were encountered. In 4 patients, laparotomy was performed for surgical exploration of hemorrhage (3 patients) or choleperitoneum, resulting in nephrectomy (1 patient). In 5 (0.8%) of 615 successful PNT procedures, we recorded septicemia, which resulted in 2 deaths. In 1 more case (0.1%), the nephrostomy tube was misplaced into the inferior vena cava. Minor complications within the follow-up period were recorded in 24 (4.5%) of 545 cases. The complication rate did not differ significantly between the consultants and registrars or whether PNT insertion was performed during regular work hours or during on-call duty. CONCLUSIONS: Ultrasound-guided PNT insertion performed solely by a urologist is a safe, feasible, and efficient procedure, regardless of the operator's experience.