Optimizing Upper-Tract Imaging for Non-Visible Haematuria.

INTRODUCTION: Non-visible haematuria (NVH) is associated with a small risk of upper-tract urothelial carcinoma (UTUC), though there is little consensus on its investigation, particularly with regard to upper-tract imaging. This study aimed to determine whether the presentation of UTUC can guide investigation of NVH in patients under 60 years old. METHODS: All patients investigated at our one-stop haematuria clinics under a cancer pathway were reviewed during a 5-year period, with all patients undergoing cystoscopy and upper-tract imaging. Retrospective analysis of all UTUC cases from our urological cancer multidisciplinary team meeting database over a 10-year period was also undertaken. RESULTS: 2,129 patients with a median age of 67 years underwent urgent investigation for haematuria between March 2015 and February 2020. 449 cases presented with NVH, of whom 124 (27.6%) were under 60. Out of 21 cases of UTUC, only 2 presented with NVH; both were over the age of 60 years. Factors that independently predicted diagnosis with urinary-tract malignancy were age ≥60 (OR 3.70, p < 0.001), visible haematuria (OR 2.50, p = 0.006), and suspicious cystoscopic findings (OR 58.06, p < 0.001). Review of all 119 UTUC cases over 10 years found 6 cases (5.0%) presenting with NVH, with one (0.8%) also presenting under 60 years. CONCLUSION: Diagnosis with UTUC is rare in patients presenting with NVH under the age of 60 years. Routine use of CTU in this low-risk group is best avoided, with ultrasonography constituting a safer first-line upper-tract imaging modality. Guidelines that risk-stratify NVH patients may be effective in reducing unnecessary investigations.

Does the mineral content of tap water correlate with urinary calculus composition?

The association between the mineral content of drinking water and urolithiasis remains elusive. The aim of this study is to investigate whether the mineral composition of tap water correlates with urinary calculus composition. Patients with calculi that underwent biochemical analysis at two urological centres in the North-West of England between November 2015 and December 2020 were included. Calculus composition was reviewed with respect to patient demographics, serum biochemical variables, and water mineral composition data obtained from the local water supply company using patient postcodes. 1711 urinary tract calculi from 1518 patients, living in 87 water supply zones were included. Water sodium concentration was an independent predictor of mixed calcium oxalate/uric acid calculi (OR 1.157, p < 0.001) and a negative independent predictor of calcium oxalate monohydrate (OR 0.896, p = 0.001) and dihydrate (OR 0.742, p = 0.034) calculi. Moreover, the magnesium-to-calcium ratio of tap water was a negative independent predictor of calcium oxalate monohydrate calculi (OR < 0.001, p = < 0.001), while tap water magnesium concentration inversely correlated with the percentage of calcium oxalate within calculi (rs = - 0.054, p = 0.026). Total water hardness did not independently predict calculus type. Many factors are implicated in the formation of urinary calculi. This study is the first to assess calculus composition in relation to tap water mineral content using postcode data on a case-by-case basis. Though total water hardness did not independently predict calculus composition, the interesting findings relating to water sodium and magnesium concentrations are in need of closer scrutiny in larger scale studies.

Amyloidosis of the Urinary Bladder: A Systematic Review and a Proposed Management Algorithm.

OBJECTIVE: To propose an algorithm for the management of bladder amyloidosis based on a systematic review of the literature, given that the bladder is the second most commonly affected organ of the urinary tract in the course of systemic or localized amyloidosis. METHODS: We searched PubMed, Cochrane Library and Scopus databases utilizing PRISMA methodology from inception to November 30, 2020 (PROSPERO: CRD42020207855). RESULTS: We included 76 studies with 184 patients (9 case series and 67 case reports). Presenting symptoms of bladder amyloidosis comprised of hematuria, irritative or obstructive urinary symptoms, and cystitis-like symptoms. The diagnosis of amyloidosis was established by histologic examination of specimens retrieved during transurethral resection of bladder lesions. Complete endoscopic resection, the cornerstone of management of localized disease, was feasible in 89.1% cases. The included patients were followed up for a mean of 54 months, within which 65 patients (35.3%) recurred. The time to first amyloidosis recurrence was 20 months (range: 1-168). Additionally, 16 individuals presented with concomitant bladder amyloidosis and bladder cancer, while 4 developed bladder malignancy during follow-up. Due to the frequent and early recurrences of patients with bladder amyloidosis, a check-up cystoscopy at 3, 12, and 24 months' after initial resection is recommended. Recurrences should be managed with transurethral resection, while intravesical instillations of dimethyl sulfoxide (DMSO) and cystectomy should be reserved for refractory cases. CONCLUSION: We propose a management algorithm for bladder amyloidosis based on the available evidence for this rare benign entity that mimics bladder cancer.

Current process and outcomes of the surgical management of LUTS due to benign prostatic enlargement: how consistent are we? - results from the multi-institutional audit of surgical management of BPE (AuSuM BPE) in the United Kingdom.

OBJECTIVE: In view of changing landscape of surgical treatment for LUTS secondary to BPE, this audit was undertaken to assess key aspects of the processes and outcomes of the current interventional treatments for BPE, across different units in the UK. MATERIALS AND METHOD: A multi-institutional snapshot audit was conducted for patients undergoing interventions for LUTS/BPE over 8-week period. Using Delphi process two-part proforma was designed to capture data. RESULTS: 529 patients were included across 20 NHS trusts in England and Wales. Median age was 73 years. Indications for surgery were acute retention (47%) and LUTS (45%). 80% of patients had prior medical therapy. TURP formed the commonest procedure. 27% patients had <23 hour hospital stay. Immediate (21%) and delayed (18%) complications were Clavien-Dindo <2 category. High proportion of patients reported residual symptoms. Type and indication of surgery were significant predictor of complications, length of stay and failure of TWOC outcomes, on multivariate analyses. There were variations in departmental processes, 50% centres used PROMs. CONCLUSION: Monopolar TURP still remains the commonest intervention for BPE. Most departments are adopting newer technologies. The audit identified opportunities for development of consistent, effective and patient centric practices as well as need for large-scale focused studies.

How well do we manage non-muscle invasive bladder tumors? A UK audit of real-life practices.

OBJECTIVE: The aim of this study was to assess the quality of TURBT (transurethral resection of bladder tumor) using surrogate parameters and evaluate adherence to the guidelines regarding the management of bladder tumors. MATERIALS AND METHODS: A clinical audit of all new diagnosis of bladder cancer was undertaken from January 2016 to January 2017. A total of 101 new bladder cancer cases were included. Surrogates of TURBT quality including presence of detrusor in the specimen, rate of re-TUR, presence of carcinoma in situ, and 3-month recurrence rates were analyzed. Adherence to guidelines regarding management of non-muscle invasive bladder cancer including time to re-TUR and utilization of single instillation chemotherapy was evaluated. RESULTS: Absence of detrusor muscle in the specimen of the initial TURBT was noted in 22.8% of the cases. The chance of including muscle in the specimen was almost four-fold for tumors larger than 3 cm. A single instillation of intravesical chemotherapy following TURBT was administered in only 40% of eligible patients; 54.3% of patients had a re-TUR, the majority (61.3%) for high-grade non-muscle invasive bladder cancer on initial TURBT. Re-TUR was done on average 10 weeks after initial TURBT. The 3-month recurrence rate was 36.0% with larger tumors (>3 cm) being more prone to early recurrences. Early recurrences were not affected by intravesical instillations with bacillus Calmette-Guérin or mitomycin C although there was a positive association between the presence of carcinoma in situ on initial resection and early recurrences. DISCUSSION AND CONCLUSION: One in two patients will have a re-TUR, and approximately one in two patients will have tumor on re-TUR. Single immediate chemotherapy instillations after TURBT are underutilized. The presence of carcinoma in situ on initial TURBT and tumor size were predictors of early recurrences.

Ex vivo Comparison of 2 Disposable versus a State-of-the-Art Reusable Ureterorenoscope.

INTRODUCTION: The success of upper urinary tract endoscopy on one hand and the high cost of purchase and maintenance of the scopes on the other hand have driven the development of disposable digital flexible ureterorenoscopy (fURS). MATERIALS AND METHODS: We performed an ex vivo comparison of 2 disposable digital fURS from different companies with a state-of-the-art reusable endoscope from another well-established scope manufacturer. The scopes were tested comparing parameters such as instrument handling, irrigation flow, image quality, and deflection. For the disposable scopes, the latter 2 were evaluated both, before and after vigorous stress testing. RESULTS: Expectedly, the most consistent finding among the 3 instruments was the marked decrease on irrigation flow following insertion of a working element, most notably a guidewire. Depth perception and ergonomic handling were comparable in all 3 instruments. Poststress testing revealed a significant loss of upward deflection in both disposable instruments, more so when an auxiliary instrument is inserted into the working channel. However, this did not appear to be the case in downward deflection. CONCLUSIONS: To our knowledge, this is the first study that used a vigorous stress testing protocol comparing disposable and reusable fURS. The newer generation disposable scope fared better than the older one. Results are encouraging and indicate that improvements are ongoing and progressing, bringing the quality of disposable scopes to the level that we are used to from our reusable high performance scopes while at the same time avoiding costly damage repairs. Continuous research and evidence-based interpretation of results in the absence of commercial bias are paramount to ensure this ongoing development.

The Evidence Paradox of the Effectiveness between the Paediatric and Adult Stone-Forming Population: A Narrative Review.

AIM/OBJECTIVE: To identify trends in the evidence base regarding the effectiveness of using α-blockers in children versus adults and compare outcomes. METHODS: A literature search up using the key words including urolithiasis/renal/ureteric stone in children/paediatric population, medical expulsive treatment (MET), α-blocker/alfuzosin/tamsulosin/doxazosin. Included were randomized or controlled clinical trials in paediatric stone formers (aged ≤18 years). Outcome measures for assessment included the overall stone expulsion rate, expulsion time, the number of pain episodes and adverse drug effects and/or reactions. Further comparison of efficacy levels using respective studies from the adult population was performed in order to identify trends, similarities and differences. RESULTS: A total of 8,259 articles were identified. Full text evaluation was possible for 28 articles. Although the picture is clearer in the paediatric group, the lack of reproducible results in adults certainly poses serious questions about data collection, analysis and interpretation in each individual study. The apparent paradox is due to the methodological differences between studies. CONCLUSION: The effectiveness of α-blockers and other medication as MET needs to be studied in multi-institutional, double-blind, placebo-controlled studies that would aim to prove superiority to placebo in contemporary clinical situations, with realistic end points and standardized outcome measure determination.

Impact of Thermo-Expandable Memokath Ureteral Stent on Renal Function in the Management of Ureteroileal Anastomotic Stricture.

PURPOSE: The study aimed to assess the impact of the Memokath 051 stent (MK) on glomerular filtration rate (GFR) and split renal function in the management of ureteroileal anastomotic strictures. MATERIALS AND METHODS: We treated 6 patients in the ages of 66-77 years, 2 of whom had bilateral strictures, with a total of 8 ureteroileal strictures using the MK stent. Five patients had chronic kidney disease (CKD) prior to MK insertion. Mean time between conduit surgery and MK insertion was 28.4 months. Serum creatinine, GFR, and MAG-3 renography were determined before stent insertion and postoperatively at 3 months. RESULTS: Postoperative complications at 3-month follow-up included migration in 2 patients, occlusion in 2 patients, and urinary tract infection in 4 patients. The mean stent indwelling time was 353.4 ± 169.3 days. Mean preoperative creatinine, GFR, right, and left split renal function were 158.3 ± 76.3 µmol/L, 43.6 ± 32.9 mL/min/1.73 m2, 52.8 ± 22.2%, and 47.1 ± 22.2%, respectively. Mean postoperative values were 168.1 ± 84 µmol/L (p = 0.84), 40.8 ± 28.4 mL/min/1.73 m2 (p = 0.56), 51.1 ± 18.3% (p = 1), and 48.8 ± 18.3% (p = 1), respectively. CONCLUSION: MK stent is a safe and efficient minimally invasive long-term treatment option to preserve GFR in patients who develop CKD through ureteroileal anastomotic stricture. In spite of MK stent insertion and alleviation of obstruction, it was presumably inserted too late to improve renal function.

Is it the End for Urologic Pelvic Laparoscopic Surgery?

AIM: To scrutinize the rapid development of robotic versus traditional laparoscopic technique in pelvic urologic surgery. INTRODUCTION: In the last few decades, advances in research and development have led to tremendous progress in medical diagnostics and treatment of disease. Minimally invasive surgery has moved from experimental to becoming the dominant form of surgical management across the surgical specialties. Laparoscopy is nowadays used widely in abdominal surgery, from simple diagnostic laparoscopy to complex colorectal and gynecologic cancer procedures. METHODS: A literature search of electronic databases (PubMed, Medscape, Embase) using the key words: "pelvic laparoscopy, urologic oncology, robotic surgery, minimally invasive access" was performed for all relevant articles in the English language. Data were extrapolated from the abstracts alone to avoid subjective bias in drawing conclusions. RESULTS: Telemedicine and telesurgery, the diagnostic and operative process is conducted from a distance. The surgeon uses computer-assisted surgery away from the bedside via a robotic system and performs the surgical task at hand. In pelvic urological cancer surgery the use of robotic technique expands to female and reconstructive procedures as well. The leap forward is so massive, that traditional laparoscopic surgery is starting to be considered less, with a growing number of organizations being now more interested in developing a robotic service. Minimally invasive surgical techniques aim to improve surgical outcome in conjunction with delivery of high-quality patient care. Quality studies demonstrating superiority and cost effectiveness are lacking, however. CONCLUSIONS: Although tremendous accomplishments took place over a few years, there is still a lot of ground to be covered in standardizing the learning process and evaluating the outcome from the application of new technologies in the field of robotic pelvic surgery.

Forming a stone in pelviureteric junction obstruction: cause or effect?

ABSTRACT Objectives To investigate a possible causal relationship for stone formation in pelviureteric junction obstruction and to outline management options. Materials and Methods A literature search and evidence synthesis was conducted via electronic databases in the English language using the key words pelviureteric junction obstruction; urolithiasis; hyperoxaluria; laparoscopic pyeloplasty; flexible nephroscopy; percutaneous nephrolithotomy, alone or in combination. Relevant articles were analysed to extract conclusions. Results Concomitant pelviureteric junction obstruction (PUJO) and renal lithiasis has been reported only scarcely in the literature. Although PUJO has been extensively studied throughout the years, the presence of calculi in such a patient has not received equal attention and there is still doubt surrounding the pathophysiology and global management. Conclusions Metabolic risk factors appear to play an important role, enough to justify metabolic evaluation in these patients. Urinary stasis and infection are well known factors predisposing to lithiasis and contribute to some extent. The choice for treatment is not always straightforward. Management should be tailored according to degree of obstruction, renal function, patient symptoms and stone size. Simultaneous treatment is feasible with the aid of minimally invasive operative techniques and laparoscopy in particular.

Forming a stone in pelviureteric junction obstruction: Cause or effect?

OBJECTIVES: To investigate a possible causal relationship for stone formation in pelviureteric junction obstruction and to outline management options. MATERIALS AND METHODS: A literature search and evidence synthesis was conducted via electronic databases in the English language using the key words pelviureteric junction obstruction; urolithiasis; hyperoxaluria; laparoscopic pyeloplasty; flexible nephroscopy; percutaneous nephrolithotomy, alone or in combination. Relevant articles were analysed to extract conclusions. RESULTS: Concomitant pelviureteric junction obstruction (PUJO) and renal lithiasis has been reported only scarcely in the literature. Although PUJO has been extensively studied throughout the years, the presence of calculi in such a patient has not received equal attention and there is still doubt surrounding the pathophysiology and global management. CONCLUSIONS: Metabolic risk factors appear to play an important role, enough to justify metabolic evaluation in these patients. Urinary stasis and infection are well known factors predisposing to lithiasis and contribute to some extent. The choice for treatment is not always straightforward. Management should be tailored according to degree of obstruction, renal function, patient symptoms and stone size. Simultaneous treatment is feasible with the aid of minimally invasive operative techniques and laparoscopy in particular.

The evolution of urolithiasis assessment and management in the new millennium.

INTRODUCTION: The aim of this review was to identify trends and developments in basic research, epidemiology, diagnosis, conservative and surgical management of urinary stone disease, and to demonstrate the evolution of urolithiasis management in the new millennium. EVIDENCE ACQUISITION: We performed a literature search on Medline according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement up to December 2015 using the following key words: urolithiasis prevalence, recurrent urinary stone, metabolic syndrome and urolithiasis, urinary stone/urolithiasis metabolic evaluation, shockwave lithotripsy, ureterorenoscopy, percutaneous nephrolithotomy/nephrolitholapaxy. The key words were chosen following consensus as the single most appropriate and descriptive terms that would yield maximal relevant results in a single search for each section. We then segregated only relevant articles in the English language of the highest quality evidence (systematic review/meta-analysis, prospective cohorts and prospective randomized trials, levels of evidence: 1A and 1B, respectively) as well as experimental research. The initial relevance screening was based on title and abstract, whereas further filtering included full text screening. The evidence is subsequently presented and discussed on each relevant section, preceded by seminal references that are used as a basis for comparison to formulate our conclusions. EVIDENCE SYNTHESIS: By using the key word "urolithiasis prevalence" we identified initially 1581 relevant articles. Following exclusion of duplicates and relevance screening, 154 articles were included for data extraction (9.77%). Of note, 31 articles focused on the pediatric population. By using the key words "metabolic syndrome and urolithiasis" we identified initially 127 relevant articles. Following exclusion of duplicates and relevance screening, 23 articles were included for data extraction (18.11%). It must be noted that the majority of studies are reviews, experimental models and prospective cohorts. By using the key words "urolithiasis metabolic evaluation" we identified initially 262 relevant articles. Following exclusion of duplicates and relevance screening, 179 articles were included for data extraction (68.32%). It must be noted that the majority of studies are reviews, experimental models and prospective cohorts. By using the key word "shockwave lithotripsy" we identified initially 695 relevant articles. Following exclusion of duplicates and relevance screening, 90 articles were included for data extraction (12.94%). By using the key word "ureterorenoscopy" we identified initially 2609 relevant articles. Following exclusion of duplicates and relevance screening, 186 articles were included for data extraction (7.12%). By using the key word "percutaneous nephrolithotomy" we identified initially 695 relevant articles. Following exclusion of duplicates and relevance screening, 381 articles were included for data extraction (10.42%). CONCLUSIONS: The management of urolithiasis has evolved greatly and in multiple directions in the past fifteen years. There is a definite compartmentalization of basic research, innovation and development focusing on distinct stages of the disease, from epidemiologic features to pathophysiology, medical and surgical aspects. Patients enjoy better delivery of care, having ever more effective options to deal with their condition. The multidisciplinary approach provides more reliable solutions and will continue to drive the development of better preventative and treatment strategies in the future.

A Comparative in Vitro Study of Power Output Deterioration over Time Between Ho:YAG Laser Fibers from Different Manufacturers as a Function of Deflection and Power Input.

OBJECTIVES: To investigate the performance of laser fibers from 6 major manufacturers in vitro and to identify the effect of time and angulations (180° and 0°) on fiber power output. MATERIALS AND METHODS: Overall, 36 single-use fibers were used. Each was tested with an energy input of 0.8, 1.4 and 2.0 Joules. A power detector measured power output after 1, 5, 10 and 15 minutes for three 15-minute cycles of continuous use. For the first 2 cycles, the fiber was bent to 180° with the use of a pre fabricated mould. Analysis of the data was performed by ANOVA and Tukey's test when the results were significant amongst groups. Statistical significance was deemed p < 0.05. RESULTS: No fiber fracture occurred. There was no significant difference in output at 15 minutes of continuous use at 0° and 180°. The reduction in energy output at the 15th minute of continuous use at 180° was not significant for any fiber type or initial input. Only output differences between the fibers proved to be significant (p = 0.001). CONCLUSION: Fiber fracture and decline in performance is not due to deflection and continuous use. Frictional forces that occur between the fiber tip and the stone fragments may be responsible.

The Role of PCA 3 as a Prognostic Factor in Patients with Castration-resistant Prostate Cancer (CRPC) Treated with Docetaxel.

AIM: To investigate potential fluctuations in prostate cancer antigen 3 (PCA 3) scores in castration-resistant prostate cancer (CRPC) patients treated with docetaxel and investigate the assay as a potential prognostic factor. PATIENTS AND METHODS: This was a prospective observational cohort study. Inclusion criteria included patients on hormonal treatment who were recently diagnosed with CRPC. Exclusion criteria included patients previously having radical treatment (surgery or radiotherapy) and patients who have completed the first cycle of chemotherapy. All urine samples were collected and analyzed using the Progensa® assay. Samples were collected before starting chemotherapy and at 12 months. A prospective database was created including routine blood tests, prostate staging and prostate-specific antigen (PSA) levels throughout the study period. The effects of chemotherapy were also recorded. RESULTS: Between January 2010 and February 2013, 12 patients were included in the study out of an initial cohort of 23 patients with CRPC. Mean follow-up was 14.8 months. Mean age at CRPC diagnosis was 73.8 years (±3.6 SD). Mean Gleason score was 8, with PSA 84.23 ng/ml (±158 SD). Mean duration of androgen deprivation treatment (ADT) was 45.16 months (±34.9 SD). Mean time to castrate-resistant state was 46.58 months (±35.3 SD). All twelve (n=12, 100%) patients had non-assessable PCA 3 scores at baseline and at 12 months follow-up. As a direct consequence, statistical analysis was not performed as the anticipated change in PCA 3 scores was not identified and correlation between measurable differences was not possible. All patients tolerated chemotherapy and completed the scheduled cycles with no serious adverse effects. CONCLUSION: To our knowledge, this is the first prospective study to demonstrate lack of expression of PCA3 in CRPC, with the result apparently not influenced by chemotherapy. There appears to be a strong association between hormonal treatment and lack of PCA 3 expression. It is still unknown whether disease progression per se affects PCA 3 scores. The gradual reduction and eventual complete non-expression of PCA 3 with ongoing treatment and disease progression provide an insight towards molecular pathways that may be connected to castration-resistant state.

Calcification of the vas deferens and seminal vesicles: a review.

INTRODUCTION: Calcification of the vas deferens and seminal vesicles is a rare condition of unknown incidence. It has been described in association with diabetes, hyperparathyroidism and genitourinary tuberculosis, amongst other conditions. Little is known about the clinical significance and management of this condition. We review the literature in an effort to find answers about an entity that is frequently appreciated as an incidental finding. MATERIALS AND METHODS: An electronic database search was performed (Medline) using the key words: vas deferens; seminal vesicles; calcification, alone or in combination. Articles were selected according to relevance and quality of evidence. RESULTS: The search included published manuscripts between 1960 and 2012. A total of 17 relevant publications were identified. The majority were written in the English language and mostly consisted of case presentations and reports of radiologic findings. CONCLUSION: Calcification of the vas deferens and seminal vesicles is a rare condition. However, it may be implicated in male factor infertility and symptoms from the urogenital tract. Treatment should be directed towards the underlying cause on an individual basis. It is unknown whether control of the primary process has any effects on the histopathological appearance of the ducts and/or their improvement of function.

Ultra-mini PCNL versus flexible ureteroscopy: a matched analysis of treatment costs (endoscopes and disposables) in patients with renal stones 10-20 mm.

PURPOSE: Latest publications state equal efficacy of a recently introduced new percutaneous technique ("ultra-mini PCNL", UMP) and flexible ureteroscopy (fURS) in the treatment of medium-size urinary stones. Today we face challenges concerning cost-effectiveness and reduction of in-hospital length of stay. In this retrospective study, we compare clinical outcome parameters and costs of treatment (endoscopes and disposables) of both techniques. METHODS: Thirty patients treated by UMP at two tertiary university centres were matched to 30 fURS patients from previously recorded databases. Data analysis included operating time, length of stay, stone-free rates (SFR), complications (>Clavien II), ancillary procedures (presurgical ureteral stenting, secondary ureteral stenting or placement of a nephrostomy tube, secondary procedures) and costs for disposable materials and instruments (endoscopes, as calculated per procedure). RESULTS: We found no significant differences in operating times (UMP vs. fURS: 121/102 min), hospital length of stay (2.3/2.0 days), SFR (84/87 %) and complications (7/7 %). Costs for disposable materials and endoscopes were 656 euro (UMP) and 1,160 euro (fURS) per procedure. CONCLUSIONS: UMP and fURS are both safe and effective in the treatment of medium-size urinary stones. Costs for endoscopes and disposable materials are significantly lower in UMP.

Laparoscopic varicocelectomy in the management of chronic scrotal pain.

BACKGROUND AND OBJECTIVES: To evaluate the usefulness of laparoscopic varicocelectomy in the management of chronic scrotal pain. METHODS: Between 2009 and 2011, 48 patients in total were treated with laparoscopic varicocelectomy for dull scrotal pain that worsened with physical activity and was attributed to varicoceles. All patients were followed up at 3 and 6 months and biannually thereafter with a physical examination, visual analog scale score, and ultrasonographic scan in selected cases. RESULTS: The mean age was 38.2 years (range, 23-54 years). The mean follow-up period was 19.6 months (range, 6-26 months). Bilateral varicoceles were present in 7 patients (14.6%), and a unilateral varicocele was present in 41 (85.4%). The varicocele was grade 3 in 27 patients (56.3%), grade 2 in 20 (41.6%), and grade 1 in 1 (2.1%). The mean preoperative visual analog scale score was 4.8 on a scale from 0 to 10. The mean postoperative visual analog scale score at 3 months was 0.8. After the procedure, 42 patients (87.5%) had a significant improvement in the visual analog scale score (P<.001); 5 (10.4%) had symptom improvement, although it was not statistically significant; and 1 (2.1%) remained unchanged. During follow-up, we observed 5 recurrences (10.4%) whereas de novo hydrocele formation was identified in 4 individuals (8.3%). CONCLUSION: Laparoscopic varicocelectomy is efficient in the treatment of symptomatic varicoceles with a low complication rate. However, careful patient selection is necessary because it appears that individuals presenting with sharp, radiating testicular pain and/or a low-grade varicocele are less likely to benefit from this procedure.

Hyoscine N-butylbromide (Buscopan®) in the treatment of acute ureteral colic: what is the evidence?

OBJECTIVE: To investigate the evidence for the use of hyoscine N-butylbromide (HBB) in the treatment of acute renal colic. METHODS: A literature search was performed using the keywords 'hyoscine N-butylbromide', 'ureteral colic', 'spasmolytic', 'anticholinergic' and 'analgesia'. The articles were given the appropriate level of evidence according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence guidelines. RESULTS: The analgesic effect of HBB as monotherapy is inferior to that of opioids and/or non-steroidal anti-inflammatory drugs (NSAIDs). It does provide an analgesic and antispasmodic effect, but not as long-lasting as NSAIDs. HBB does not serve as an adjunct to opioids. Furthermore, it does not facilitate passage of ureteral stones and has no effect on expulsion rate. CONCLUSIONS: HBB is often used where urinary tract smooth muscle spasm is thought to be part of the pathophysiological process. According to the evidence, administration of HBB follows non-peer-reviewed protocols which are based on empiric recommendations. Its role is still unclear, as it appears to have no advantage when used as monotherapy over established forms of analgesia. There appears to be a time-dependent relation to pain reduction following parenteral administration, but this needs to be confirmed by more prospective randomized cohorts.