Antibiotics are not necessary during routine cystoscopic stent removal: A randomized controlled trial at UC San Diego.

INTRODUCTION: Current American Urological Association (AUA) Best Practice Statement recommends antibiotic prophylaxis for cystoscopy with manipulation, including stent removal; although no Level 1b trials explicitly address prophylaxis for stent removal. We sought to determine the efficacy of prophylactic antibiotics to prevent infectious complications after stent removal. MATERIALS AND METHODS: Following institutional review board approval, patients undergoing removal of ureteral stent placed during stone surgery were recruited from July 2016 to March 2019. Patients were recruited at the time of stent removal and randomized to treatment (single dose 500 mg oral ciprofloxacin) or control group (no antibiotics). Telephone contact was attempted within 14 days of stent removal to assess for urinary tract infection (UTI) symptoms, antibiotic prescriptions, or Emergency Department visits. Primary outcome was UTI within 1 month of stent removal - defined by irritative voiding symptoms, fever or abdominal pain associated with positive urine culture (Ucx) (>100k colony-forming units/mL). RESULTS: Seventy-seven patients were enrolled, with 58 meeting final inclusion criteria for the analysis (33 treatment, 25 controls). No differences were seen with clinical and demographic variables, except a higher body mass index in the treatment group (P = 0.007). Positive Ucx rate before stone surgery (16.7% vs. 11.8%, P = 0.819) and at the time of stent removal (16.0% vs. 11.1%, P = 0.648) was not significantly different in treatment versus control groups, respectively. Primary outcome: No patients in either cohort developed symptomatic culture-diagnosed UTI within 1 month of stent removal. Of patients with documented phone follow-up (treatment n = 29, control n = 22), only one patient (control) reported any positive response on phone survey. CONCLUSIONS: We found a low infectious complication rate regardless of antibiotic prophylaxis use during cystoscopic stent removal. The necessity of antibiotics during routine cystoscopic stent removal warrants possible reevaluation of the AUA best practice statement.

Comparison of lymph node yield in robot-assisted laparoscopic prostatectomy with that in open radical retropubic prostatectomy.

OBJECTIVE: • To investigate both the feasibility and the adequacy of pelvic lymph node dissection (PLND) during robot-assisted laparoscopic prostatectomy (RALP) by comparing lymph node yields obtained during RALP with those obtained during traditional open retropubic radical prostatectomy (RRP). PATIENTS AND METHODS: • We retrospectively reviewed 1047 patients who underwent radical prostatectomy between 2001 and 2009. • In all, 626 patients underwent RALP while 421 patients had traditional open RRP. All patients undergoing bilateral PLND were included in our analysis. • Lymph node yields and lymph node involvement for each surgical approach were calculated and examined. • PLND-related complications were analysed. RESULTS: • Of the 1047 patients, 816 patients underwent bilateral PLND of whom 473 underwent RALP, while 343 underwent RRP. The mean lymph node yields for the RALP cohort (7.1, interquartile range 4-10) was significantly higher (P < 0.001) than for the RRP cohort (6.0, interquartile range 3-8). • The percentage of patients with nodal involvement was 1.1 for RALP and 2.3 for RRP (P= 0.167). • Mean age, preoperative PSA values, and pre- and postoperative Gleason scores were similar between the two cohorts. • PLND-related complications were similar between both cohorts. CONCLUSIONS: • In patients undergoing RALP, PLND is feasible and provides lymph node yields comparable with those of the standard open approach. • PLND should be strongly considered in all radical prostatectomy patients when clinically indicated, regardless of surgical technique.

Transperitoneal robotic-assisted laparoscopic prostatectomy after prosthetic mesh herniorrhaphy.

BACKGROUND AND OBJECTIVES: We report our institutional experience performing transperitoneal robotic-assisted laparoscopic prostatectomy (RALP) in patients with prior prosthetic mesh herniorrhaphy to assess the feasibility of this procedure in this patient population. METHODS: From October 2005 to January 2008, transperitoneal robotic-assisted laparoscopic prostatectomies were performed and prospectively recorded. We retrospectively reviewed 309 patients. RESULTS: Twenty-seven patients (8.7%) were found to have a history of prior hernia repair with prosthetic mesh placement. The mean age was 55.7, estimated blood loss (EBL) was 228 mL, operative (console) time was 197 minutes, and length of hospital stay (LOS) was 1.62 days. In contrast, patients undergoing RALP with no history of mesh herniorrhaphy had a mean age of 59.3, EBL of 302 mL, console time of 193 minutes, and LOS of 2.2 days. These differences were not statistically significant. The mesh herniorrhaphy cohort had a lower percentage of organ-confined disease, but no difference was seen in margin status, continence, or potency rates after one year. CONCLUSIONS: Transperitoneal RALP is a feasible option for previously operated on patients with prosthetic mesh herniorrhaphy. Two areas that we identified as critical were the initial step of gaining access for pneumoperitoneum and port placement, and meticulous dissection to expose the mesh, which can be subsequently avoided and left intact. As RALP continues to gain popularity, urologists will continue to exploit the advantages of robotic surgery to perform increasingly challenging cases.

Effect of percentage of positive prostate biopsy cores on biochemical outcome in low-risk PCa treated with brachytherapy or 3D-CRT.

OBJECTIVES: To investigate the significance of the percentage of positive biopsy cores (PPBCs) in predicting the biochemical outcome in patients with low-risk prostate cancer undergoing brachytherapy or three-dimensional conformal external beam radiotherapy (3D-CRT). METHODS: We retrospectively reviewed 360 patients with low-risk prostate cancer who had undergone low dose-rate brachytherapy ((125)I) or 3D-CRT from 1993 to 2006. Of the 360 patients, 189 had undergone 3D-CRT and 171 had undergone brachytherapy. The patients were stratified according to treatment modality and PPBCs (<34%, 34%-50%, >50%). Biochemical failure was defined by the 2006 Radiation Therapy Oncology Group-American Society for Therapeutic Radiology and Oncology, Phoenix Consensus Conference definition. RESULTS: The median follow-up in the 3D-CRT and brachytherapy groups was 51 and 37 months, respectively. The number of patients who had a PPBCs of <34%, 34%-50%, and >50% in the 3D-CRT and brachytherapy cohorts was 154, 26, and 9 and 133, 25, and 15, respectively. The 5-year freedom from biochemical failure rate for 3D-CRT and brachytherapy was 95% and 96%, respectively; the corresponding median prostate-specific antigen nadirs were 0.7 and 0.3 ng/mL (P < .001). No significant differences were found in age, stage, Gleason score, or PPBCs between the 2 cohorts. Cox regression analysis showed that the pretreatment prostate-specific antigen level, stage, PPBCs, and treatment modality did not predict for the time to biochemical failure. When stratified by PPBCs, no significant difference in FFBF for either modality was seen. CONCLUSIONS: In patients with low-risk prostate cancer, brachytherapy and 3D-CRT remain excellent treatment choices, regardless of the tumor volume as estimated by the PPBCs. Longer follow-up and the recruitment of men with a greater volume of disease (>50% PPBCs) are needed to confirm these preliminary findings.

Uropharmacology for the primary care physician.

Advances in the understanding of the pathophysiology of a variety of urological disorders have resulted in the development of novel medications to manage these diseases. While many disorders such as erectile dysfunction, overactive bladder, hypogonadism and benign prostatic hypertrophy have traditionally been managed primarily by urologists, the use of these newer medications has become commonplace in the primary care setting. For example, symptomatic benign prostatic hyperplasia therapy, while historically treated with primary surgical intervention, is now commonly initially managed with medical therapy. Prostate cancer patients are being treated with newer formulations of long term hormone therapy that range from monthly to yearly administration. Additionally, the open dialogue about erectile dysfunction can be directly traced to the development of oral therapy for this condition. Testosterone replacement therapy can be administered using a variety of oral, transdermal and intramuscular therapies in order to minimize side effects and provide a more consistent dosing pattern. Finally, overactive bladder, which is a significant problem socially, has many new medications available for its treatment. This article will review some of the newer classes of urological medications, provide an understanding of basic uropharmacology that may guide treatment recommendations, and provide insight into the potential adverse side effects and interactions of these useful medications.

Robotic dismembered pyeloplasty in a horseshoe kidney after failed endopyelotomy.

We report our experience performing a robot-assisted dismembered pyeloplasty on a patient with a ureteropelvic junction obstruction in a horseshoe kidney and a prior history of endopyelotomy. We provide 18-month follow-up demonstrating that robotic pyeloplasty is a reasonable second treatment option for patients with horseshoe kidneys with failed prior endourological management.