Single-site laparoscopic orchidopexy in an infant.

We describe a laparoscopic orchidopexy performed on an 18-month-old child through a single infraumbilical site.

Enterococcus faecalis cellulitis/fasciitis after hypospadias surgery.

We describe a case of Enterococcus faecalis-associated cellulitis/fasciitis after hypospadias surgery.

Levels of evidence ratings in the urological literature: an assessment of interobserver agreement.

OBJECTIVE: To determine to what extent urologists with no specific training agree upon level of evidence (LoE) ratings of studies published in the urological literature, as LoE are commonly referenced as a measure of evidence quality. MATERIALS AND METHODS: In all, 86 clinical research studies published in four major urology journals were reviewed. Each article was independently reviewed by eight reviewers using a standardized data abstraction form. Articles were assessed for type of study (therapy, prognosis, diagnosis or economic) and LoE (I, II, III or IV). Reviewers received only written instructions and no formal training in the application of this classification system. RESULTS: Of the 86 articles, 69% related to therapy, 16% to prognosis, and 15% to diagnosis. Eight studies (9%) provided Level I evidence, 18 studies (21%) Level II, 14 studies (16%) Level III and 46 studies (54%) Level IV evidence. The intraclass correlation coefficient (95% confidence interval) based on all reviewers (eight reviewers) was 0.67 (0.59-0.74; P= 0.001) for the type of study and 0.55 (0.48-0.64; P= 0.001) for the LoE. In an analysis limited to a subset of studies in which all reviewers agreed upon the type of study question (n= 40) the intraclass correlation coefficient was 0.79 (0.70-0.86; P= 0.001). CONCLUSION: In the present study there was a low interobserver agreement for LoE ratings by urologists with no specific training. These findings suggest caution in the interpretation of LoE ratings and emphasize the importance of specific training for individuals that are charged with quality of evidence determinations.

Endoscopic stone management in children.

PURPOSE OF REVIEW: The management of urolithiasis in children has significantly changed over the past 20 years. Extracorporeal shockwave lithotripsy (SWL) was initially the preferred modality of treatment. More recently, ureteroscopy and percutaneous nephrolithotomy (PCNL) are being used at an increasing frequency in the management of pediatric stone disease. RECENT FINDINGS: Development has been made in various aspects of pediatric endoscopic stone management. Ureteroscopy and PCNL have been applied at an increasing frequency to treat pediatric stone disease, which has guided modifications to improve the procedures. Increased endoscopic experience with managing urolithiasis has broadened the indications wherein these methods are utilized. Technology is continually advancing to meet the needs of this population. Ureteroscopes have been modified to accommodate the pediatric ureter, optics advanced, and access sheaths are used to improve results. In addition, technique is constantly being refined. SUMMARY: Further experience will direct surgeons as to when ureteroscopy and PCNL are appropriate. The incidence of urolithiasis is on the rise in developing nations; there is a need to address the most efficient method of treatment that minimizes the morbidity to the child.

Evolution of laparoscopy in pediatric urology.

The use of laparoscopy has evolved over the last 30 years, particularly in the last decade, from merely extirpative or diagnostic procedures to intricate reconstructive procedures on the major genitourinary organs. The development of laparoscopy as a method of treating urological problems has progressed more slowly in children compared with adults; perhaps due to the availability of miniaturized technology, the steep learning curve and the high success of traditional open surgery. This article seeks to provide a comprehensive review of the evolution of laparoscopy from its inception to its present-day applications in the field of pediatric urology, including the current indications and results of various laparoscopic procedures.

Evaluating the evidence: statistical methods in randomized controlled trials in the urological literature.

PURPOSE: Randomized controlled trials potentially provide the highest level of evidence to inform clinical decision making. Appropriate use of statistical methods is a critical aspect of all clinical research, including randomized controlled trials. We report the first formal evaluation to our knowledge of the statistical methods of randomized controlled trials published in the urological literature in 1996 and 2004. MATERIALS AND METHODS: All human subjects randomized controlled trials published in 4 leading urology journals in 1996 and 2004 were identified for formal review. A standardized evaluation form was developed based on the Consolidated Standards of Reporting Trials statement. Each article was evaluated by 2 independent reviewers with formal training in research design and biostatistics who were blinded to study authors and institution. Discrepancies were settled by consensus. RESULTS: A total of 152 randomized controlled trials were reviewed (65 in 1996, 87 in 2004). The median sample size (IQR) per arm of parallel design randomized controlled trials published in 1996 and 2004 was 36 (11, 96) and 50 (26, 134) study subjects, respectively (p = 0.157). Sample size justifications were provided by 19% of studies in 1996 and 47% of studies in 2004 (p = 0.001). Of randomized controlled trials 16 (25%) vs 32 (37%) identified a single primary outcome variable (p = 0.110). Effect size estimates for primary or secondary outcome variables were provided by 5% vs 13% (p = 0.090) and the precision of the effect was detailed by 5% vs 10% of randomized controlled trials (p = 0.195). CONCLUSIONS: This formal review suggests that statistical analysis in urological randomized controlled trials has improved. However, considerable deficiencies remain. Ongoing education in applied statistics may further improve urological randomized controlled trial reporting.

A prospective, randomized, double-blinded placebo-controlled comparison of extended release oxybutynin versus phenazopyridine for the management of postoperative ureteral stent discomfort.

OBJECTIVES: Ureteral stents commonly cause lower urinary tract and flank discomfort. We evaluated the use of extended release oxybutynin versus phenazopyridine versus placebo for the management of ureteral stent discomfort after ureteroscopy. METHODS: Each of 60 patients who received a unilateral stent after ureteroscopy was given a blister pack containing 21 unmarked capsules of either extended release oxybutynin 10 mg, phenazopyridine 200 mg, or placebo in a prospective, randomized, and double-blinded fashion. Patients were instructed to take 1 capsule 3 times daily immediately after the procedure. Patients were given 50 tablets of oral narcotic to be taken as needed. Patients reported bothersome scores for flank pain, suprapubic pain, urinary frequency, urgency, dysuria, and hematuria on postoperative day 1, day 2, and the day of stent removal. Narcotic use was also recorded. RESULTS: Eight patients were excluded from the analysis for stent migration necessitating early removal (1), uncontrollable pain (1), failure to complete blister pack (4), and inability to contact for follow-up surveys (2). There was no difference in bothersome score among the groups for flank pain, suprapubic pain, urinary frequency, urgency, and dysuria. The phenazopyridine group reported less hematuria on postoperative day 1 when compared with placebo, which was statistically significant. The oxybutynin group required fewer narcotics, but this finding was not statistically significant. CONCLUSIONS: Although this study failed to show a significant difference in bothersome scores among the groups, the small sample size precludes definitive conclusion. Future studies pooling these data will determine the overall treatment effect and the optimal management of ureteral stent morbidity.

Urolithiasis: not just a 2-legged animal disease.

PURPOSE: In this systematic review we summarize information on animal models of stone formation, the similarities of stone formation between humans and nonhuman animals, and the management of naturally occurring stones in animals, particularly dogs and cats. MATERIALS AND METHODS: A comprehensive review of the peer reviewed literature was performed using the key words urolithiasis and animals. The search was then limited to articles in English that were published within the last 30 years (1977 to 2007). RESULTS: Multiple animal species are affected by urolithiasis and the mechanisms of formation appear to mirror those in humans. Recently described models of animal stone disease may help us better understand and ultimately treat nephrolithiasis in humans. CONCLUSIONS: The pathogenesis of urolithiasis and treatment protocols in animals parallel those of humans. Given the number of similarities between treatment patterns for humans and animals, many urologists are now being integrated into the treatment of animals.

Levels of evidence in the urological literature.

PURPOSE: The concept of levels of evidence is one of the guiding principles of evidence based clinical practice. It is based on the understanding that certain study designs are more likely to be affected by bias than others. We provide an assessment of the type and levels of evidence found in the urological literature. MATERIALS AND METHODS: Three reviewers rated a random sample of 600 articles published in 4 major urology journals, including 300 each in 2000 and 2005. The level of evidence rating system was adapted from the Center of Evidence Based Medicine. Sample size was estimated to detect a relative increase in the proportion of studies that provided a high level of evidence (I and II combined) from 0.2 to 0.3 with 80% power. RESULTS: Of the 600 studies reviewed 60.3% addressed questions of therapy or prevention, 11.5% addressed etiology/harm, 11.3% addressed prognosis and 9.2% addressed diagnosis. The levels of evidence provided by these studies from I to IV were 5.3%, 10.3%, 9.8% and 74.5%, respectively. A high level of evidence was provided by 16.0% of studies in 2000 and by 15.3% in 2005 (p = 0.911). CONCLUSIONS: This study suggests that a majority of studies in the urological literature provide low levels of evidence that may not be well suited to guide clinical decision making. We propose that editors of leading urology journals should promote awareness for this guiding principle of evidence based clinical practice by providing a level of evidence designation with each published study.

The effect of frequency doubled double pulse Nd:YAG laser fiber proximity to the target stone on transient cavitation and acoustic emission.

PURPOSE: Scant information has been published describing the effect of laser fiber distance from the stone target on the mechanism of calculus fragmentation. Using high speed photography and acoustic emission measurements we characterized the impact of laser fiber proximity on stone comminution. We evaluated the effect of laser fiber distance from the stone target on resultant cavitation bubble formation and shock wave generation. MATERIALS AND METHODS: Stone fragmentation was assessed using a FREDDY (frequency doubled double pulse Nd:YAG) (World of Medicine, Orlando, Florida) laser and a holmium laser. The FREDDY laser was operated using a 420 microm fiber at an output energy of 120 and 160 mJ in single and double pulse settings, and a pulse repetition rate of 1 Hz. The holmium laser was operated using a 200 microm fiber at an output energy of 1 to 3 J and a pulse repetition rate of 1 Hz. The surface of a 1 cm square BegoStone (Bego, Bremen, Germany) attached to an X-Y-Z translational stage was aligned perpendicular to the laser fiber, which was immersed in a Lucite tank filled with water at room temperature. An Imacon 200 high speed camera was used to capture transient cavitation bubbles at a framing rate of up to 1,000,000 frames per second. Acoustic emission signals associated with shock waves generated during the rapid expansion and collapse of the cavitation bubble were measured using a 1 MHz focused ultrasound transducer. RESULTS: At laser fiber distances of 3.0 mm or less cavitation bubbles and shock waves were observed with the FREDDY laser. In contrast to the holmium laser, the bubble size and shock wave intensity of the FREDDY laser was inversely related to the fiber-to-stone distance over the range tested (0.5 to 3.0 mm). CONCLUSIONS: While bubble size was noted to increase with a larger stone-to-fiber distance using the holmium laser, to consistently generate cavitation bubbles and shock waves using the FREDDY laser the laser fiber should be operated within 3.0 mm of the target stone. These findings have significant implications during clinical laser stone fragmentation.

Changing gender prevalence of stone disease.

PURPOSE: Recent studies suggest that the incidence of renal stone formation has been increasing and the male predominance of nephrolithiasis is decreasing, which may be due to changes in diet and lifestyle. We examined changes in the prevalence by gender of inpatient hospital discharges for urinary stone disease. MATERIALS AND METHODS: The Nationwide Inpatient Sample was used for analysis. Discharges with an International Classification of Diseases, 9th revision, Clinical Modification principal diagnosis of 592.0 (calculus of kidney) or 592.1 (calculus of ureter) from 1997 to 2002 were included in the investigation. RESULTS: An estimated mean+/-SE 1,013,621+/-19,310 discharges for stone disease occurred from 1997 to 2002. Discharges for renal calculus increased by 18.9% during the study period (p<0.001), while discharges for ureteral calculus remained relatively constant. After adjusting for population changes discharges for renal calculi increased by 14.2% (p=0.002). In females discharges for renal calculi increased by 21.0% and discharges for ureteral calculi increased by 19.2% (each p<0.001). After adjusting for population changes renal calculus and ureteral calculus discharges in females increased by 22.0% (p=0.001) and 14.5% (p=0.005), respectively. CONCLUSIONS: In this nationally representative sample the population adjusted rate of discharges for stone disease in females dramatically increased from 1997 to 2002. This alteration represents a change in the prevalence by gender of treated stone disease from a 1.7:1 to 1.3:1 male-to-female ratio. It may reflect variations in the underlying prevalence by gender of stone disease. We speculate that the increasing incidence of nephrolithiasis might be due to lifestyle associated risk factors, such as obesity.

A critical assessment of the quality of reporting of randomized, controlled trials in the urology literature.

PURPOSE: Randomized, controlled trials are the gold standard for evidence based assessment of therapeutic interventions. In 1996 the Consolidated Standards of Reporting Trials statement was published in an effort to standardize the reporting of clinical trials. To our knowledge we report the first systematic assessment of randomized, controlled trial quality in the urology literature by Consolidated Standards of Reporting Trials standards. MATERIALS AND METHODS: All human subject randomized, controlled trials published in 4 leading urology journals in 1996 and 2004 were identified for formal review. A standardized evaluation form was developed based on the Consolidated Standards of Reporting Trials statement. Each article was evaluated by 2 independent reviewers and discrepancies were settled by consensus. A Consolidated Standards of Reporting Trials criteria summary score was calculated on a scale of 0 to 22. RESULTS: A total of 152 randomized, controlled trials met inclusion criteria. The mean+/-SEM Consolidated Standards of Reporting Trials summary score was 10.2+/-0.3 (median 10.3) and 12.0+/-0.3 (median 12.2) in 1996 and 2004, respectively, with a mean difference of 1.8 (95% CI 1.0, 2.6; p=0.001). Reporting of important methodological criteria, eg sample size justification and randomization implementation, improved from 1996 to 2004. Improvement notwithstanding, reporting of key methodological criteria remained consistently below 50% in 2004. CONCLUSIONS: This formal review suggests that randomized, controlled trial reporting in the urology literature has improved since the publication of the Consolidated Standards of Reporting Trials statement in 1996. Certain areas, such as reporting of trial methods, continue to meet Consolidated Standards of Reporting Trials criteria in fewer than half of publications. Ongoing graduate and postgraduate education in trial design and evidence based practice may result in further improvement in randomized, controlled trial reporting.

Relationship between body mass index and prostate cancer screening in the United States.

PURPOSE: Obesity is associated with more advanced disease and worse outcomes in men with prostate cancer. To our knowledge the relationship between obesity and prostate cancer screening behavior in men 40 or older is unknown. Thus, we examined associations between body mass index and prostate cancer screening behavior. MATERIALS AND METHODS: We used the 2002 Behavioral Risk Factor Surveillance System to study prostate cancer screening in a representative sample of 57,827 men 40 years or older. Primary outcomes were the proportion of men ever screened and the proportion screened in the last year for prostate cancer. RESULTS: Obese men were more likely than normal weight men to have had a prostate specific antigen test (62.1% vs 56.1%, p <0.001) and to have had a prostate specific antigen test in the last year (44.2% vs 38.2%, p <0.001). After controlling for sociodemographic characteristics obese men remained more likely than normal weight men to have had a prostate specific antigen test (OR 1.46, 95% CI 1.33-1.61) and to have had a prostate specific antigen test in the last year (OR 1.42, 95% CI 1.30-1.55). Respondents reporting an ongoing relationship with a physician (OR 2.88, 95% CI 2.57-3.22) and black nonHispanic men vs white men (OR 1.58, 95% CI 1.38-1.81) were also more likely to have had a prostate specific antigen test in the last year. CONCLUSIONS: Obese men are more likely than normal weight men to be screened for prostate cancer. Associations between advanced stage, worse outcomes and obesity may not be explained by disparities in the screening of obese men for prostate cancer.

Forced versus minimal intravenous hydration in the management of acute renal colic: a randomized trial.

BACKGROUND AND PURPOSE: The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic. PATIENTS AND METHODS: Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20) or minimal IV hydration at 20 mL of normal saline per hour (N = 23). A visual analog pain scale was completed hourly for a total of 4 hours. Demographic information, laboratory and imaging results, narcotic use in morphine equivalents (ME), and pain scores were recorded and compared. Spontaneous stone passage rates were also calculated by careful patient follow-up. Results were considered statistically significant at p < 0.05. RESULTS: Stone size was equivalent in the two treatment groups (p > 0.05). There was no difference in the narcotic requirement in ME (p = 0.644) between the two groups. Similarly, there was no difference in hourly pain score or stone-passage rates between the groups (p > 0.05). CONCLUSIONS: Treatment of uncomplicated renal colic has traditionally included vigorous intravenous hydration, as well as medications for the control of pain and nausea. Our data suggest that maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use. Moreover, it appears the state of hydration has little impact on stone passage.

Prostate specific antigen testing in men older than 75 years in the United States.

PURPOSE: Although there is general agreement that men older than 75 years are unlikely to benefit from prostate specific antigen testing, patient reported testing rates in these patients exceed 30%. We examined physician reported PSA testing in elderly men, and physician and practice characteristics associated with testing. MATERIALS AND METHODS: Using the 1999 to 2002 National Ambulatory Medical Care Survey, a nationally representative sample of outpatient visits to nonfederal office based physicians, we measured rates of prostate specific antigen testing by age group in men without prostate cancer who were 40 years or older and who visited outpatient family medicine, internal medicine or urology clinics. RESULTS: An estimated 42.3 million prostate specific antigen tests were performed from 1999 to 2002, of which 5.91 million (14.0%) were performed in men older than 75 years. The population based testing rate was 6.1% in patients 40 to 49-year-old, 26.0% in patients 50 to 75-year-old and 27.8% in patients older than 75 years. Urologists performed 35.4% of prostate specific antigen tests in men older than 75 years. Controlling for sociodemographic variables physicians with a laboratory on site were more likely to perform a prostate specific antigen test (OR 1.35, 95% CI 1.07 to 1.71). In men older than 75 years the odds of prostate specific antigen testing were 1.58 times higher (95% CI 1.01 to 2.50) in practices with a laboratory on site. CONCLUSIONS: Up to a third of men older than 75 years undergo prostate specific antigen testing despite an average life expectancy of less than 10 years. Physician and practice characteristics are associated with prostate specific antigen PSA testing.

Clinical research and statistical methods in the urology literature.

PURPOSE: We provide a systematic assessment of the quality and accuracy of statistical reporting in the urology literature. MATERIALS AND METHODS: All original research publications with adult human subjects in a single issue (August 2004) of 4 leading urology journals were identified for formal review. A standardized evaluation form was developed in consultation with an experienced biostatistician and subsequently tested. Two independent reviewers with at least 1 year of formal training in research design and biostatistics who were blinded to authors and institutions reviewed each article. Discrepancies were settled by consensus and/or adjudication by the biostatistician. RESULTS: Of the 169 articles screened 97 met eligibility criteria for review. Cohort (43 of 97 or 44%) or cross-sectional (28 of 97 or 29%) designs comprised the majority of these studies. Only 10 randomized clinical trials (12.4%) were identified. Statistical tests were identified in 83 studies (93%). Overall 69 of 83 studies (71%) providing statistical comparisons had at least 1 statistical error, including using the wrong test for the data type in 28%, inappropriate use of a parametric test in 22% and failure to account for multiple comparisons in 65%. In studies applying multivariate analysis (29%) over fitting the model with too many variables was the most common statistical flaw (39%). CONCLUSIONS: This formal review suggests that statistical methods are often used inappropriately in the urology literature, thereby, potentially undermining the validity of study results and conclusions. An effort to raise the awareness of appropriate statistical techniques through postgraduate education appears indicated.