Citrate salts for preventing and treating calcium containing kidney stones in adults.

BACKGROUND: Kidney stones affect people worldwide and have a high rate of recurrence even with treatment. Recurrences are particularly prevalent in people with low urinary citrate levels. These people have a higher incidence of calcium phosphate and calcium oxalate stones. Oral citrate therapy increases the urinary citrate levels, which in turn binds with calcium and inhibits the crystallisation thus reduces stone formation. Despite the widespread use of oral citrate therapy for prevention and treatment of calcium oxalate stones, the evidence to support its clinical efficacy remains uncertain. OBJECTIVES: The objective of this review was to determine the efficacy and adverse events associated with citrate salts for the treatment and prevention of calcium containing kidney stones. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Specialised Register to 29 July 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that assessed the efficacy and adverse events associated with citrate salts for the treatment and prevention of calcium containing kidney stones in adults treated for a minimum of six months. DATA COLLECTION AND ANALYSIS: Two authors assessed studies for inclusion in this review. Data were extracted according to predetermined criteria. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS: We included seven studies that included a total of 477 participants, most of whom had oxalate stones. Of these, three studies (247 participants) compared potassium citrate with placebo or no intervention; three (166 participants) compared potassium-sodium citrate with no intervention; and one (64 participants) compared potassium-magnesium citrate with placebo. Overall, quality of the reporting of the included studies was considered moderate to poor, and there was a high risk of attrition bias in two studies.Compared with placebo or no intervention, citrate therapy significantly reduced the stone size (4 studies, 160 participants: RR 2.35, 95% CI 1.36 to 4.05). New stone formation was significantly lower with citrate therapy compared to control (7 studies, 324 participants: RR 0.26, 95% CI 0.10 to 0.68). The beneficial effect on stone size stability was also evident (4 studies, 160 participants: RR 1.97, 95% CI 1.19 to 3.26). Adverse events were reported in four studies, with the main side effects being upper gastrointestinal disturbance and one patient reported a rash. There were more gastrointestinal adverse events in the citrate group; however this was not significant (4 studies, 271 participants: RR 2.55, 95% CI 0.71 to 9.16). There were significantly more dropouts due to adverse events with citrate therapy compared to control (4 studies, 271 participants: RR 4.45, 95% CI 1.28 to 15.50). The need for retreatment was significantly less with citrate therapy compared to control (2 studies, 157 participants: RR 0.22, 95% CI 0.06 to 0.89). AUTHORS' CONCLUSIONS: Citrate salts prevent new stone formation and reduce further stone growth in patients with residual stones that predominantly contain oxalate. The quality of reported literature remains moderate to poor; hence a well-designed statistically powered multi-centre RCT is needed in order to answer relevant questions concerning the efficacy of citrate salts.

Surgical simulators in urological training--views of UK Training Programme Directors.

What's known on the subject? and What does the study add? The role of surgical simulators is currently being debated in urological and other surgical specialties. Simulators are not presently implemented in the UK urology training curriculum. The availability of simulators and the opinions of Training Programme Directors' (TPD) on their role have not been described. In the present questionnaire-based survey, the trainees of most, but not all, UK TPDs had access to laparoscopic simulators, and that all responding TPDs thought that simulators improved laparoscopic training. We hope that the present study will be a positive step towards making an agreement to formally introduce simulators into the UK urology training curriculum. To discuss the current situation on the use of simulators in surgical training. To determine the views of UK Urology Training Programme Directors (TPDs) on the availability and use of simulators in Urology at present, and to discuss the role that simulators may have in future training. An online-questionnaire survey was distributed to all UK Urology TPDs. In all, 16 of 21 TPDs responded. All 16 thought that laparoscopic simulators improved the quality of laparoscopic training. The trainees of 13 TPDs had access to a laparoscopic simulator (either in their own hospital or another hospital in the deanery). Most TPDs thought that trainees should use simulators in their free time, in quiet time during work hours, or in teaching sessions (rather than incorporated into the weekly timetable). We feel that the current apprentice-style method of training in urological surgery is out-dated. We think that all TPDs and trainees should have access to a simulator, and that a formal competency based simulation training programme should be incorporated into the urology training curriculum, with trainees reaching a minimum proficiency on a simulator before undertaking surgical procedures.

An unusual presentation of non-small cell lung carcinoma.

Lung cancer is the most common malignancy in the Western world and usually presents with respiratory symptoms. The diagnosis of lung cancer is normally made by chest radiography followed by histological confirmation with either radiological or endoscopically guided biopsies. Very rarely, imaging does not help with the initial diagnosis. Haematuria is a common presentation and generally requires urological follow-up with radiological and cystoscopic examination. The differential diagnosis includes urothelial and renal cancers. We present the case of a patient who initially presented to urologists with haematuria and was thought to have a urological malignancy. Contrast enhanced computerised tomography (CT) of both the chest and abdomen after initial endoscopic examination was non-diagnostic. It was only laparoscopic removal of enlarged para-aortic lymph nodes which ultimately provided the diagnosis of non-small cell lung carcinoma.

Extracorporeal shockwave therapy for Peyronie's disease: who benefits?

BACKGROUND AND PURPOSE: Extracorporeal shockwave therapy (ESWT) has been reported to improve the symptoms of Peyronie's disease. However, the response rates to this treatment appear to be variable. This study aimed to determine whether any patient or plaque characteristics are associated with a better outcome. PATIENTS AND METHODS: A series of 36 patients with Peyronie's disease received ESWT as a primary treatment. Subjective response rates were compared on the basis of patient age, degree of pretreatment penile curvature, predisposing medical factors, duration of disease, and extent of plaque calcification. RESULTS: Ten men (27.8%) reported subjective improvements in curvature after ESWT. Of the factors considered, only age and pretreatment curvature influenced outcomes: 50% of the men below the mean age reported improvement compared with 5.6% of older men and 62.5% of men with mild curvature reported improvement compared with 8.3% of those with severe curvature. CONCLUSION: The response to EWST is not the same for all men with Peyronie's disease. Younger men and those with milder curvature have the best outcomes.