Which Patients Should Have Early Surgical Intervention for Acute Ureteral Colic?

PURPOSE: Early surgical intervention is an attractive option for acute ureteral colic but existing evidence does not clarify which patients benefit. We compared treatment failure rates in patients receiving early intervention and patients offered spontaneous passage to identify subgroups that benefit from early intervention. MATERIALS AND METHODS: We used administrative data and structured chart review to study consecutive patients attending 9 emergency departments in 2 Canadian provinces with confirmed 2.0 to 9.9 mm ureteral stones. We described patient, stone and treatment characteristics, and performed multivariable regression to identify factors associated with treatment failure, defined as intervention or hospitalization within 60 days. Our secondary outcome was emergency department revisit rate. RESULTS: Overall 1,168 of 3,081 patients underwent early intervention. Those with stones smaller than 5 mm experienced more treatment failures (31.5% vs 9.9%, difference 21.6%, 95% CI 16.9 to 21.2) and emergency department revisits (38.5% vs 19.7%, difference 18.8%, 95% CI 13.8 to 23.8) with early intervention than with spontaneous passage. Patients with stones 7.0 mm or larger experienced fewer treatment failures (34.7% vs 58.6%, risk difference 23.9%, 95% CI 11.3 to 36.6) and similar emergency department revisit rates with early intervention. Patients with 5.0 to 6.9 mm stones had fewer treatment failures with intervention (37.4% vs 55.5%, risk difference 18.1%, 95% CI 7.1 to 28.9) if stones were in the proximal or middle ureter. CONCLUSIONS: Early intervention improves outcomes for patients with large (greater than 7 mm) ureteral stones or 5 to 7 mm proximal or mid ureteral stones. Early intervention may increase morbidity for patients with stones smaller than 5 mm. These findings could help inform future guidelines.

Pulse modulation with Moses technology improves popcorn laser lithotripsy.

PURPOSE: Moses™ technology has been developed to improve holmium laser fragmentation at 1-2 mm distance from the stone. Because popcorn lithotripsy is a non-contact technique, we compared short pulse (SP) and Moses distance (MD) modes in an in vitro model. METHODS: BegoStones were fragmented using a 120 W Ho:YAG laser (P120 Moses) and a 230 µm core fiber introduced through a ureteroscope. 20 W (1 J × 20 Hz; 0.5 J × 40 Hz) and 40 W (1 J × 40 Hz; 0.5 J × 80 Hz) settings (total energy 4.8 kJ) were tested using SP and MD modes. We assessed fragment size distribution and mass lost in fluid (initial mass-final dry mass of all sievable fragments). High-speed video analysis of fragmentation strike rate and vapor bubble characteristics was conducted for 1 J × 20 Hz and 0.5 J × 80 Hz. Laser strike rate (number of strikes divided by frequency) was categorized as: (1) direct-a visual plume of dust ejected from stone while in contact with fiber tip; (2) indirect-a visual plume of dust ejected with distance between stone and fiber tip. RESULTS: For 1 J × 20 Hz (20 W), MD resulted in more mass lost in fluid and a lower distribution of fragments ≥ 2 mm compared to SP (p < 0.05). 0.5 J × 80 Hz (40 W) produced no fragments ≥ 2 mm, and there were no significant differences in fragment distribution between MD and SP (p = 0.34). When using MD at 1 J × 20 Hz, 96% of strikes were indirect vs 61% for SP (p = 0.059). In contrast to the single bubble of SP, with MD, there was forward movement of the collapsing second bubble, away from the fiber-tip. CONCLUSIONS: For lower frequency and power popcorn settings, pulse modulation results in more fragmentation through true non-contact laser lithotripsy.

Comparison of flexible ureteroscopy damage rates for lower pole renal stones by laser fiber type.

OBJECTIVES: Laser lithotripsy, often used during ureteronephroscopy (URNS), requires the Ho:YAG optical fiber transmit energy via total internal reflection (TIR). In critical lower pole deflections, energy may refract into the cladding causing fiber failure and scope damage. New optical fiber technology aims to have increased tolerance for high degrees of flexion. We compared two brands of laser fibers with sub-300 micron cores (Sureflex, Boston Flexiva) to determine failure rates and scope repair costs. METHODS: A retrospective cohort study comparing these two fibers for patients at a single academic institution who underwent flexible URNS with laser lithotripsy was performed from September 2013 to October 2015. Preoperative imaging was evaluated for stone burden and location. Intraoperative variables were collected, including energy use, lower pole lasering, laser fiber malfunction, and scope damage. The primary outcome was scope damage caused by laser fiber malfunction. Secondary outcome was scope repair costs. Fisher's exact test and two tailed t-tests were used. RESULTS: Of 223 subjects, 143 met inclusion criteria, and 8 had laser fiber failure. All failures occurred with the Sureflex fiber (8 of 63, 13%) vs the Boston Flexiva fiber (0 of 80, 0%) (P < 0.01). Malfunctions occurred in 8 of 79 lower pole stone applications versus 0 of 64 non-lower pole stone laser applications (P < 0.01). No other risk factor was different between fiber cohorts, except energy setting. Scope repair cost averaged $9155 CDN, yielding an average repair cost per case of $1144 CDN for the Sureflex versus $0 for the Boston fiber (P < 0.01). CONCLUSIONS: Both optical fibers perform well in non-lower pole locations. However, the challenge for laser fibers in lower pole URNS is to maintain TIR. Fiber failure reflects an inability to maintain reflection and is not based on energy used or stone burden. The Boston Flexiva laser fiber has fewer failures, resulting in $0 repair cost per case, compared to the Sureflex fiber in URNS with an average repair cost of $1144 CDN per case. Lasers Surg. Med. 50:798-801, 2018. © 2018 Wiley Periodicals, Inc.

Noninfectious Penile Lesions.

Noninfectious penile lesions are classified by clinical presentation as papulosquamous (e.g., psoriasis), inflammatory (e.g., lichen sclerosus, lichen nitidus, lichen planus), vascular (e.g., angiokeratomas), or neoplastic (e.g., carcinoma in situ, invasive squamous cell carcinoma). Psoriasis presents as red or salmon-colored plaques with overlying silvery scales, often with extragenital cutaneous lesions. Lichen sclerosus presents as a phimotic, hypopigmented prepuce or glans penis with a cellophane-like texture. Lichen nitidus usually produces asymptomatic pinhead-sized, hypopigmented papules. The lesions of lichen planus are pruritic, violaceous, polygonal papules that are typically systemic. Angiokeratomas are typically asymptomatic, well-circumscribed, red or blue papules, often with annular or figurate configurations. Carcinoma in situ should be suspected if there are velvety red or keratotic plaques on the glans penis or prepuce, whereas invasive squamous cell carcinoma presents as a painless lump, ulcer, or fungating mass. Some benign lesions, such as psoriasis and lichen planus, may mimic carcinoma in situ or invasive squamous cell carcinoma. Biopsy is indicated if the diagnosis is in doubt or neoplasm cannot be excluded. The management of benign noninfectious penile lesions usually involves observation, topical corticosteroids, or topical calcineurin inhibitors. Neoplastic lesions generally warrant organ-sparing surgery.

Common Questions About Chronic Prostatitis.

Chronic prostatitis is relatively common, with a lifetime prevalence of 1.8% to 8.2%. Risk factors include conditions that facilitate introduction of bacteria into the urethra and prostate (which also predispose the patient to urinary tract infections) and conditions that can lead to chronic neuropathic pain. Chronic prostatitis must be differentiated from other causes of chronic pelvic pain, such as interstitial cystitis/bladder pain syndrome and pelvic floor dysfunction; prostate and bladder cancers; benign prostatic hyperplasia; urolithiasis; and other causes of dysuria, urinary frequency, and nocturia. The National Institutes of Health divides prostatitis into four syndromes: acute bacterial prostatitis, chronic bacterial prostatitis (CBP), chronic nonbacterial prostatitis (CNP)/chronic pelvic pain syndrome (CPPS), and asymptomatic inflammatory prostatitis. CBP and CNP/CPPS both lead to pelvic pain and lower urinary tract symptoms. CBP presents as recurrent urinary tract infections with the same organism identified on repeated cultures; it responds to a prolonged course of an antibiotic that adequately penetrates the prostate, if the urine culture suggests sensitivity. If four to six weeks of antibiotic therapy is effective but symptoms recur, another course may be prescribed, perhaps in combination with alpha blockers or nonopioid analgesics. CNP/CPPS, accounting for more than 90% of chronic prostatitis cases, presents as prostatic pain lasting at least three months without consistent culture results. Weak evidence supports the use of alpha blockers, pain medications, and a four- to six-week course of antibiotics for the treatment of CNP/CPPS. Patients may also be referred to a psychologist experienced in managing chronic pain. Experts on this condition recommend a combination of treatments tailored to the patient's phenotypic presentation. Urology referral should be considered when appropriate treatment is ineffective. Additional treatments include pelvic floor physical therapy, phytotherapy, and pain management techniques. The UPOINT (urinary, psychosocial, organ-specific, infection, neurologic/systemic, tenderness) approach summarizes the various factors that may contribute to presentation and can guide treatment.

Screening for asymptomatic nephrolithiasis in primary hyperparathyroidism patients is warranted.

BACKGROUND: We aimed to investigate the prevalence, characteristics, and management of nephrolithiasis in primary hyperparathyroidism (PHPT) patients. METHODS: Medical records of patients who underwent parathyroidectomy at a tertiary care hospital in British Columbia from January 2016 to April 2023 were retrospectively reviewed. Demographic data, laboratory results, imaging reports, and urologic consultations were examined. Descriptive statistics and relevant statistical tests, including logistic regressions, were utilized for data analysis. RESULT: Of the 413 PHPT patients included in the study population, 41.9% harbored renal stones, and nearly half (48.6%) required urological interventions. Male sex, elevated preoperative serum ionized calcium (iCa) and 24-h urinary calcium (24 â€‹h urine Ca) levels were independent risk factors for stone formation. Additionally, male sex, younger age, and lower preoperative serum 25-hydroxyvitamin D (25(OH)D) level were associated with higher odds of requiring urological intervention for stones. CONCLUSIONS: This study identified significant prevalence of asymptomatic renal calcifications in PHPT patients, with a substantial proportion necessitating urological intervention. These findings emphasize the importance of incorporating screening and treatment of renal stones into the management of PHPT patients.

Optimal power settings for Holmium:YAG lithotripsy.

PURPOSE: We determined the optimal Ho:YAG lithotripsy power settings to achieve maximal fragmentation, minimal fragment size and minimal retropulsion. MATERIALS AND METHODS: Stone phantoms were irradiated in water with a Ho:YAG laser using a 365 µm optical fiber. Six distinct power settings were tested, including 0.2 to 2.0 J and 10 to 40 Hz. For all cohorts 500 J total radiant energy were delivered. A seventh cohort (0.2 J 40 Hz) was tested post hoc to a total energy of 1,250 J. Two experimental conditions were tested, including with and without phantom stabilization. Total fragmentation, fragment size and retropulsion were characterized. In mechanism experiments using human calculi we measured crater volume by optical coherence tomography and pressure transients by needle hydrophone across similar power settings. RESULTS: Without stabilization increased pulse energy settings produced increased total fragmentation and increased retropulsion (each p <0.0001). Fragment size was smallest for the 0.2 J cohorts (p <0.02). With stabilization increased pulse energy settings produced increased total fragmentation and increased retropulsion but also increased fragment size (each p <0.0001). Craters remained symmetrical and volume increased as pulse energy increased. Pressure transients remained modest at less than 30 bars even at 2.0 J pulse energy. CONCLUSIONS: Holmium:YAG lithotripsy varies as pulse energy settings vary. At low pulse energy (0.2 J) less fragmentation and retropulsion occur and small fragments are produced. At high pulse energy (2.0 J) more fragmentation and retropulsion occur with larger fragments. Anti-retropulsion devices produce more efficient lithotripsy, particularly at high pulse energy. Optimal lithotripsy laser dosimetry depends on the desired outcome.

Multi-institutional assessment of ureteroscopic laser papillotomy for chronic flank pain associated with papillary calcifications.

PURPOSE: We evaluated the long-term safety, efficacy and durability of ureteroscopic laser papillotomy for chronic flank pain associated with renal papillary calcifications. MATERIALS AND METHODS: We reviewed the medical records of all patients who underwent ureteroscopic laser papillotomy in the absence of free urinary calculi at our institutions from 1998 through 2008. Success was defined as patient report of significant pain relief. The duration of response was considered the time from papillotomy to repeat papillotomy in the same renal unit, patient report of recurrent pain or final followup. RESULTS: Ureteroscopic Ho:YAG laser papillotomy was done a total of 176 times in 65 patients, including 147 unilateral and 29 bilateral procedures. Of the patients 39 underwent multiple procedures (2 to 12). Symptomatic followup was available in 50 patients (146 procedures) during a mean of 38 months. Significantly less pain was reported after 121 procedures (83%). The mean duration of response per procedure was 26 months and 30 patients (60%) had a mean remission duration of greater than 1 year. Postoperatively hospital admission was required after 14 procedures (8%). There was no significant change in the mean estimated glomerular filtration rate during a mean 41.3-month followup. Seven of the 65 patients (11%) had hypertension before papillotomy. In 3 of the 49 patients (6.1%) with adequate followup new hypertension developed during a mean of 38 months. CONCLUSIONS: Ureteroscopic laser papillotomy is safe and effective. In patients with papillary calcifications and characteristic chronic, noncolicky pain this procedure provides significant, moderately durable symptom relief.

Mechanisms of Pulse Modulated Holmium:YAG Lithotripsy.

Introduction: This study aimed at answering three research questions: (1) Under the experimental conditions studied, what is the dominant mechanism of Holmium:YAG lithotripsy with or without pulse modulation? (2) Under what circumstances can laser pulse modulation increase crater volume of stone ablation per joule of emitted radiant energy? (3) Are BegoStone phantoms a suitable model for laser lithotripsy studies? Materials and Methods: The research questions were addressed by ablation experiments with BegoStone phantoms and native stones. Experiments were performed under three stone conditions: dry stones in air, hydrated stones in air, and hydrated stones in water. Single pulses with and without pulse modulation were applied. For each pulse mode, temporal profile, transmission through 1 mm water, and cavitation bubble collapse pressures were measured and compared. For each stone condition and pulse mode, stones were ablated with a fiber separation distance of 1 mm and crater volumes were measured using optical coherence tomography. Results: Pulses with and without pulse modulation had high (>80%) transmission through 1 mm of water. Pulses without pulse modulation generated much higher peak pressures than those with pulse modulation (62.3 vs 11.4 bar). Pulse modulation resulted in similar or larger craters than without pulse modulation. Trends in BegoStone crater volumes differed from trends in native stones. Conclusions: This results of this study suggest that the dominant mechanism is photothermal with possible photoacoustic contributions for some stone compositions. Pulse modulation can increase ablation volume per joule of emitted radiant energy, but the effect may be composition specific. BegoStones showed unique infrared ablation characteristics compared with native stones and are not a suitable model for laser lithotripsy studies.

Does early intervention improve outcomes for patients with acute ureteral colic?

OBJECTIVES: Early surgical intervention is increasingly employed for patients with ureteral colic, but guidelines and current practice are variable. We compared 60-day outcomes for matched patients undergoing early intervention vs. spontaneous passage. METHODS: This multicentre propensity-matched cohort analysis used administrative data and chart review to study all eligible emergency department (ED) patients with confirmed 2.0-9.9 mm ureteral stones. Those having planned stone intervention within 5 days comprised the intervention cohort. Controls attempting spontaneous passage were matched to intervention patients based on age, sex, stone width, stone location, hydronephrosis, ED site, ambulance arrival and acuity level. The primary outcome was treatment failure, defined as rescue intervention or hospitalization within 60 days, using a time to event analysis. Secondary outcome was ED revisit rate. RESULTS: Among 1154 matched patients, early intervention did not reduce the risk of treatment failure (adjusted hazard ratio 0.94; P = 0.61). By 60 days, 21.8% of patients in both groups experienced the composite primary outcome (difference 0.0%; 95% confidence interval - 4.8 to 4.8%). Intervention patients required more hospitalizations (20.1% vs. 12.8%; difference 7.3%; 95% CI 3.0-11.5%) and ED revisits (36.1% vs. 25.5%; difference 10.6%; 95% CI 5.3-15.9%), but (insignificantly) fewer rescue interventions (18.9% vs. 21.3%; difference - 2.4%; 95% CI - 7.0 to 2.2%). CONCLUSIONS: In matched patients with 2.0-9.9 mm ureteral stones, early intervention was associated with similar rates of treatment failure but greater patient morbidity, evidenced by hospitalizations and emergency revisits. Physicians should adopt a selective approach to interventional referral and consider that spontaneous passage probably provides better outcomes for many low-risk patients.

RéSUMé: OBJECTIFS: L'intervention chirurgicale précoce est de plus en plus utilisée pour les patients atteints de coliques urétérales, mais les lignes directrices et la pratique actuelle sont variables. Nous avons comparé les résultats à 60 jours pour les patients appariés subissant une intervention précoce par rapport au passage spontané. LES MéTHODES: Cette analyse de cohorte multicentrique par appariement de propension a utilisé des données administratives et l'examen des dossiers pour étudier tous les patients admissibles des services d'urgence (ED) ayant des calculs urétéraux confirmés de 2,0-9,9 mm Ceux qui avaient planifié une intervention de calcul dans les cinq jours constituaient la cohorte d'intervention. Les témoins tentant de passer spontanément ont été appariés aux patients d'intervention en fonction de l'âge, du sexe, de la largeur du calcul, de l'emplacement du calcul, de l'hydronéphrose, du site de l'urgence, de l'arrivée de l'ambulance et du niveau d'acuité. Le résultat principal était l'échec de traitement, défini comme l'intervention de sauvetage ou l'hospitalisation dans les 60 jours, utilisant un temps à l'analyse d'événement. Le résultat secondaire était le taux de revisite à l'urgence RéSULTATS: Sur 1154 patients appariés, une intervention précoce n'a pas réduit le risque d'échec du traitement (ratio de risque ajusté = 0,94 ; P = 0,61). Au bout de 60 jours, 21,8 % des patients des deux groupes avaient atteint le résultat primaire composite (différence = 0,0 % ; intervalle de confiance à 95 % -4,8 % à 4,8 %). Les patients d'intervention ont nécessité plus d'hospitalisations (20,1 % contre 12,8 % ; différence = 7,3 % ; IC 95 %, 3,0 à 11,5 %) et de nouvelles visites à l'urgence (36,1 % contre 25,5 % ; différence = 10,6 % ; IC 95 %, 5,3 à 15,9 %), mais (de manière non significative) moins d'interventions de sauvetage (18,9 % contre 21,3 % ; différence = 2,4 % ; IC 95 %, -7,0 à 2,2 %). CONCLUSIONS: Chez des patients appariés présentant des calculs urétéraux de 2,0 à 9,9 mm, l'intervention précoce a été associée à des taux similaires d'échec du traitement mais à une morbidité plus importante des patients, comme en témoignent les hospitalisations et les revisites aux urgences. Les médecins devraient adopter une approche sélective de l'orientation interventionnelle et considérer que le passage spontané offre probablement de meilleurs résultats pour de nombreux patients à faible risque.

Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic.

OBJECTIVE: In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure. METHODS: We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group. RESULTS: Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk. CONCLUSIONS: Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.

RéSUMé: OBJECTIF: Chez les patients des services d'urgence (SU) atteints de colique urétérale, la valeur pronostique de l'hydronéphrose n'est pas claire. Notre objectif était de déterminer si l'hydronéphrose peut différencier les patients à faible risque appropriés pour l'essai de passage spontané de ceux qui ont des calculs cliniquement importants susceptibles de subir un échec de passage. MéTHODES: Nous avons utilisé des données administratives et un examen structuré des dossiers pour évaluer une cohorte consécutive de patients atteints de calculs urétéraux qui avaient subi une tomodensitométrie dans neuf hôpitaux canadiens de deux villes. Nous avons utilisé la tomodensitométrie, l'étalon-or pour l'imagerie des calculs, pour évaluer l'hydronéphrose et la taille des calculs. Nous avons décrit la précision de la classification de la gravité de l'hydronéphrose pour la détection de gros calculs (> 5 mm). Chez les patients tentant un passage spontané, nous avons utilisé la régression bayésienne hiérarchique pour déterminer l'association de l'hydronéphrose avec l'échec du passage, défini par le besoin d'intervention de sauvetage dans les 60 jours. Pour illustrer l'utilité pronostique, nous avons signalé la probabilité d'échec de passage avant le test chez tous les patients admissibles (sans directives sur l'hydronéphrose) à la probabilité d'échec de passage post-test dans chaque groupe d'hydronéphrose. RéSULTATS: Sur 3251 patients, 70% d'hommes et d'âge moyen 51 ans, 38% avaient un gros calcul, dont 23%, 29%, 53% et 72% avec une hydronéphrose absente, légère, modérée et sévère. Les taux d'échec au passage étaient de 15%, 20%, 28% et 43% dans les catégories d'hydronéphrose respectives et de 23% dans l'ensemble. L'hydronéphrose « absente ou légère ¼ a permis d'identifier un sous-ensemble important de patients (64%) présentant de faibles taux d'échec au passage. Une hydronéphrose modérée prédisait un risque d'échec de passage légèrement plus élevé, et une hydronéphrose sévère un risque sensiblement plus élevé. CONCLUSIONS: L'absence d'hydronéphrose et une hydronéphrose légère permettent d'identifier les patients à faible risque, peu susceptibles d'avoir un échec de passage, qui peuvent être appropriés pour un essai de passage spontané sans imagerie CT. Une hydronéphrose modérée est faiblement associée à des calculs plus gros mais pas à un échec de passage significativement plus important. L'hydronéphrose sévère est une constatation importante qui justifie une imagerie définitive et une référence. Différencier l'hydronéphrose « modérée-sévère ¼ de l'« absence-légère ¼ fournit une valeur de stratification du risque. Un classement plus granulaire de l'hydronéphrose n'est pas utile sur le plan pronostique.

Noninfectious penile lesions.

Family physicians commonly diagnose and manage penile cutaneous lesions. Noninfectious lesions may be classified as inflammatory and papulosquamous (e.g., psoriasis, lichen sclerosus, angiokeratomas, lichen nitidus, lichen planus), or as neoplastic (e.g., carcinoma in situ, invasive squamous cell carcinoma). The clinical presentation and appearance of the lesions guide the diagnosis. Psoriasis presents as red or salmon-colored plaques with overlying scales, often with systemic lesions. Lichen sclerosus presents as a phimotic, hypopigmented prepuce or glans penis with a cellophane-like texture. Angiokeratomas are typically asymptomatic, well-circumscribed, red or blue papules, whereas lichen nitidus usually produces asymptomatic pinhead-sized, hypopigmented papules. The lesions of lichen planus are pruritic, violaceous, polygonal papules that are typically systemic. Carcinoma in situ should be suspected if the patient has velvety red or keratotic plaques of the glans penis or prepuce, whereas invasive squamous cell carcinoma presents as a painless lump, ulcer, or fungating irregular mass. Some benign lesions, such as psoriasis and lichen planus, can mimic carcinoma in situ or squamous cell carcinoma. Biopsy is indicated if the diagnosis is in doubt or neoplasm cannot be excluded. The management of benign penile lesions usually involves observation or topical corticosteroids; however, neoplastic lesions generally require surgery.

Evaluation of 24 holmium:YAG laser optical fibers for flexible ureteroscopy.

PURPOSE: Prior study has shown that holmium:YAG laser fiber performance differs among manufacturers. We determined the performance and threshold for failure of 24 commercially available holmium:YAG laser fibers. MATERIALS AND METHODS: Single use and reusable fibers were tested in small (150 to 300 microm) and medium (300 to 400 microm) core diameter sizes. All fibers were evaluated for flexibility, failure threshold and true fiber diameter. Flexibility was measured by maximally deflecting a Stryker U-500 ureteroscope with the fiber in the working channel. The diameter of each fiber was measured by a digital micrometer. The failure threshold was assessed by bending the fibers to 180 degrees, beginning with a radius of 1.25 cm. A VersaPulse 100 W holmium:YAG laser was operated at 1.2 J and 10 Hz for 1 minute or until fiber fracture. The bend radius was decreased in 0.25 cm increments and testing was repeated until a minimum bend radius of 0.5 cm was attained or until the fiber failed. RESULTS: Of the small core fibers the SureFlex LLF-150 and LLF-273, OptiLite SMH1020F and Dornier LG Super 270 had the highest threshold for failure. The Accuflex 200 had the lowest failure threshold failing at the largest bend radius (1.75 cm). Of the medium core fibers the SureFlex LLF-365, Accuflex 365 and Lumenis SL 365 had the highest failure threshold, while the Dornier LG 400 and Lumenis EZ SL 365 were the lowest. The reusable Lumenis 365 fiber had a higher failure threshold than the single use Lumenis 365 fiber. CONCLUSIONS: Commercially available holmium:YAG laser fibers differ significantly in their performance characteristics.

Paediatric painful bladder syndrome/interstitial cystitis: diagnosis and treatment.

To describe the pathophysiology, diagnosis and controversies surrounding the diagnosis and pharmacological treatments of painful bladder syndrome/interstitial cystitis (PBS/IC) in children, we reviewed adult and paediatric literature pertaining to PBS/IC. Paediatric PBS/IC presents similarly to adult PBS/IC. The diagnosis is made by exclusion. Paediatric PBS/IC patients complain most commonly of urinary frequency, and abdominal pain occurs in up to 88% of affected children. Enuresis may also be a presenting complaint. Urinalysis and urine cultures are unremarkable. Management of paediatric PBS/IC is similar to that of adult PBS/IC, and non-surgical management includes dietary, lifestyle and pharmacological therapy. Pharmacological options include pentosan polysulfate, amitriptyline, hydroxyzine, cimetidine or intravesical therapies (dimethyl sulfoxide or 'therapeutic solution').

The relationship between sexual abuse and interstitial cystitis/painful bladder syndrome.

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic syndrome characterized by irritative voiding symptoms and pelvic pain or discomfort. IC/PBS represents localized bladder pathophysiologic changes and central nervous system upregulation. Patients exhibit bladder hyperalgesia and allodynia. Childhood sexual abuse occurs in up to 27% of females in the United States. Adults with a prior history of abuse or traumatization demonstrate hypothalamic-pituitary-adrenal (HPA) axis abnormalities, similar to IC/PBS patients. Childhood sexual abuse and physical traumatization are associated with subsequent lifelong risks of chronic pain syndromes. IC/PBS patients have increased rates of sexual abuse or physical traumatization histories compared with controls. IC/PBS patients with abuse histories tend to have greater pain intensity and lesser irritative voiding symptoms compared with nonabused IC/PBS patients. This article reviews the relationship between sexual abuse, HPA axis abnormalities, IC/PBS pathophysiology, and the role of sexual abuse on subsequent IC/PBS.