Conservative management of staghorn stones.

INTRODUCTION: Since the seminal works by Singh and Blandy in the 1970s, the management of staghorn stones has almost exclusively involved surgical intervention. In contrast, a more recent study found that conservative management was not as unsafe as previously believed. The present review sought to examine the available literature to understand the implications of a conservative strategy. METHODS: A systematic search of the literature was carried out using MEDLINE®, Embase™ and the Cochrane Central Register of Controlled Trials. All papers looking at management of staghorn calculi were reviewed and studies with a conservative management arm were identified. Outcomes of interest were recurrent or severe urinary tract infections, progressive renal deterioration, dialysis requirements, morbidity and disease specific mortality. Owing to the lack of relevant data, a descriptive review was carried out. RESULTS: Our literature search yielded 10 suitable studies involving a total of 304 patients with staghorn stones managed conservatively. Progressive renal deterioration occurred in 0-100% of cases (mean 27.5%) with a higher rate among bilateral staghorn sufferers (44% vs 9%). Dialysis was required in 9% of patients (20% bilateral, 6% unilateral). The mean rate of severe infection was 8.7% and recurrent urinary tract infections occurred in as high as 50% of cases (80% bilateral, 41% unilateral). Disease specific mortality ranged from 0% to 67% (mean 20.5%). CONCLUSIONS: It appears that conservative management of staghorn calculi is not as unsafe as previously thought and selection of patients with unilateral asymptomatic stones with minimal infection should be considered.

Should Finasteride Be Routinely Given Preoperatively for TURP?

Objective. The aim of the review was to compare the use of finasteride to placebo in patients undergoing TURP procedures. Material & Methods. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966-November 2011), EMBASE (1980-November 2011), CINAHL, Clinicaltrials.gov, Google Scholar, reference lists of articles, and abstracts from conference proceedings without language restriction for studies comparing finasteride to placebo patients needing TURPs. Results. Four randomised controlled trials were included comparing finasteride to a placebo. A meta-analysis was not conducted due to the disparity present in the results between the studies. Three of the studies found that finasteride could reduce either intra- or postoperative bleeding after TURP. One study found finasteride to significantly lower the microvessel density (MVD) and vascular endothelial growth factor (VEGF). None of the studies reported any long-term complications related to either the medication or the procedure. Conclusion. finasteride reduces bleeding either during or after TURP.

There are calls for a national screening programme for prostate cancer: what is the evidence to justify such a national screening programme?

INTRODUCTION: Prostate cancer is the commonest cancer in men and a major health issue worldwide. Screening for early disease has been available for many years, but there is still no national screening programme established in the United Kingdom. OBJECTIVE: To assess the latest evidence regarding prostate cancer screening and whether it meets the necessary requirements to be established as a national programme for all men. METHODS: Electronic databases and library catalogues were searched electronically and manual retrieval was performed. Only primary research results were used for the analysis. RESULTS: In recent years, several important randomised controlled trials have produced varied outcomes. In Europe the largest study thus far concluded that screening reduced prostate cancer mortality by 20%. On the contrary, a large American trial found no reduction in mortality after 7-10 years follow-up. Most studies comment on the adverse effects of screening - principally those of overdiagnosis and subsequent overtreatment. DISCUSSION: Further information about the natural history of prostate cancer and accuracy of screening is needed before a screening programme can be truly justified. In the interim, doctors and patients should discuss the risks, benefits and sequelae of taking part in voluntary screening for prostate cancer.

Oral 5-aminolevulinic acid induced Photodynamic Diagnostic Ureterorenoscopy--does the blood pressure require monitoring?

BACKGROUND: Photodynamic Diagnosis has been proven to improve detection of superficial bladder cancer and improve visualisation of resection margins. The use of 5-aminolevulinic acid as the photosensitising agent has been associated with side effects, specifically hypotension. We aimed to evaluate the effect of oral 5-ALA on the blood pressure in a group of patient who underwent Photodynamic Diagnostic Ureterorenoscopy. METHODS: We carried out an observational study on all patients who underwent PDD-Ureterorenoscopy with oral 5-ALA between July 2009 and September 2011. Pre-administration, hourly post-administration and hourly post-operative blood pressures were noted. Mean arterial blood pressure and the threshold for cerebral ischaemia were calculated as well. RESULTS: The study includes thirty-eight procedures which involved twenty-four patients with a mean age of 74 (SD±16.95). Hypotension was defined as <80% of the systolic or diastolic baseline blood pressure. Twenty patients were hypotensive pre-operatively after the ingestion of 5-ALA while 21 patients were hypotensive post-operatively. Three patients crossed their MAP threshold pre-operatively and were symptomatic. Fast infusion of intravenous fluids improved their symptoms. CONCLUSION: Hypotension is a common occurrence after the ingestion of 5-ALA. Patients undergoing PDD Ureterorenoscopy should have their blood pressure monitored closely after the ingestion of 5-ALA.