Impact of Case Volume on Shock Wave Lithotripsy Outcomes: Data from the National Shock Wave Lithotripsy Database of New Zealand.

Purpose: To assess the impact of individual operator case volume on shock wave lithotripsy (SWL) treatment outcomes in more than 9000 stone cases over a 20-year period in New Zealand. Materials and Methods: Stone cases treated with SWL on the Mobile Medical Technology (MMT) vehicle between June 19, 1995, and December 1, 2014, were identified. Data collection was undertaken prospectively for patient, stone, and treatment characteristics, and retrospectively for treatment outcomes. Multivariate analysis using binary logistic regression was undertaken to assess whether radiographer stone case volume (stones/year) was an independent predictor of SWL success (stone free or clinically insignificant residual fragments ≤4 mm at follow-up). Results: Sixteen radiographers delivered treatment to the included cohort (9039 stone cases), with a median case volume (stones/year) of 73 (range: 37-197) and median total of 425 stones treated (range: 71-1721). The two radiographers with highest case volumes achieved the highest success rates. Radiographer case volume (stones/year) was independently associated with SWL success (odds ratio [OR]: 1.004, 95% confidence interval [CI]: 1.003-1.005, p < 0.0001) and reduced need for post-SWL hospital admission (OR: 0.997, 95% CI: 0.994-1.000, p = 0.028), but there was no associated decrease in post-SWL urosepsis (OR: 0.999, 95% CI: 0.974-1.025, p = 0.941), perinephric hematoma (OR: 1.003, 95% CI: 0.985-1.020, p = 0.778), or need for auxiliary procedures (OR: 1.000, 95% CI: 0.998-1.002, p = 0.871). Conclusions: SWL success rates can be improved by increasing the frequency of cases performed by individual operators. In this multicenter cohort of more than 9000 stone cases treated over a 20-year period, the best outcomes were seen for those radiographers performing >150 cases per year.

Long-term sexual health outcomes in men with classic bladder exstrophy.

OBJECTIVES: To identify the long-term sexual health outcomes and relationships in men born with classic bladder exstrophy (CBE). MATERIALS AND METHODS: A prospectively maintained institutional database comprising 1248 patients with exstrophy-epispadias was used. Men aged ≥18 years with CBE were included in the study. A 42-question survey was designed using a combination of demographic information and previously validated questionnaires. RESULTS: A total of 215 men met the inclusion criteria, of whom 113 (53%) completed the questionnaire. The mean age of the respondents was 32 years. Ninety-six (85%) of the respondents had been sexually active in their lifetime, and 66 of these (58%) were moderately to very satisfied with their sex life. The average Sexual Health Inventory for Men score was 19.8. All aspects of assessment using the Penile Perception Score questionnaire were on average between 'very dissatisfied' and 'satisfied'. Thirty-two respondents (28%) had attempted to conceive with their partner. Twenty-three (20%) were successful in conceiving, while 31 (27%) reported a confirmed fertility problem. A total of 31 respondents (27%) reported undergoing a semen analysis or post-ejaculatory urine analysis. Of these, only four respondents reported azoospermia. CONCLUSION: Patients with CBE have many of the same sexual and relationship successes and concerns as the general population. This is invaluable information to give to both the parents of boys with CBE, and to the boys themselves as they transition to adulthood.

Patient-Reported Impact of Pelvic Organ Prolapse on Continence and Sexual Function in Women With Exstrophy-Epispadias Complex.

OBJECTIVE: This study aimed to characterize long-term urogynecologic issues of women with a history of bladder exstrophy and pelvic organ prolapse (POP) and to assess the impact of POP repair on continence and sexual function. DESIGN: Patient demographics and surgical history related to exstrophy and POP were collected through chart review. Patient perceptions regarding sexual function, urinary continence, and quality of life were assessed through Web-based administration of validated questionnaires: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and POP-Urinary Incontinence Sexual Questionnaire. SETTING: Maryland, United States. PARTICIPANTS: Review of a single-institution exstrophy-epispadias complex database resulted in 25 adult female patients with a history of POP treated at the authors' institution. Eleven patients participated and were included in the analysis. MAIN OUTCOME MEASURES: Urinary continence and sexual function. RESULTS: All participants underwent surgical repair for prolapse, with 7 (63.6%) experiencing unsuccessful initial repair and subsequent recurrence. Median total number of POP repairs was 2.5 (1-4). After correction of POP, patients reported a median improvement in International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form scores of 11 (21 to -1) of 21 and in POP-Urinary Incontinence Sexual Questionnaire scores of 9.5 (6.5-33.0) of 48.0. With regard to urinary continence, 6 (54.5%) patients presently reported no incontinence, 3 (27.3%) reported mild incontinence, and 2 (18.2%) reported continuous incontinence. CONCLUSIONS: Pelvic organ prolapse poses significant reductions in quality of life for women born with exstrophy, with effects on urinary continence and sexual function. Identification and correction of prolapse seems to result in notable improvements in the lives of these patients.

Routine Antibiotic Prophylaxis Is Not Required for Patients Undergoing Shockwave Lithotripsy: Outcomes from a National Shockwave Lithotripsy Database in New Zealand.

PURPOSE: To assess the effectiveness of routine prophylactic antibiotics in the prevention of urinary tract infection (UTI) after extracorporeal shockwave lithotripsy (SWL) and identify predictors of UTI development in a multicenter series of over 10,000 stone cases treated in New Zealand over a 20-year period. MATERIALS AND METHODS: Patients treated with SWL on the Mobile Medical Technology vehicle between June 19, 1995 and December 1, 2014 were identified. Data collection was undertaken prospectively for patient, stone and treatment characteristics, and, retrospectively, for treatment outcomes. The primary outcome was clinical UTI, defined as development of UTI symptoms requiring antibiotic therapy. Secondary outcomes included urinary sepsis, need for hospital admission due to infectious complications, and length of hospital stay. Multivariate analysis was undertaken to identify factors independently associated with the development of post-SWL UTI. RESULTS: Antibiotic prophylaxis was used in 62.1% (n = 6710) of cases. On comparing patients who received prophylactic antibiotics to those in whom antibiotics were withheld, no significant differences were observed in terms of post-SWL UTI (1.1% vs 1.3%, p = 0.335) or urinary sepsis (0.04% vs 0.15%, p = 0.075). The use of prophylactic antibiotics was not independently associated with post-SWL UTI (OR: 1.269, 95% CI: 0.886-1.818, p = 0.194). Female gender, larger stone size, and higher number of delivered shocks were predictive of UTI development, but antibiotic prophylaxis did not appear to offer any benefit in this subgroup. CONCLUSIONS: Routine antibiotic prophylaxis was not associated with a reduction in clinical UTI after SWL in this cohort of over 10,000 stone cases in New Zealand.

Shock wave lithotripsy (SWL): outcomes from a national SWL database in New Zealand.

OBJECTIVES: To present the national outcomes for New Zealand of over 9000 stone cases treated with SWL at 21 centres over a 20 year period. SUBJECTS/PATIENTS AND METHODS: Stone cases treated with SWL on board the Mobile Medical Technology (MMT) vehicle between 19 June 1995 and 1 December 2014 were identified, and data collection undertaken prospectively for patient, stone and treatment characteristics, and retrospectively for treatment outcomes. The primary outcome was treatment success, defined as complete stone clearance or clinically insignificant residual fragments (CIRFs) of ≤4 mm. Secondary outcomes were stone free rate, complications and auxiliary procedures, and all statistical analyses were descriptive. RESULTS: 9538 stone cases (7769 patients) were included. The overall, cumulative success rate was 58.7%; this included 45.1% that were stone free and 13.5% in which there were CIRFs ≤4 mm. Success rates varied widely by stone size and location. Overall rates of urinary tract infection, perinephric haematoma, hospital admission and ureteral stent placement were 1.1%, 0.2%, 6.8% and 4.1%, respectively. Variations in SWL protocols across centres limits the overall reliability of our findings. CONCLUSION: SWL remains a low morbidity management option requiring careful patient selection. This study provides valuable data for patient counseling and the formation of evidence based guidelines in SWL. The MMT SWL service has demonstrated that is it possible to deliver a high volume specialist stone service without requiring patients to travel further for treatment.

Systematic review and meta-analysis of the clinical effectiveness of bipolar compared with monopolar transurethral resection of the prostate (TURP).

To compare monopolar and bipolar transurethral resection of the prostate (TURP) for clinical effectiveness and adverse events. We conducted an electronic search of MEDLINE, Embase, CENTRAL, Science Citation Index, and also searched reference lists of articles and abstracts from conference proceedings for randomised controlled trials (RCTs) comparing monopolar and bipolar TURP. Two reviewers independently undertook data extraction and assessed the risk of bias in the included trials using the tool recommended by the Cochrane Collaboration. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. From the 949 abstracts that were identified, 94 full texts were assessed for eligibility and a total of 24 trials were included in the review. No statistically significant differences were found in terms of International Prostate Symptom Score (IPSS) or health-related quality of life (HRQL) score. Results for maximum urinary flow rate were significant at 3, 6 and 12 months (all P < 0.001), but no clinically significant differences were found and the meta-analysis showed evidence of heterogeneity Bipolar TURP was associated with fewer adverse events including transurethral resection syndrome (risk ratio [RR] 0.12, 95% confidence interval [CI] 0.05-0.31, P < 0.001), clot retention (RR 0.48, 95% CI 0.30-0.77, P = 0.002) and blood transfusion (RR 0.53, 95% CI 0.35-0.82, P = 0.004) Several major methodological limitations were identified in the included trials; 22/24 trials had a short follow-up of ≤1 year, there was no evidence of a sample size calculation in 20/24 trials and the application of GRADE showed the evidence for most of the assessed outcomes to be of moderate quality, including all those in which statistical differences were found. Whilst there is no overall difference between monopolar and bipolar TURP for clinical effectiveness, bipolar TURP is associated with fewer adverse events and therefore has a superior safety profile. Various methodological limitations were highlighted in the included trials and as such the results of this review should be interpreted with caution. There is a need for further well-conducted, multicentre RCTs with long-term follow-up data.