Tamsulosin does not increase 1-week passage rate of ureteral stones in ED patients.

OBJECTIVE: The objective of the study is to determine if tamsulosin initiated in the emergency department (ED) decreases the time to ureteral stone passage at 1 week or time to pain resolution, compared to placebo. METHODS: We performed a prospective, randomized, double-blinded, placebo-controlled trial of tamsulosin vs placebo in ED patients with ureterolithiasis on computed tomography. Patients were identified and enrolled between April 2007 and February 2009 and were randomized to either 0.4 mg of tamsulosin or placebo for 1 week. We contacted participants using a telephone survey on post-ED visit days 1, 2, 3, and 7. The primary outcome was time to stone passage, with secondary outcomes being maximum pain score and amount of pain medication required. RESULTS: Of the 127 patients enrolled during this study, 15 were lost to follow-up, and 12 required surgical interventions before the 7-day mark, leaving 100 patients for analysis. Of the 100 patients, 53 received tamsulosin and 47 received placebo. There was no difference between groups in percentage of male, mean age, initial serum creatinine, average stone size, stone location, and history of prior stone. The probability that the patient did not pass a stone at 7 days was not different between tamsulosin and placebo, 62.1% (95% confidence interval, 49.1%-75.1%) vs 54.4% (95% confidence interval, 40.3%-68.6%; P = .58). There was no significant difference in the high pain score (P = .12) or hydrocodone/acetaminophen intake (P = .76) between treatment groups at any of the time points. CONCLUSION: This study reveals no difference in the proportion of stone passage or high pain score and pain medication utilization at 7 days between tamsulosin and placebo.

Clinicopathologic analysis of extracapsular extension in prostate cancer: should the clinical target volume be expanded posterolaterally to account for microscopic extension?

PURPOSE: We performed a complete pathologic analysis examining extracapsular extension (ECE) and microscopic spread of malignant cells beyond the prostate capsule to determine whether and when clinical target volume (CTV) expansion should be performed. METHODS AND MATERIALS: A detailed pathologic analysis was performed for 371 prostatectomy specimens. All slides from each case were reviewed by a single pathologist (N.S.G.). The ECE status and ECE distance, defined as the maximal linear radial distance of malignant cells beyond the capsule, were recorded. RESULTS: A total of 121 patients (33%) were found to have ECE (68 unilateral, 53 bilateral). Median ECE distance=2.4 mm [range: 0.05-7.0 mm]. The 90th-percentile distance = 5.0 mm. Of the 121 cases with ECE, 55% had ECE distance>or=2 mm, 19%>or=4 mm, and 6%>or=6 mm. ECE occurred primarily posterolaterally along the neurovascular bundle in all cases. Pretreatment prostrate-specific antigen (PSA), biopsy Gleason, pathologic Gleason, clinical stage, bilateral involvement, positive margins, percentage of gland involved, and maximal tumor dimension were associated with presence of ECE. Both PSA and Gleason score were associated with ECE distance. In all 371 patients, for those with either pretreatment PSA>or=10 or biopsy Gleason score>or=7, 21% had ECE>or=2 mm and 5%>or=4 mm beyond the capsule. For patients with both of these risk factors, 49% had ECE>or=2 mm and 21%>or=4 mm. CONCLUSIONS: For prostate cancer with ECE, the median linear distance of ECE was 2.4 mm and occurred primarily posterolaterally. Although only 5% of patients demonstrate ECE>4 to 5 mm beyond the capsule, this risk may exceed 20% in patients with PSA>or=10 ng/ml and biopsy Gleason score>or=7. As imaging techniques improve for prostate capsule delineation and as radiotherapy delivery techniques increase in accuracy, a posterolateral CTV expansion should be considered for patients at high risk.

Does periprostatic block reduce pain during transrectal prostate biopsy? A randomized, placebo-controlled, double-blinded study.

INTRODUCTION: Currently, the use of local anesthetic at the time of transrectal ultrasound-guided biopsy of the prostate is not universally accepted, as the needle injection itself causes pain. In prior studies, lidocaine was compared to placebo in separate patient groups. We present the first study to evaluate both lidocaine and placebo injected in each patient. MATERIALS AND METHODS: Fifty patients received periprostatic injections of both lidocaine and placebo, randomized to separate sides of the prostate, in a randomized, double-blind, placebo-controlled trial design. Injections were delivered at the angle between the seminal vesicle and prostate on each side. Patients graded pain on a visual analog scale (VAS) (0-10) after injections and after each biopsy. Patients were surveyed to evaluate overall pain and discomfort before discharge. We used Student's t-test to compare the mean VAS scores between lidocaine and placebo. RESULTS: The mean (SD) VAS after biopsy was 1.9 (1.4) on the lidocaine side and 2.3 (1.4) on the placebo side (P = 0.202). Pain after the injection itself was similar to pain after biopsy, with the mean (SD) VAS of 2.4 (1.6) and 2.2 (1.7) after lidocaine and placebo injections, respectively (P = 0.546). None of the differences were statistically significant. Twenty-nine (59.2%) patients reported no pain at the time of discharge. CONCLUSIONS: Pain experienced during transrectal biopsy of the prostate is mild and is not significantly lowered with periprostatic nerve block. Pain from injection itself is similar to pain from core biopsies. Pain from transrectal ultrasound-guided biopsy of the prostate is well tolerated with no anesthesia.

Inguinal herniation of a transplant ureter: rare cause of obstructive uropathy.

We present a rare case of late renal allograft failure from ureteral obstruction resulting from inguinal herniation. A 72-year-old man presented with an elevated creatinine and hydroureteronephrosis of a transplanted kidney on ultrasound. Noncontrast computed tomography demonstrated an inguinal hernia containing ureter, and a nephrostomy tube was placed. The hernia and ureter were temporarily reduced during antegrade stent insertion. Creatinine normalized and we performed inguinal herniorrhaphy with polypropylene mesh. The ureter was not reimplanted. Renal function remained stable after nephrostomy tube removal. Simple herniorrhaphy without ureteral reimplantation may fix the case of ureteral obstruction from inguinal herniation.

Trends toward laparoscopic nephrectomy at a community hospital.

PURPOSE: For proper indications at university hospitals laparoscopic nephrectomy is often considered the standard of care. At community hospitals past surveys have not demonstrated this change. We describe the changing practice patterns of performing laparoscopic nephrectomies in indicated patients at our community hospital. We reviewed our data on monitoring our training program. MATERIALS AND METHODS: A retrospective chart review was performed of 381 consecutive complete nephrectomies performed at our institution from February 2000 to December 2003, including 62 live donor nephrectomies. Patient age, pathological size, operative time, estimated blood loss, duration to solid food intake and duration of hospitalization were compared between open nephrectomy and laparoscopic nephrectomy groups using the Wilcoxon 2-sample test. Surgical practice and surgeon characteristics were also described. RESULTS: Patients who underwent laparoscopic nephrectomy demonstrated superior postoperative recovery with earlier return to solid diet and shorter hospitalization. The 2 groups were similar in regard to major complication rates. The number of laparoscopic nephrectomies increased annually, while the number of open nephrectomies decreased. The number of laparoscopic urologists increased annually. More importantly laparoscopic urologists performed an increasing number of nephrectomies, while nonlaparoscopic urologists faced a decrease in the number of nephrectomies performed. There appeared to be little evidence of hand assisted laparoscopic nephrectomy as a bridge to learning standard laparoscopic nephrectomy. CONCLUSIONS: Our training paradigm has safely and effectively trained community urologists to perform laparoscopic nephrectomies. Laparoscopic nephrectomy is now considered a standard treatment option along with conventional open surgery and it should be offered to the patient in the medical setting. Although fellowship trained urologists can certainly add expertise to any program, community based hospitals do not have to depend on them.