Chronic prostatitis: management strategies.

The National Institutes of Health (NIH) has redefined prostatitis into four distinct entities. Category I is acute bacterial prostatitis. It is an acute prostatic infection with a uropathogen, often with systemic symptoms of fever, chills and hypotension. The treatment hinges on antimicrobials and drainage of the bladder because the inflamed prostate may block urinary flow. Category II prostatitis is called chronic bacterial prostatitis. It is characterized by recurrent episodes of documented urinary tract infections with the same uropathogen and causes pelvic pain, urinary symptoms and ejaculatory pain. It is diagnosed by means of localization cultures that are 90% accurate in localizing the source of recurrent infections within the lower urinary tract. Asymptomatic inflammatory prostatitis comprises NIH category IV. This entity is, by definition, asymptomatic and is often diagnosed incidentally during the evaluation of infertility or prostate cancer. The clinical significance of category IV prostatitis is unknown and it is often left untreated. Category III prostatitis is called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). It is characterized by pelvic pain for more than 3 of the previous 6 months, urinary symptoms and painful ejaculation, without documented urinary tract infections from uropathogens. The syndrome can be devastating, affecting 10-15% of the male population, and results in nearly 2 million outpatient visits each year. The aetiology of CP/CPPS is poorly understood, but may be the result of an infectious or inflammatory initiator that results in neurological injury and eventually results in pelvic floor dysfunction in the form of increased pelvic muscle tone. The diagnosis relies on separating this entity from chronic bacterial prostatitis. If there is no history of documented urinary tract infections with a urinary tract pathogen, then cultures should be taken when patients are symptomatic. Prostatic localization cultures, called the Meares-Stamey 4 glass test, would identify the prostate as the source for a urinary tract infection in chronic bacterial prostatitis. If there is no infection, then the patient is likely to have CP/CPPS. For healthcare providers, the focus of therapy is symptomatic relief. The first therapeutic measure is often a 4- to 6-week course of a fluoroquinolone, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. Second-line pharmacotherapy involves anti-inflammatory agents for pain symptoms and alpha-adrenergic receptor antagonists (alpha-blockers) for urinary symptoms. Potentially more effective is pelvic floor training/biofeedback, but randomized controlled trials are needed to confirm this. Third-line agents include 5alpha-reductase inhibitors, glycosaminoglycans, quercetin, cernilton (CN-009) and saw palmetto. For treatment refractory patients, surgical interventions can be offered. Transurethral microwave therapy to ablate prostatic tissue has shown some promise. The treatment algorithm provided in this review involves a 4- to 6-week course of antibacterials, which may be repeated if the initial course provides relief. Pain and urinary symptoms can be ameliorated with anti-inflammatories and alpha-blockers. If the relief is not significant, then patients should be referred for biofeedback. Minimally invasive surgical options should be reserved for treatment-refractory patients.

Radiographic parameters on noncontrast computerized tomography predictive of shock wave lithotripsy success.

PURPOSE: Accurate prediction of shock wave lithotripsy success for given patient and radiographic parameters will lead to improved selection of patients for shock wave lithotripsy vs more invasive treatment. In this study we determined which radiographic parameters are the most predictive of shock wave lithotripsy success, and present a method to incorporate these into current and future models based on nonradiographic parameters. MATERIALS AND METHODS: A retrospective case-control study was performed to determine average, maximum and standard deviation of stone attenuation values, stone size and skin-to-stone distance on preoperative noncontrast computerized tomography for 220 patients successfully treated with shock wave lithotripsy and 105 patients in whom shock wave lithotripsy failed. RESULTS: Average stone attenuation is the best independent predictor of shock wave lithotripsy success as determined by the Student t test (p <0.0001) and receiver operating characteristic curves. Odds and likelihood ratios are provided for shock wave lithotripsy success for incremental average HU cutoffs. An average HU cutoff can be established over which the refined probability of success is below an arbitrary minimally acceptable cutoff of a 60% stone-free rate. Using pre-test probabilities of shock wave lithotripsy success from nomograms in the literature, our data suggest that shock wave lithotripsy should be first line therapy for solitary 6 to 10 mm stones with an average stone attenuation of less than 1,000 and 640 HU for the proximal ureter and renal pelvis, respectively. CONCLUSIONS: Average stone attenuation is a convenient radiographic measure that can be used to refine a known probability of shock wave lithotripsy success. Clinical HU cutoff guidelines can be determined based on current or future predictive nomograms based on other parameters.

A new computer enhanced visual learning method to train urology residents in pediatric orchiopexy: a prototype for Accreditation Council for Graduate Medical Education documentation.

PURPOSE: Residency programs must continue to restructure teaching and assessment of surgical skills to improve the documentation of Accreditation Council for Graduate Medical Education competencies. To improve teaching and documenting resident performance we developed a computer enhanced visual learning method that includes a curriculum and administrative reports. The curriculum consists of 1) study of a step-by-step surgical tutorial of computer enhanced visuals that show specific surgical skills, 2) a checklist tool to objectively assess resident performance and 3) a log of postoperative feedback that is used to structure deliberate practice. All elements of the method are repeated with each case performed. We used the Accreditation Council for Graduate Medical Education index case of orchiopexy to pilot this project. MATERIALS AND METHODS: All urology residents who trained at our institution from January 2006 to October 2007 performed orchiopexy using the computer enhanced visual learning method. The computer enhanced visual learning tutorial for orchiopexy consisted of customized computer visuals that demonstrate 11 steps or skills involved in routine inguinal orchiopexy, eg ligate hernia. The attending urologist rated resident competence with each skill using a 5-point Likert scale and provided specific feedback to the resident suggesting ways to improve performance. These ratings were weighted by case difficulty. The computer enhanced visual learning weighted score at entry into the clinical rotation was compared to the best performance during the rotation in each resident. RESULTS: Seven attending surgeons and 24 urology residents (resident training postgraduate years 1 to 8) performed a total of 166 orchiopexies. Overall the residents at each postgraduate year performed an average of 7 cases each with complexity ratings that were not significantly different among postgraduate year groups (average 2.4, 1-way ANOVA p not significant). The 7 attending surgeons did not differ significantly in assessment of skill performance or case difficulty (1-way ANOVA p not significant). Of the 24 residents 23 (96%) showed improvement in computer enhanced visual learning score/skill performance. In the entire group the average computer enhanced visual learning weighted score increased more than 50% from entry to best performance (137 to 234 orchiopexy units, paired t test p <0.0001). CONCLUSIONS: Computer enhanced visual learning is a novel method that enhances resident learning by breaking a core procedure into discrete steps and providing a platform for constructive feedback. Computer enhanced visual learning, which is a checklist tool, complies with Accreditation Council for Graduate Medical Education documentation requirements. Computer enhanced visual learning has wide applicability among surgical specialties.

Asymptomatic bacteriuria and symptomatic urinary tract infections during pregnancy.

Urinary tract infections are common complications of pregnancy; upper tract infections in particular may lead to significant morbidity for both the mother and fetus. Bacteriuria is a significant risk factor for developing pyelonephritis in pregnant women. Therefore, proper screening and treatment of bacteriuria during pregnancy is necessary to prevent complications. All women should be screened for bacteriuria in the first trimester, and women with a history of recurrent urinary tract infections or anomalies should have repeat bacteriuria screening throughout pregnancy. Treatment of bacteriuria should include 3-day therapy with appropriate antimicrobials, and women should be followed closely after treatment because recurrence may occur in up to one third of patients.

The natural history of renal stone fragments following ureteroscopy.

OBJECTIVES: To describe the natural history of postureteroscopic renal stone fragments ≤4 mm based on computed tomography (CT) follow-up. The goal of ureteroscopy is to fragment stones, actively basket and remove fragments larger than 1 mm, and allow the remaining fragments to pass spontaneously. The reality is that smaller fragments may be difficult to extract or may be missed. METHODS: Patients treated with ureteroscopy and holmium laser lithotripsy for urolithiasis by a single surgeon from May 2001 to July 2008 at a tertiary referral center were identified. Patients with residual renal fragments measuring ≤4 mm on initial postoperative CT and at least one additional follow-up CT were included. Outcomes measured were fragment growth and location, stone event (emergency department visit, hospitalization, or additional intervention), and spontaneous fragment passage. RESULTS: Of 330 ureteroscopies, 51 met inclusion criteria. For these patients, the mean follow-up duration was 18.9 months (1.6 years). Among 46 ureteroscopies for calcium-based stones, 9 patients (19.6%) experienced a stone event, 10 patients (21.7%) spontaneously passed their fragments, and the remaining 27 patients (58.7%) retained asymptomatic residual fragments. Among this asymptomatic group, mean fragment sizes were similar at 2.7, 3.3, 3.5, and 3.0 mm at mean follow-up durations of 2.8, 10.2, 16.8, and 33.0 months, respectively. CONCLUSIONS: This study suggests that among patients with postureteroscopic renal stone fragments ≤4 mm, approximately one in five (or 19.6%) will experience a stone event over the following 1.6 years. The remaining patients will either become stone-free via spontaneous passage or retain asymptomatic stable-sized fragments.

Is the transition from open to robotic prostatectomy fair to your patients? A single-surgeon comparison with 2-year follow-up.

Robot-assisted radical prostatectomy (RARP) is a procedure thought to require experience with a significant number of cases before mastering. Most RARP series examine outcomes after the learning curve or by combining results from multiple surgeons. We review a single surgeon's experience during the transition from open radical retropubic prostatectomy (RRP) to RARP using a matched case-control model. We prospectively analyzed 50 RARP cases and made comparison with the last 50 consecutive RRP cases. Operative time was longer for RARP than RRP (341 versus 235 min, p < 0.01), and mean estimated blood loss was less for RARP than RRP (533 versus 1,540 ml, p < 0.01). There was a trend towards fewer positive surgical margins (PSM) for RARP (10%) than RRP (24%; p = 0.06). High-risk patients were found to have a greater percentage of PSM following RRP (70%) in comparison with RARP (17%; p = 0.04). The number of patients who experienced complications was no different between groups (16 versus 12, p = 0.37). Erectile function at 12, 18, and 24 months showed no difference between groups (p = 0.15, 0.92, and 0.23, respectively). There was no difference in continence at 1 year (88.6% versus 89.1%; p = 0.94). During 27.1 months of follow-up for the RARP group and 30.4 months for the RRP group, 92% and 94% of patients had an undetectable prostate-specific antigen (PSA) (defined as ≤0.1), respectively (p = 0.38). We report similar outcomes in patients undergoing RARP by a surgeon transitioning from RRP to RARP, confirming that the learning curve does not affect patient outcomes over a 2-year follow-up.

Laparoscopic nephroureterectomy and management of the distal ureter: a review of current techniques and outcomes.

Laparoscopic nephroureterectomy (LNU) is becoming an increasingly common alternative treatment for transitional cell carcinoma (TCC) of the renal pelvis and ureter due to decreased perioperative morbidity, shorter hospitalization, and comparable oncologic control with open nephroureterectomy (ONU). Mobilization of the kidney and proximal ureter may be performed through a transperitoneal, retroperitoneal, or hand-assisted approach. Each technique is associated with its own benefits and limitations, and the optimal approach is often dictated by surgeon preference. Our analysis of the literature reflects equivalent cancer control between LPN and OPN at intermediate follow-up with significantly improved perioperative morbidity following LPN. Several methods for bladder cuff excision have been advocated, however, no individual technique for management of the distal ureter proved superior. Overall, complete en-bloc resection with minimal disruption of the urinary tract should be optimized to maintain oncologic outcomes. Longer follow-up and prospective studies are needed to fully evaluate these techniques.

Impact of prostate median lobe anatomy on robotic-assisted laparoscopic prostatectomy.

OBJECTIVES: Robotic-assisted laparoscopic prostatectomy (RALP) is becoming widely used for the management of prostate cancer. Although prostate size does not affect operative times for RALP, the effect of a large median prostate lobe has not been described. METHODS: One hundred fifty-four men underwent RALP by one surgeon between 2005 and 2007. Patients were categorized into 2 groups based on the presence or absence of a large median prostate lobe identified during RALP. The RALP was divided into sections from bladder mobilization to vesicourethral anastomosis. Operative times and outcomes were recorded prospectively. RESULTS: Of the 154 patients, 29 (18%) of the men had large median prostate lobes. Men with large median lobes were slightly older, but had similar prostate-specific antigen, body mass index, clinical and pathologic stage, biopsy and prostatectomy Gleason grade, tumor volumes, and surgical margin rate compared with men without median lobes. Yet, prostate weight, estimated blood loss, and hospital stay was significantly greater in men with large median lobes. The overall operative time for the RALP was greater in men with a large median lobe caused by an increased time required for posterior bladder neck and seminal vesicle dissection. There was no difference in complications such as urine leaks, bladder neck contractures, and migration of Hem-o-lok clips into the bladder. Continence at 3 and 6 months after RALP were not significantly different in men with large median lobes. CONCLUSIONS: Despite equivalent oncological outcomes, we demonstrate a significant increase in operative times among men with large median lobes.

Computed tomography-determined stone-free rates for ureteroscopy of upper-tract stones.

BACKGROUND AND PURPOSE: Most series on ureteroscopy for urolithiasis use postoperative plain radiography of the kidneys, ureters, and bladder (KUB) or intravenous urography (IVU) to determine outcomes. These imaging modalities, however, are not very sensitive and may overestimate stone-free rates (SFRs). The aim of our study was to assess SFRs after ureteroscopy for urolithiasis using CT follow-up. PATIENTS AND METHODS: A total of 92 patients underwent 113 ureteroscopic procedures for either renal or ureteral stones. Success of ureteroscopy was then determined by the absence of any stone fragments (stone-free). Stone-clearance rates (SCRs) were also calculated for < or = 2 mm and < or = 4 mm residual stone fragments. RESULTS: Each renal unit contained a mean of 1.87 stones with a mean stone diameter of 8 +/- 6 mm. The overall SFR was 50.4%. SFRs were significantly higher for ureteral stones (80%) than renal stones (34.8%) (P = 0.0001). Renal units with multiple stones were less likely to be stone free than those with single stones (P = 0.011). No difference in SFRs was found between lower pole and non-lower-pole stones. CONCLUSIONS: Overall SFRs by CT were lower than SFRs reported by radiography of the KUB or IVU criteria. Further studies to identify the clinical significance and natural history of residual stone fragments on CT scan after ureteroscopy are needed.

Cystoscope- and robot-assisted bladder diverticulectomy.

BACKGROUND AND PURPOSE: Minimally invasive approaches to manage bladder diverticula have become increasingly popular; however, intracorporeal identification of bladder diverticula may be challenging. We report a novel technique for diverticular illumination using flexible cystoscopy. PATIENTS AND METHODS: After management of bladder neck obstruction, two patients with bladder diverticula and persistent lower urinary tract symptoms underwent robot-assisted bladder diverticulectomy. Cystoscopic illumination was used in both cases to aid diverticular identification and dissection. RESULTS: Our technique was simple to perform and facilitated identification and dissection of bladder diverticula. Postoperative cystography revealed no evidence of residual diverticula. CONCLUSIONS: Cystoscope-assisted illumination provides a straightforward method of identifying bladder diverticula during robot-assisted laparoscopic diverticulectomy.

Management of distal ureter in laparoscopic nephroureterectomy--a comprehensive review of techniques.

Approximately 5% of all urothelial tumors in adults arise from the upper tracts. While the gold standard treatment is open nephroureterectomy, laparoscopic nephroureterectomy is becoming increasingly popular. Oncologic principles dictate that complete excision of the transmural ureter and bladder cuff and avoidance of urine spillage are paramount. This can be challenging laparoscopically and multiple techniques have been described. We review described surgical techniques, published oncologic data, as well as advantages and disadvantages for each technique including open excision, cystoscopic detachment and ligation, laparoscopic stapling, ureteral intussusception, transurethral resection of ureteral orifice (TURUO) and modifications of TURUO. To date, no controlled studies have been performed demonstrating one technique's superiority.

Percutaneous radiofrequency ablation-induced perinephric hematoma with acute renal failure in a solitary kidney.

Iatrogenic occurrences (including radiologically guided renal biopsy, shockwave lithotripsy, and minimally invasive ablative procedures) of subcapsular hematoma that lead to acute renal failure are rare but serious. The advancement of minimally invasive procedures has led to an increase in this complication, especially in patients with a solitary kidney. Fortunately, prompt surgical evacuation of the hematoma in these patients allows decompression of the renal parenchyma and recovery of renal function. We report a case of acute renal failure in a patient with a solitary kidney that resulted from a subcapsular hematoma as a complication of radiofrequency ablation.

Clinical urological outcomes following primary tethered cord release in children younger than 3 years.

PURPOSE: Current practice at our institution is to recommend tethered cord release at diagnosis to prevent the onset or worsening of symptoms. Tethered cord release is frequently performed in children younger than 3 years who often have no urological manifestations. To our knowledge there are currently no long-term data on urological outcomes in this age group. MATERIALS AND METHODS: We completed a retrospective review of 475 cases of tethered cord release performed at a single institution between 1995 and 2002. Of these surgeries 173 were performed in children younger than 3 years. Clinical outcomes, and preoperative and postoperative urodynamic and radiographic studies were evaluated. RESULTS: A total of 79 patients met study criteria. Average age at surgery was 9.6 months and average followup was 5.2 years (range 6 months to 11.2 years). At followup 49 patients (62.1%) had no urological complaints and 30 (38%) had urological problems. A total of 20 children (25.3%) had minor problems (constipation, delayed toilet training or other) and 10 (12.7%) had major problems (need for clean intermittent catheterization, febrile urinary tract infection or reflux). Of 66 patients 30 (45.5%) had abnormal preoperative urodynamics. One of 31 patients (3.2%) had hydronephrosis on preoperative ultrasound. Statistical analysis revealed that abnormal preoperative urodynamics and ultrasound were not predictive of major urological problems. Lipomatous dysraphism and preoperative musculoskeletal symptoms positively correlated with major urological problems (p = 0.0076 and 0.0484, respectively). CONCLUSIONS: The majority of children did not experience urological problems following tethered cord release. Only a small set of children had major urological problems. Children with lipomatous dysraphism and musculoskeletal symptoms were more likely to experience poor urological outcomes.