Comparison of efficacy of three commonly used alpha-blockers as medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis

ABSTRACT Introduction: The efficacy of alpha-blockers as medical expulsive therapy (MET) is well established. However, it is not known which of the three most commonly used alpha-blockers (tamsulosin, alfuzosin and silodosin) is the most efficacious. With this study we aimed to assess the efficacy of the three commonly used alpha-blockers as MET for distal ureter stones. Materials and Methods: For this review, we searched multiple databases such as PubMed/Medline, Scopus, Embase, OviD SP, CINAHL, and web of science to identify all the relevant randomized studies comparing the efficacy of tamsulosin, alfuzosin, and silodosin. Preferred reporting items for systematic reviews for network meta-analysis (PRISMA-NMA) were followed while conducting this review and the study protocol was registered with PROSPERO (CRD42020175706). Results: In this review, 31 studies with 7077 patients were included. Compared to placebo all the treatment groups were more effective for both stone expulsion rate (SER) and stone expulsion time (SET). For both SER and SET, silodosin had the highest SUCRA (94.8 and 90.4) values followed by alfuzosin (58.8 and 64.9) and tamsulosin (46.2 and 44.5). The incidence of postural hypotension was similar with all the drugs, whereas, the incidence of retrograde ejaculation was significantly higher for silodosin. Overall confidence for each comparison group in this review ranged from "very low" to "moderate" according to the CINeMA approach. Conclusion: Among the three commonly used alpha-blockers silodosin is the most efficacious drug as MET for lower ureter stones followed by alfuzosin and tamsulosin.

Mucormycosis in the Urinary Bladder-the Devil Is in the Details.

Mucormycosis is a fungal infection involving rhinocerebral, pulmonary, cutaneous, gastrointestinal and disseminated forms with high morbidity and mortality with rare involvement of the urinary bladder. Diagnosis is made by examining under a microscope, identifying broad, nonseptate, irregular and ribbon-shaped hyphae. Timely diagnosis and starting antifungal drugs are key to successful treatment.

Impact of pathological factors on survival in patients with upper tract urothelial carcinoma: a systematic review and meta-analysis

ABSTRACT Introduction: There is an ongoing need to identify various pathological factors that can predict various survival parameters in patients with upper tract urothelial carcinoma (UTUC). With this review, we aim to scrutinize the impact of several pathological factors on recurrence free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) in patients with UTUC. Materials and Methods: Systematic electronic literature search of various databases was conducted for this review. Studies providing multivariate hazard ratios (HR) for various pathological factors such as tumor margin, necrosis, stage, grade, location, architecture, lymph node status, lymphovascular invasion (LVI), carcinoma in situ (CIS), multifocality and variant histology as predictor of survival parameters were included and pooled analysis of HR was performed. Results: In this review, 63 studies with 35.714 patients were included. For RFS, all except tumor location (HR 0.94, p=0.60) and necrosis (HR 1.00, p=0.98) were associated with worst survival. All the pathological variables except tumor location (HR 0.95, p=0.66) were associated with worst CSS. For OS, only presence of CIS (HR 1.03, p=0.73) and tumor location (HR 1.05, p=0.74) were not predictor of survival. Conclusions: We noted tumor grade, stage, presence of LVI, lymph node metastasis, hydronephrosis, variant histology, sessile architecture, margin positivity and multifocality were associated with poor RFS, CSS and OS. Presence of CIS was associated with poor RFS and CSS but not OS. Tumor necrosis was associated with worst CSS and OS but not RFS. Tumor location was not a predictor of any of the survival parameters.

Comparison of efficacy of three commonly used alpha-blockers as medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis.

INTRODUCTION: The efficacy of alpha-blockers as medical expulsive therapy (MET) is well established. However, it is not known which of the three most commonly used alpha-blockers (tamsulosin, alfuzosin and silodosin) is the most efficacious. With this study we aimed to assess the efficacy of the three commonly used alpha-blockers as MET for distal ureter stones. MATERIALS AND METHODS: For this review, we searched multiple databases such as PubMed/Medline, Scopus, Embase, OviD SP, CINAHL, and web of science to identify all the relevant randomized studies comparing the efficacy of tamsulosin, alfuzosin, and silodosin. Preferred reporting items for systematic reviews for network meta-analysis (PRISMA-NMA) were followed while conducting this review and the study protocol was registered with PROSPERO (CRD42020175706). RESULTS: In this review, 31 studies with 7077 patients were included. Compared to placebo all the treatment groups were more effective for both stone expulsion rate (SER) and stone expulsion time (SET). For both SER and SET, silodosin had the highest SUCRA (94.8 and 90.4) values followed by alfuzosin (58.8 and 64.9) and tamsulosin (46.2 and 44.5). The incidence of postural hypotension was similar with all the drugs, whereas, the incidence of retrograde ejaculation was significantly higher for silodosin. Overall confidence for each comparison group in this review ranged from "very low" to "moderate" according to the CINeMA approach. CONCLUSION: Among the three commonly used alpha-blockers silodosin is the most efficacious drug as MET for lower ureter stones followed by alfuzosin and tamsulosin.

Impact of pathological factors on survival in patients with upper tract urothelial carcinoma: a systematic review and meta-analysis.

INTRODUCTION: There is an ongoing need to identify various pathological factors that can predict various survival parameters in patients with upper tract urothelial carcinoma (UTUC). With this review, we aim to scrutinize the impact of several pathological factors on recurrence free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) in patients with UTUC. MATERIALS AND METHODS: Systematic electronic literature search of various databases was conducted for this review. Studies providing multivariate hazard ratios (HR) for various pathological factors such as tumor margin, necrosis, stage, grade, location, architecture, lymph node status, lymphovascular invasion (LVI), carcinoma in situ (CIS), multifocality and variant histology as predictor of survival parameters were included and pooled analysis of HR was performed. RESULTS: In this review, 63 studies with 35.714 patients were included. For RFS, all except tumor location (HR 0.94, p=0.60) and necrosis (HR 1.00, p=0.98) were associated with worst survival. All the pathological variables except tumor location (HR 0.95, p=0.66) were associated with worst CSS. For OS, only presence of CIS (HR 1.03, p=0.73) and tumor location (HR 1.05, p=0.74) were not predictor of survival. CONCLUSIONS: We noted tumor grade, stage, presence of LVI, lymph node metastasis, hydronephrosis, variant histology, sessile architecture, margin positivity and multifocality were associated with poor RFS, CSS and OS. Presence of CIS was associated with poor RFS and CSS but not OS. Tumor necrosis was associated with worst CSS and OS but not RFS. Tumor location was not a predictor of any of the survival parameters.

Comparison of efficacy and safety of various management options for large upper ureteric stones a systematic review and network meta-analysis.

To compare the safety and efficacy of various surgical modalities to manage large (> 1 cm) upper ureter stones. Systematic literature search was conducted to include all randomized studies comparing various treatment options for large (> 1 cm) upper ureteric stones. This review included 13 randomized studies with 1871 patients. Laparoscopic ureterolithotomy (LUL) and percutaneous nephrolithotomy (PNL) were superior to ureteroscopy (URS) and shockwave lithotripsy (SWL) for stone-free rates and need for auxiliary treatments. LUL and PNL were equally effective for stone-free rates and the need for auxiliary treatments. According to SUCRA values for stone-free rates and the need for auxiliary treatments, LUL was the best, followed by PNL. For the duration of surgery, there was no significant difference among all the techniques on network analyses, and SWL was the best according to SUCRA values. Length of hospital stay was significantly shorter for URS than LUL and PNL from network analysis, but there was no significant difference for the rest of the comparisons. Overall complications were similar in all the groups. According to the CINeMa approach, the confidence rating ranged from "very low" to "moderate" for various comparisons. LUL followed by PNL is the most efficacious treatment modality for upper ureteric stones compared to SWL and URS in terms of stone-free rates. However, due to the poor quality of included studies, further high-quality randomized studies are needed.

Comparison of efficacy of various drugs used for medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis.

OBJECTIVES: Medical expulsive therapy has been found to be effective for distal ureteric stones; however, which drug is most efficacious in terms of stone expulsion rate (SER) and stone expulsion time (SET) is not known. With this review we aimed to compare the efficacy of various drug treatments for distal ureter stones used as medical expulsive therapy in terms of SER and SET. METHODS: Systematic literature search was conducted to include all the randomised study comparing various drug interventions for lower ureter stones. Standard preferred reporting items for systematic review and meta-analysis for network meta-analysis (PRISMA-NMA) were pursued. RESULTS: In this review, 50 randomised studies with 12,382 patients were included. For stone expulsion rate (SER), compared with placebo all the treatment groups were more effective except nifedipine and sildenafil. According to the SUCRA values obtained, naftopidil plus steroid was the highest rank and nifedipine lowest. For stone expulsion time (SET), compared with placebo only tadalafil plus silodosin, nifedipine plus steroid, alfuzosin, silodosin, tadalafil and tamsulosin were more effective. SUCRA values were highest for tadalafil plus silodosin and least for naftopidil plus steroid. From subgroup analysis with individual drugs for SER, SUCRA values were highest for naftopidil followed by silodosin and SET was highest for silodosin and least for naftopidil. CONCLUSION: For lower ureter stone, tadalafil plus silodosin is the best combination and silodosin best individual drug considering the SET and SER. Nifedipine as monotherapy is no more effective than control group.

Prolonged natural history of a cystic renal cell carcinoma: A case report.

We describe the successful management of a 50-year male who presented with gradually progressive abdominal swelling for over 20 years. The highlights of the case are giant renal mass occupying the whole abdomen and the absence of metastasis despite a long history.

Dismembered extravesical reimplantation of ectopic ureter in duplex kidney with incontinence.

Ectopic ureter is a rare but pertinent cause of incontinence in young women. We report a 12-year-old girl who presented with reports of incontinence since birth. She was evaluated and found to have complete duplication of the left ureter, with the upper moiety ureter opening into the vestibule of the vagina just below the external urethra meatus. She was managed surgically by dismembered extravesical reimplantation of the upper moiety ureter instead of the conventional method of common sheath reimplantation, sparing the patient a wide cystostomy and intravesical dissection. One year postsurgery, the patient is asymptomatic and dry. Dismembered reimplantation of the ectopic ureter is a simple and reproducible technique which avoids manipulation of the normal lower moiety ureter and its associated potential complications. At the same time, it ensures that the patient is dry without any adverse effect on the lower moiety or its ureter.

A Rare Cause of Acute Abdomen: Testicular Torsion in an Inguinal Undescended Testis.

Testicular torsion is well-known urologic emergency. It warrants urgent diagnosis and surgical intervention for successful outcomes. The incidence of undescended testis in new born is 2%-8% and reduces to <1% by 1 year of age. In majority of cases, it is located in inguinal canal. Though undescended testis is a known risk factor for testicular torsion, there are limited cases reports in the literature. Testicular torsion in undescended testis is difficult to diagnose due to vague symptoms and absence of testicular signs. We report a unique case of testicular torsion in an inguinal undescended testis in a 14-year young male.

Endothelial Dysfunction in Patients With Erectile Dysfunction: A Double-Blind, Randomized-Control Trial Using Tadalafil.

OBJECTIVE: To assess whether tadalafil improves endothelial dysfunction(EnD) in a placebo-controlled randomized-control trial. METHODS: Erectile dysfunction and EnD were assessed by the International Index of Erectile Function (IIEF-5) and flow-mediated dilation (FMD) of the brachial artery respectively, at baseline and 4 weeks by blinded observer. Patients with FMD of < 15% were randomized in 1:1 ratio to receive either placebo or tadalafil. Both placebo and tadalafil in similar-appearing capsules but coded separately, were dispensed by a blinded co-investigator. Compliance and drug-related events were recorded. The randomization codes were then decoded and appropriate statistical tests applied. RESULTS: 89 patients were randomized and 82 completed the study. Both groups were comparable. Posttreatment, there were significant improvements in IIEF-5 score (pre- vs posttreatment; tadalafil: 11.432 vs 15.937, P < .001 and placebo 11.232 vs 14.935, P < .00) and FMD% pre- vs posttreatment; tadalafil: 11.222 vs 13.827, P < .001 and placebo: 11.617 vs 14.027, P < .001). Intergroup comparison did not show any significant difference in IIEF scores (mean change in tadalafil vs placebo group: 3.719 vs 4.433, P = .223) and FMD% (mean change tadalafil vs placebo group: 2.426 and 2.829, P = .528). The adverse events were significantly more in the tadalafil group (tadalafil vs placebo 14 adverse reactions [ADR] vs 5 ADR, P < .001). CONCLUSION: The response of low-dose tadalafil on IIEF and FMD is largely similar to placebo; however, the utility of FMD% in young patients and placebo effect needs to be studied further. Pattanaik S, Kaundal P, Mavuduru RS, et al. Endothelial Dysfunction in Patients With Erectile Dysfunction: A Double-Blind, Randomized-Control Trial Using Tadalafil. Sex Med 2019;7:41-47.