Mineral content variations between Australian tap and bottled water in the context of urolithiasis.

Objectives: The objective of this study is to investigate the variations in mineral content of tap drinking water across major Australian cities, compared with bottled still and sparkling water, and discuss the possible implications on kidney stone disease (KSD). Materials and Methods: The mineral composition of public tap water from 10 metropolitan and regional Australian cities was compared using the drinking water quality reports published from 2019 to 2021 by the respective water service utilities providers. Specifically, average levels of calcium, bicarbonate, magnesium, sodium, potassium, and sulphates were compared with published mineral content data from bottled still and sparkling drinking water in Australia. Results: The median or mean (depending on report output) mineral composition was highly variable for calcium (range 1.3 to 20.33 mg/L), magnesium (range 1.1 to 11.2 mg/L), bicarbonate (range 12 to 79 mg/L), sodium (range 3 to 47.1 mg/L), potassium (range 0.4 to 3.23 mg/L) and (sulphates range <1 to 37.4 mg/L). Calcium, magnesium and bicarbonate levels in tap water were lower than in bottled sparkling water. Consumption of 3 L/day of the most calcium rich tap water would fulfil 4.7% of the RDI, compared with 8.7% with bottled sparkling water. Consumption of 3 L of the most magnesium rich tap water would fulfil 8% of the RDI, compared with 13.6% with bottled sparkling water. Conclusion: The mineral content of tap drinking water varied substantially across major Australian city centres. Bottled sparkling water on average provided higher levels of calcium, bicarbonate and magnesium and may be preferred for prevention of calcium oxalate stones. These findings may assist counselling of patients with KSD depending on geographic location in the context of other modifiable risk factors and 24-h urine analysis results.

Guideline of guidelines: management of recurrent urinary tract infections in women.

OBJECTIVE: To compare recurrent urinary tract infection (rUTI) guidelines from major urological and non-urological organisations internationally and identify areas of consensus and discrepancy. METHODS: PubMed, Google Scholar and the official webpages of major urological, gynaecological, infectious diseases and general practice organisations were searched for rUTI guidelines in March 2022. Nine guidelines were included for review: European Association of Urology, National Institute for Health and Care Excellence (NICE), Society of Obstetricians and Gynaecologists of Canada, American Academy of Family Physicians, Mexican College of Gynaecology and Obstetrics Specialists, Swiss Society of Gynaecology and Obstetrics, Spanish Society of Infectious Diseases and Clinical Microbiology, German Association of Scientific Medical Societies, and the combined American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. RESULTS: The definition and evaluation of rUTIs, and antibiotic prophylaxis strategies, were mostly consistent across guidelines, and emphasised the importance of obtaining urine cultures and limiting cystoscopy and upper tract imaging in women without risk factors. Variable recommendations were noted for symptomatic treatment, self-initiated antibiotics, and antibiotic-sparing preventative strategies such as cranberry, vaginal oestrogen, immunoactive prophylaxis with OM-89, intravesical glycosaminoglycan instillation, and phytotherapeutics. Recent randomised evidence supports the use of methenamine hippurate. Either continuous or post-coital prophylactic antibiotics were supported by all guidelines. None of the guidelines were tailored to the management recurrent complicated UTI. CONCLUSION: Multiple rUTI guidelines were identified and mostly limited their recommendations to otherwise healthy non-pregnant women with uncomplicated cystitis. Variation was noted, particularly in antibiotic-sparing preventative strategies. Some conflicting recommendations are due to more recent guidelines including updated evidence. Future guidelines should consider recommendations to assist management of complex patient groups, such as recurrent complicated UTI.

Characterization of tumor thrombus in renal cell carcinoma with prostate specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT).

INTRODUCTION: Venous tumor thrombus (TT) occurs as part of the natural history of renal cell carcinoma (RCC) local progression in a small minority of cases. MRI is currently the most accurate imaging modality for determining TT extent. PSMA PET/CT may improve RCC staging and IVC TT characterization. The objective of this study was to investigate the role of PSMA PET/CT in defining superior extent of TT in RCC and TT IVC tributary vessel spread, with comparative accuracy vs. MRI, to assess suitability for resection and inform preoperative surgical planning. METHODS: Patients who underwent PSMA PET/CT for assessment of renal malignancy with TT from 2015 to 2020 at 3 tertiary hospitals in Brisbane, Australia, were retrospectively identified. TT extent was classified using Mayo Clinic levels and compared according to imaging modality. RESULTS: Fourteen patients were included, all of which were clear cell RCC. Ten patients also underwent MRI, 6 of which were concordant in extent according to MRI and PSMA PET. Discordant extent occurred in 4 patients, of which 2 patients had non-PSMA avid thrombus (Mayo level 0 and level 3 on MRI). Further discordance was seen in a patient with adrenal vein and lumbar vein TT only seen on MRI and PSMA PET/CT, respectively. Finally, discordant extent was seen in another patient with Mayo level 4 TT without lumbar vein involvement on MRI vs. level 3 on PSMA PET/CT with lumbar vein involvement. CONCLUSIONS: PSMA PET/CT can provide additional information about TT extent in RCC which may not be seen on MRI. Additional information from PSMA PET/CT in this setting may assist surgical planning, in addition to detection of metastatic disease.

Dual-Tracer Positron-Emission Tomography Using Prostate-Specific Membrane Antigen and Fluorodeoxyglucose for Staging of Prostate Cancer: A Systematic Review.

PSMA PET is more accurate than conventional imaging (CT/bone scan) for staging of intermediate- or high-risk prostate cancer (PCa), but 5-10% of primary tumours have low PSMA ligand uptake. FDG PET has been used to further define disease extent in end-stage castrate-resistant PCa and may be beneficial earlier in the disease course for more accurate staging. The objective of this study was to review the available evidence for patients undergoing both FDG and PSMA PET for PCa staging at initial diagnosis and in recurrent disease. A systematic literature review was performed for studies with direct, intraindividual comparison of PSMA and FDG PET for staging of PCa. Assessment for radioligand therapy eligibility was not considered. Risk of bias was assessed. 543 citations were screened and assessed. 13 case reports, three retrospective studies, and one prospective study were included. FDG after PSMA PET improved the detection of metastases from 65% to 73% in high-risk early castration-resistant PCa with negative conventional imaging (M0). Positive FDG PET was found in 17% of men with negative PSMA PET for postprostatectomy biochemical recurrence. Gleason score ≥8 and higher PSA levels predicted FDG-avid metastases in BCR and primary staging. Variant histology (ductal and neuroendocrine) was common in case reports, resulting in PSMA-negative FDG-positive imaging for 3 patients. Dual-tracer PET for PCa may assist in characterising high-risk disease during primary staging and restaging. Further studies are required to determine the additive benefit of FDG PET and if the FDG-positive phenotype may indicate a poorer prognosis.

Solitary castrate-resistant prostate cancer metastasis to adrenal gland with concordant intense avidity on PSMA and FDG PET.

Isolated prostate cancer metastasis to the adrenal gland is rare. We report a case of concordant high uptake in a solitary adrenal metastasis on both prostate-specific membrane antigen and fluorodeoxyglucose positron-emission tomography in a patient with castrate-resistant prostate cancer. Good initial biochemical response was achieved with laparoscopic adrenalectomy. The patient developed lymph node recurrence 12 months later, although remains asymptomatic on hormonal treatment 22 months post-operatively, in keeping with prior results for metastasis-directed therapy which can delay time to additional treatment. Application of dual tracer PET can be valuable for prostate cancer staging and guidance of metastasis-directed treatment.

Trends in urethral stricture management over two decades.

OBJECTIVES: To identify trends in the management of urethral stricture disease in Australia, assess changes in the standard of care, and examine the availability of genitourinary reconstructive surgery. METHODS: Data on eight stricture management procedures were collected online via Medicare Item Reports from the Australian Government Department of Human Services, and then matched to population data from the Australian Bureau of Statistics. A survey was disseminated via the Urological Society of Australia and New Zealand (USANZ) asking whether active members performed urethroplasty and whether this was done in a rural, regional or metropolitan setting. RESULTS: Over a 22-year period, there were 140 540 endoscopic procedures and 5136 urethroplasties, with 27.4 endoscopic procedures per urethroplasty. From 1994 to 2016, the per capita number of passage of sounds and dilatation procedures decreased by 74% and 75%, respectively, with increases in use of optical urethrotomy of 70% and in single-stage urethroplasty of 144%. Overall, the ratio of all endoscopic procedures vs urethroplasty decreased from 58.9 to 16.8. There were as few as 16 surgeons in the USANZ performing urethroplasty, with seven providing this service in regional areas. Seven had formal fellowship training. CONCLUSION: There has been a clear shift from repetitive endoscopic procedures towards urethroplasty, but the former still make up the majority of interventions. This may be explained by patients not being referred for urethroplasty earlier in the course of disease and there appears to be a gap in genitourinary reconstructive expertise in regional and rural areas.

Urachal Mucinous Cystadenocarcinoma.

A 57-year-old man presented with a 6-month history of pelvic fullness. He had no lower urinary tract symptoms or altered bowel habits. On examination, there was a non-tender pelvic mass which extended from the pubic symphysis to the level of the umbilicus. CT scan of the abdomen demonstrated a 22×11×11 cm cystic mass arising from the pelvis extending into the midline and superiorly to the umbilicus. Other than raised carcinoembryonic antigen of 7.6 ng/mL (<5.0), the remainder of his blood test were unremarkable. Flexible cystoscopy demonstrated a convex deformity of the bladder wall in keeping with the compression and displacement as seen on the CT. The patient underwent an open excision of the cystic structure (urachal remnant), partial cystectomy, partial excision of anterior abdominal wall and pelvic lymphadenectomy. A check cystogram performed 12 days following the initial operation was unremarkable.