Clinical Utility of a Single-Use Flexible Cystoscope Compared with a Standard Reusable Device: A Randomized Noninferiority Study.

Objective: A noninferiority assessment of single-use digital flexible cystoscopy (FC) compared with standard reusable FC for bladder cancer surveillance, and investigation of lower urinary tract symptoms. Patients and Methods: Patients requiring FC who met inclusion criteria were randomly assigned to have their procedure performed using a single-use cystoscope (Ambu® aScope™ 4 Cysto System) or a standard reusable cystoscope (Olympus CYF-VH flexible video cystoscope). Primary outcomes were noninferiority of the single-use cystoscope, in terms of effective procedure completion rate, image quality, light quality, and maneuverability. Secondary objectives compared safety, operative, and perioperative time. The noninferiority margin was set at -10%. Results: One hundred one patients completed the study (n = 50 trial, n = 51 control). All primary outcomes demonstrated noninferiority of the single-use cystoscope, compared with standard reusable FC. Effective completion rate, image quality, light quality, and maneuverability between single-use and reusable cystoscopes were 100% and 98% (confidence interval [CI]: -0.059 to 0.019); 96% and 100% (CI: -0.014 to 0.092); 98% and 100% (CI: -0.018 to 0.058); and 98% and 100% (CI: -0.018 to 0.058). There was no difference in operation time (p = 0.415) or total theater use time (p = 0.441) between groups. Adverse event rates were 4.08% and 4.16% in the trial group and control groups, respectively. Conclusion: The single-use Ambu flexible cystoscope is noninferior to standard FC in terms of procedure completion and light quality, image quality, and maneuverability. Single-use flexible cystoscopes are an effective and safe alternative to reusable flexible cystoscopes and may act as a suitable alternative or adjunct in the urologist's armamentarium.

Transfusion-Related Renal Dysfunction After Cardiac Surgery: The Role of Myeloid-Related Protein_14 in Neutrophil-Mediated Tubular Damage.

Transfusion is a specific cause of acute kidney injury (AKI) after cardiac surgery. Whether there is an association between the composition of blood products and the onset of AKI is unknown. The present study suggests that the transfusion of packed red blood cells containing a high amount of myeloid-related protein 14 (MRP_14) could increase the incidence of AKI after cardiac surgery. In a mouse model, MRP_14 increased the influx of neutrophils in the kidney after ischemia-reperfusion and their ability to damage tubular cells. Higher concentrations of MRP_14 were found in packed red blood cells from female donors or prepared by whole blood filtration.

Preconditioning against renal ischaemia reperfusion injury: the failure to translate to the clinic.

Acute kidney injury (AKI) as a result of ischaemia-reperfusion represents a major healthcare burden worldwide. Mortality rates from AKI in hospitalized patients are extremely high and have changed little despite decades of research and medical advances. In 1986, Murry et al. demonstrated for the first time the phenomenon of ischaemic preconditioning to protect against ischaemia-reperfusion injury (IRI). This seminal finding paved the way for a broad body of research, which attempted to understand and ultimately harness this phenomenon for human application. The ability of preconditioning to limit renal IRI has now been demonstrated in multiple different animal models. However, more than 30 years later, a safe and consistent method of protecting human organs, including the kidneys, against IRI is still not available. This review highlights agents which, despite strong preclinical data, have recently failed to reduce AKI in human trials. The multiple reasons which may have contributed to the failure to translate some of the promising findings to clinical therapies are discussed. Agents which hold promise in the clinic because of their recent efficacy in preclinical large animal models are also reviewed.

Zinc preconditioning protects against renal ischaemia reperfusion injury in a preclinical sheep large animal model.

Ischaemia-reperfusion injury (IRI) during various surgical procedures, including partial nephrectomy for kidney cancer or renal transplantation, is a major cause of acute kidney injury and chronic kidney disease. Currently there are no drugs or methods for protecting human organs, including the kidneys, against the peril of IRI. The aim of this study was therefore to investigate the reno-protective effect of Zn2+ preconditioning in a clinically relevant large animal sheep model of IRI. Further the reno-protective effectiveness of Zn2+ preconditioning was tested on normal human kidney cell lines HK-2 and HEK293. Anaesthetised sheep were subjected to uninephrectomy and 60 min of renal ischaemia followed by reperfusion. Sheep were preconditioned with intravenous injection of zinc chloride prior to occlusion. Serum creatinine and urea were measured before ischaemia and for 7 days after reperfusion. HK-2 and HEK293 cells were subjected to in vitro IRI using the oxygen- and glucose-deprivation model. Zn2+ preconditioning reduced ischaemic burden determined by creatinine and urea rise over time by ~ 70% in sheep. Zn2+ preconditioning also increased the survival of normal human kidney cells subjected to cellular stress such as hypoxia, hydrogen peroxide injury, and serum starvation. Overall, our protocol incorporating specific Zn2+ dosage, number of dosages (two), time of injection (24 and 4 h prior), mode of Zn2+ delivery (IV) and testing of efficacy in a rat model, a large preclinical sheep model of IRI and cells of human origin has laid the foundation for assessment of the benefit of Zn2+ preconditioning for human applications.

Contemporary Accuracy of Digital Abdominal X-Ray for Follow-Up of Pure Calcium Urolithiasis: Is There Still a Role?

Radiological imaging remains the cornerstone of follow-up of patients with urolithiasis. Plain abdominal X-ray (XRKUB) of these patients is largely becoming obsolete in favor of noncontrast computed tomography of the abdomen and pelvis (CTKUB), which offers superior sensitivity and specificity. Contentiousness exists, however, related to the radiation doses associated with CT. Calcium oxalate remains the most common stone composition across most populations. These calculi are radiopaque and thus follow-up with XRKUB may be appropriate in some settings, avoiding the higher radiation doses associated with standard protocol CT. With the emergence of low-dose CT, however, and the modest accuracy of XRKUB, the ongoing role for XRKUB in the management of urolithiasis is debatable. In this study, we assessed the proportion of pure calcium urolithiasis visible on XRKUB to assess the utility of XRKUB for follow-up of pure calcium urolithiasis. Hospital laboratory databases were analysed to identify patients who had undergone urological intervention and extraction of urolithiasis composed of pure calcium salts, who had undergone CTKUB and XRKUB during the same episode for diagnosis of the calculus. One hundred five calculi were included and the imaging for each patient analyzed. 79/105 calculi (75%) identified on CT were visible on XRKUB. The median calculus visible on XRKUB was 7.0 mm (interquartile range [IQR] 5.0-10.0 mm), the median calculus not seen was 4.25 mm (IQR 3.5-7.0 mm) as measured on CT (p < 0.01). XRKUB accuracy varied according to calculus position within the renal tract. Calculi were most often visible in the renal pelvis and proximal ureter (86%), 50% of mid-ureteral and 72% of distal ureteral calculi were visible (p = 0.01). Until low-dose CT protocols become widely adopted, XRKUB still has a limited role in the management of pure calcium urolithiasis in selected patients. Due to its modest accuracy in many settings, this role is limited mainly to larger proximal urolithiasis.

Prostate cancer nodal oligometastasis accurately assessed using prostate-specific membrane antigen positron emission tomography-computed tomography and confirmed histologically following robotic-assisted lymph node dissection.

We herein present a case of a 76-year-old gentleman, where prostate-specific membrane antigen positron emission tomography-computed tomography (PSMA PET-CT) was used to accurately detect prostate cancer (PCa), pelvic lymph node (LN) metastasis in the setting of biochemical recurrence following definitive treatment for PCa. The positive PSMA PET-CT result was confirmed with histological examination of the involved pelvic LNs following pelvic LN dissection.

Urinary alkalisation for symptomatic uncomplicated urinary tract infection in women.

BACKGROUND: Uncomplicated urinary tract infection (UTI) is the most common bacterial infection in women, characterised by dysuria and urinary frequency. Urinary alkalisers are widely used in some countries for the symptomatic treatment of uncomplicated UTI, and they are recommended in some national formularies. However, there is a lack of empirical evidence to support their use for UTI and some healthcare guidelines advise against their use. OBJECTIVES: We aimed to look at the benefits and harms of the use of urinary alkalisers for the treatment of uncomplicated UTIs in adult women. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Specialised Register to 19 January 2016 through contact with the Trials Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: All randomised controlled trials (RCTs) and quasi-RCTs on the use of (any) urinary alkalisers (either exclusively or non-exclusively) for the symptomatic treatment of uncomplicated UTI amongst women aged 16 and over, were included. Studies were eligible if they included patients whose diagnosis of UTI was decided by symptoms alone, or positive urine dipstick test or urine culture; and patients with recurrent UTI, provided patients had no symptoms of UTI in the two weeks prior to the onset of symptoms that lead them to seek medical advice. Studies were ineligible if they studied patients with complicated UTIs; immune-compromising conditions; acute pyelonephritis; or chronic conditions such as interstitial cystitis. DATA COLLECTION AND ANALYSIS: Three authors independently assessed and screened papers, and this was repeated by two separate authors (independently). An additional investigator acted as arbitrator, where necessary. There were no papers which fulfilled the inclusion criteria for this review, and therefore no data extraction was performed. MAIN RESULTS: Our search identified 172 potential studies for inclusion. However, following assessment none fulfilled the inclusion criteria for this review. AUTHORS' CONCLUSIONS: Until relevant evidence is generated from randomised trials, the safety and efficacy of urinary alkalisers for the symptomatic treatment of uncomplicated UTI remains unknown.

Radiation dosing in the investigation and follow-up of urolithiasis: Comparison between historical and contemporary practices.

PURPOSE: Computed tomography (CT) is the gold standard imaging modality for the diagnosis and follow-up of urolithiasis. Before the use of CT, intravenous urography (IVU) was the imaging modality of choice. CT remains contentious because of the cancer risk related to radiation exposure above a threshold level. We aimed to compare the radiation exposure dose to the average patient with urolithiasis in the era of CT with that of IVU. MATERIALS AND METHODS: Our hospital medical records database was searched for patients who presented to the Emergency Department over a 1-month period in 1990 with a diagnosis of renal colic. Patients with the same presentation, from the same month, in 2013 were also identified. A total of 14 patients from each year fulfilled the inclusion criteria. The estimated effective radiation exposure dose for each patient was calculated by using data from population-based studies. RESULTS: The median effective radiation dose per patient in the 1990 group, for initial diagnosis and subsequent follow-up, was 4.05 mSv (interquartile range [IQR], 3.7-4.4 mSv). The corresponding median dose in the 2013 group was 4.2 mSv (IQR, 4.2-4.9 mSv), and there was no evidence of a statistical difference between the groups (p=0.8). CONCLUSIONS: Despite the contentiousness related to the use of serial CT scanning, our study demonstrated that for radiological investigation and follow-up of urolithiasis, the estimated effective radiation exposure dose to each patient is only marginally higher than in the era of IVU, with improvements in length of hospital stay and time to definitive diagnosis.

Primary malignant melanoma of the urinary bladder and ureter.

Primary malignant melanoma of the urinary bladder is a rare lesion. We report the case of a 78-year-old male with no previous history of cutaneous melanoma who presented with hematuria. Further investigation with imaging and cystoscopy raised suspicion of a primary bladder and ureteric melanoma, which had subsequently metastasized. This was confirmed with histological assessment and a thorough search for alternative primary lesions. Unfortunately, our patient passed away prior to receiving any oncological treatment for his metastatic melanoma, underscoring both the high mortality of this lesion and the need for a consensus on definitive treatment.

Supervisor volume affects oncological outcomes of trainees performing open radical prostatectomy.

BACKGROUND: The relationship between biochemical failure (BF) rate and surgeon experience following open radical prostatectomy (ORP) has been well established, but BF when ORP is performed by urology trainees who are supervised by urologists of differing volume has not. We aimed to compare the oncological outcomes from ORP when a urology trainee as primary operator and is supervised by a high- or low-volume consultant urologist. METHODS: Using a centralized whole of population dataset, created through the Victorian Radical Prostatectomy Registry, patients were classified as either those where a consultant was the primary operator, a urology trainee was the primary operator and supervised by a high-volume consultant or those where a urology trainee was supervised by a low-volume consultant. BF- and prostate cancer (PCa)-specific mortality was compared between these latter two groups and the consultant-only group. RESULTS: We found BF- and PCa-specific mortality rate to be poorer when ORP was performed by a urology trainee supervised by a low-volume consultant compared with consultant-led surgery (hazard ratio (HR) = 1.33, P = 0.022; subhazard ratio (SHR) = 2.31, P = 0.010, respectively). When a urology trainee, as primary operator, was supervised by a high-volume consultant, there was no statistical difference in BF- or PCa-specific mortality rate following ORP compared with consultant-led surgery (HR = 1.19, P = 0.234; SHR = 1.53, P = 0.346, respectively). There was a trend evident with decreasing supervisor volume leading to worse oncological and mortality outcomes for trainee-led cases. CONCLUSION: This study demonstrates the value of high-volume and fellowship-trained urologists in performing and teaching ORP. As outcomes are increasingly scrutinized with audits, the best strategy for clinicians to maintain standards and optimal patient outcomes is to understand these elements and direct trainees to appropriate centres for training and fellowships.

Renal colic: current protocols for emergency presentations.

Flank pain caused by renal colic is a common presentation to emergency departments. This paper reviews the acute clinical assessment of these patients, outlines appropriate diagnostic strategies with labwork and imaging and updates the reader on conservative treatments, suitable choices for analgesia and indications for surgical intervention. Prompt diagnosis and appropriate treatment instituted in the Emergency Department can rapidly and effectively manage this excruciatingly painful condition.

Metastatic signet ring cell carcinoma of unknown primary source.

An elderly man presented to the emergency department following a motorbike accident. He had sustained chest injuries and a grade 1 splenic laceration. He had a moderate amount of free fluid and some omental standing on trauma CT, which was concerning for occult malignancy. A follow-up CT 4 weeks later showed a marked progression of the ascites and omental stranding. Ascitic tap was negative for malignancy. Tumour markers were normal. The patient developed a proximal small bowel obstruction which appeared to be related to this omental caking in the left upper quadrant on CT. Gastroduodenoscopy did not display any mass lesion. There was an external compression of the duodenum which could not be traversed with the scope. Laparoscopy showed a widespread peritoneal carcinomatosis. Biopsies of the omentum and peritoneum confirmed metastatic signet ring cell carcinoma (cytokeratin 7 and cytokeratin 20 positive). The patient was palliated but died 2 weeks after his diagnosis.

Candida dubliniensis encrustation of an obstructing upper renal tract calculus.

We present the case of a 53-year-old man, with a history of alcohol abuse, requiring intensive care unit admission, with an obstructing right upper renal calculus and Klebsiella pneumoniae urosepsis. Ureteroscopic treatment of this obstruction displayed a small calculus within the renal pelvis completely encapsulated within a fungal bezoar. Laboratory analysis of the fungal mass found it to be Candida dubliniensis.