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BJU Int ; 2019 Apr 04.
Artigo em Inglês | MEDLINE | ID: mdl-30946525


OBJECTIVES: To assess the effect of tolterodine in the treatment of nocturnal urinary incontinence (NUI) after ileal orthotopic neobladder (ONB). PATIENTS AND METHODS: This is a prospective randomised placebo-controlled crossover study ( NCT02877901). Patients with NUI after ONB were randomly allocated into two equal groups. Group T received 4 mg extended-release tolterodine at bed-time and Group P received placebo for 4 weeks followed by 2 weeks of washout, then crossed over to the alternate therapy for 4 weeks. Patients were assessed by the number of pads used per night (PPN) and with the Arabic version of the International Consultation on Incontinence Modular Questionnaire-Short Form (ICIQ-SF) at both phases of the study. The outcomes were the rate of NUI improvement and medication adverse events. RESULTS: Out of 172 patients, 150 and 122 patients were evaluated at both phases of the study. The mean ICIQ-SF scores and PPN were significantly decreased in Group T compared to Group P in both study phases (P < 0.001). In Group T, 15 (10%) and 11 (9%) patients became dry after the first allocation and crossover, respectively. In Group T, 60 (77.9%) patients reported improvement vs four (5.5%) in Group P (P < 0.001) after the first allocation. Similarly, 46 (73%) and seven (11.9%) patients showed improvement in groups T and P after the crossover, respectively (P < 0.001). Dry mouth occurred in 31 (20.8%) patients. CONCLUSIONS: Tolterodine seems to be a good choice for treatment of NUI after radical cystectomy and ONB. However, further studies are needed to delineate the long-term effects and the associated urodynamic characteristics.

Urology ; 121: 58-65, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30031005


OBJECTIVE: To assess the non-inferiority of Low-power Holmium laser enucleation of the prostate (LP-HoLEP) to high-power (HP-HoLEP) for enucleation efficiency pertaining to the advantages of lower cost and minimal postoperative dysuria, storage symptoms, and negative sexual impact. PATIENTS AND METHODS: HoLEP was performed using 100W Versapulse, Luminis Inc., with 2J/25Hz for LP-HoLEP (61 patients) and 2J/50Hz for HP-HoLEP (60 patients). Two surgeons with different experience performed equal number of both procedures. Non-inferiority of enucleation efficiency (enucleated weight/min) was evaluated. All perioperative parameters were recorded and compared. Dysuria was assessed at 2 weeks by dysuria visual analog scale, urinary (Q.max and IPSS) and sexual (sexual health inventory for men score) outcome measures were evaluated at 1, 4, and 12 months. RESULTS: Baseline and perioperative parameters were comparable between the two groups. Mean enucleation efficiency was 1.42±0.6 vs 1.47±0.6 gm/min, P = .6 following LP-HoLEP and HP-HoLEP, respectively. Patients reported postoperative dysuria similarly in both groups as per dysuria visual analog scale. There was significant comparable improvement in IPSS (international prostate symptom score) and Q.max in both groups at different follow-up points. At one year, median IPSS and Q.max were comparable in both groups (P = .4 and .7 following LP-HoLEP and HP-HoLEP, respectively). Median postoperative reduction in prostate specific antigen was 89% (42:99) following LP-HoLEP vs 81% (62:94) after HP-HoLEP, P = .92. Both groups showed comparable perioperative and late postoperative complications. There were no statistically significant changes in the last follow-up sexual health inventory for men score in comparison to baseline score. CONCLUSION: LP-HoLEP is non-inferior to HP-HoLEP in terms of all efficiency parameters regardless level of surgeon experience.

Disuria , Terapia a Laser , Lasers de Estado Sólido/uso terapêutico , Complicações Pós-Operatórias , Hiperplasia Prostática , Qualidade de Vida , Disfunções Sexuais Fisiológicas , Ressecção Transuretral da Próstata , Idoso , Disuria/diagnóstico , Disuria/etiologia , Disuria/psicologia , Humanos , Terapia a Laser/efeitos adversos , Terapia a Laser/instrumentação , Terapia a Laser/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/psicologia , Próstata/diagnóstico por imagem , Próstata/patologia , Próstata/cirurgia , Hiperplasia Prostática/diagnóstico , Hiperplasia Prostática/psicologia , Hiperplasia Prostática/cirurgia , Disfunções Sexuais Fisiológicas/diagnóstico , Disfunções Sexuais Fisiológicas/etiologia , Disfunções Sexuais Fisiológicas/psicologia , Ressecção Transuretral da Próstata/efeitos adversos , Ressecção Transuretral da Próstata/instrumentação , Ressecção Transuretral da Próstata/métodos , Resultado do Tratamento , Escala Visual Analógica
World J Urol ; 36(11): 1845-1852, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29736609


PURPOSE: To compare the efficacy of three chemoprophylaxis approaches in prevention of post-transrectal biopsy infectious complications (TBICs). METHODS: Patients were randomly assigned to receive ciprofloxacin 3 days 500 mg B.I.D 3 days starting the night prior to biopsy (standard prophylaxis), augmented prophylaxis using ciprofloxacin and single preprocedure shot of 160 mg gentamicin IM (augmented prophylaxis) and rectal swab culture-based prophylaxis (targeted prophylaxis). Patients were assessed 2 weeks prior to biopsy, at biopsy and 2 weeks after. Primary end point was occurrence of post-TBICs that included simple UTI, febrile UTI or sepsis. Secondary end points were post-biopsy change in the inflammatory markers (TLC, ESR and CRP), unplanned visits, hospitalization and occurrence of fluoroquinolones resistance (FQ-R; bacterial growth on MacConkey agar plate with 10 µg/ml ciprofloxacin) in the fecal carriage of screened men. RESULTS: Between April/2015 and January/2017, standard, augmented and targeted prophylaxes were given to 163, 166 and 167 patients, respectively. Post-TBICs were reported in 43 (26%), 13 (7.8%) and 34 (20.3%) patients following standard, augmented and targeted prophylaxes protocols, respectively (P = 0.000). Post-TBICs included UTI in 23 (4.6%), febrile UTI in 41 (8.2%) and sepsis in 26 (5.2%) patients. Significantly lower number of post-biopsy positive urine culture was depicted in the augmented group (P = 0.000). The number of biopsy cores was statistically different in the three groups (P = 0.004). On multivariate analysis, augmented prophylaxis had independently lower post-TBICs (OR 0.2, 95% CI 0.1-0.4, P = 0.000) when compared with the other two groups regardless of the number of biopsy cores taken (OR 1.07, 95% CI 0.95-1.17, P = 0.229). Post-biopsy hospitalization was needed in four (2%), one (0.6%) and ten (6%) patients following standard, augmented and targeted prophylaxes, respectively (P = 0.014). However, sepsis-related hospitalization was not statistically different. Post-biopsy changes in the inflammatory markers were significantly less in augmented prophylaxis (P < 0.05). FQ-R was depicted in 139 (83.2%) of the screened men. CONCLUSION: Augmented prophylaxis with single-dose gentamicin is an effective and practical approach. Targeted prophylaxis might be reserved for cases with contraindication to gentamicin.

Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Biópsia com Agulha de Grande Calibre/métodos , Ciprofloxacino/uso terapêutico , Gentamicinas/uso terapêutico , Próstata/patologia , Sepse/prevenção & controle , Infecções Urinárias/prevenção & controle , Adenocarcinoma/diagnóstico , Adenocarcinoma/patologia , Idoso , Glicemia/metabolismo , Sedimentação Sanguínea , Proteína C-Reativa/metabolismo , Técnicas de Cultura , Febre/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Hiperplasia Prostática/diagnóstico , Hiperplasia Prostática/patologia , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/patologia , Prostatite/diagnóstico , Prostatite/patologia , Reto/microbiologia , Sepse/epidemiologia , Cateterismo Urinário/estatística & dados numéricos , Infecções Urinárias/epidemiologia
J Urol ; 197(4): 1099-1107, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27825972


PURPOSE: Despite being endorsed in most guidelines, wide adoption of holmium laser enucleation of the prostate is hindered by learning difficulties. We prospectively assessed the learning curve using a multidimensional approach. MATERIALS AND METHODS: We prospectively report all perioperative safety and efficacy outcome measures as well as the need for reoperation and continence status. Case difficulty and learning curve characterization variables were considered, looking for predictors of different outcome measures. Our analysis included the first 313 procedures done by a total of 3 surgeons. RESULTS: Prostate volume and the number of previously performed cases independently predicted operative and enucleation efficiency (mean ± SD 0.76 ± 0.36 and 1.2 ± 0.6 gm per minute, respectively). Both measures plateaued only after the first 40 procedures. The mean percent reduction in postoperative prostate specific antigen was 80% ± 19%. A significantly lower decrease was independently predicted by the transrectal ultrasound depiction of a grossly multinodular prostate (p = 0.000, R2 = 0.59). Perioperative safety measures showed significant improvement after the first and second 20 procedures apart from hospital stay and catheter time. Urinary incontinence was reported in 89 (28.5%), 26 (8.3%) and 7 cases (2.2%) at 1, 4 and 12 months, respectively. Only the number of previously performed cases predicted urinary incontinence at 1 month, which was significantly reduced following the first 20 procedures (plateau) (OR 0.99, 95% CI 0.98-0.999, p = 0.03). The I-PSS (International Prostate Symptom Score) preoperative storage subdomain (OR 0.7, 95% CI 0.4-0.9, p = 0.04), case density (OR 0.3, 95% CI 0.2-0.6, p = 0.01) and number of previously performed cases (OR 0.97, 95% CI 0.98-0.999, p = 0.02) predicted urinary incontinence at 4 months, which was significantly reduced after the first and second 20 procedures. Persistent urinary incontinence at 12 months was significantly associated with fewer previously performed cases (median 60, range 0 to 211 vs 20, range 0 to 99, p = 0.04) with no plateauing through the curve. CONCLUSIONS: Plateauing through the learning curve of holmium laser enucleation of the prostate is a moving target. Looking at different outcome measures, different levels of experience are needed to reach the plateau. Preoperative prostate volume, the number of previously performed cases and case density are the main influential factors in the curve. Urinary incontinence is the most relevant clinical outcome that was significantly affected by learning, although its transient nature is assuring.

Terapia a Laser , Lasers de Estado Sólido/uso terapêutico , Curva de Aprendizado , Prostatectomia/educação , Prostatectomia/métodos , Hiperplasia Prostática/cirurgia , Idoso , Humanos , Masculino , Estudos Prospectivos
Urology ; 85(1): 195-8, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25444630


OBJECTIVE: To report our experience with different approaches for management of pouch stones in children with ileal-based urinary reservoir. PATIENTS AND METHODS: Charts of children who underwent ileal-based urinary reservoirs between 2000 and 2009 were retrospectively reviewed. Patients who were diagnosed with reservoir calculi were identified; medical records were reviewed for patients' demographics, diversion details, stone criteria, mode of treatment, perioperative complications, and recurrence rate. RESULTS: We identified 26 children with pouch stones after urinary diversion. There were 11 boys (42%) and 15 girls (58%). Mean age was 11 years (range, 4-16 years). Mean time for diagnosis was 42 months (24-120 months). Pouch stones were asymptomatic in 10 patients (38%). Fifteen cases were postbladder augmentation and 11 cases postcontinent cutaneous diversion. The mean stone size was 4 cm (range, 1-10 cm), and mean Hounsfield Unit was 585 (205-1090). Seventeen children (65%) had positive urine culture result, whereas 9 children were sterile. Seven children (27%) required open poucholithotomy, whereas 19 patients (73%) were managed endoscopically. Percutaneous approach was done in 5 children, whereas urethral access was used in 7 children. Mechanical extraction was performed in 12 cases, and stone disintegration was required in 7 cases. Eight children developed stone recurrence. Mean time for recurrence was 11 months (range, 3-19 months). Six children were after endoscopic disintegration, and all required redo endoscopic extraction. Stone analysis was available in 15 patients (struvite stones in 10 cases and calcium phosphate in 5 cases). CONCLUSION: Pouch stones are established long-term complication of urinary diversion. Open and endoscopic approaches are valid treatment strategies.

Íleo/cirurgia , Complicações Pós-Operatórias/terapia , Bexiga Urinária/cirurgia , Cálculos Urinários/terapia , Coletores de Urina , Adolescente , Anastomose Cirúrgica , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Retrospectivos