Antimicrobial prophylaxis in management of urinary tract stones by extracorporeal shock-wave lithotripsy: is it necessary?

OBJECTIVES: In a prospective randomized study, we evaluated the incidence of urinary tract infections following extracorporeal shock-wave lithotripsy (ESWL) and the necessity of prophylactic antibiotic administration in patients treated with this modality. METHODS: A total of 360 consecutive patients with renal and ureteric stones who had sterile urine before ESWL treatment and did not have any increased risk of infection received either a single dose of 400 mg of ofloxacin or no prophylaxis. Patients were followed by simple urine analysis and urine cultures together, with clinical evaluations. RESULTS: Only 3 patients (0.8%) had positive urine cultures at 1 week after ESWL. Two of these patients were in the antibiotic prophylaxis group. CONCLUSIONS: The incidence of urinary tract infections after ESWL is extremely low, provided that patients have sterile urine before ESWL, and prophylactic antibiotics are not required.

Impact of the expression of epidermal growth factor, transforming growth factor alpha, and epidermal growth factor receptor on the prognosis of superficial bladder cancer.

OBJECTIVES: To investigate the correlation of epidermal growth factor receptor (EGFR) expression and its ligands EGF and transforming growth factor-alpha (TGF-alpha) with disease outcome in a cohort of patients with superficial bladder cancer. METHODS: Tumor samples of 21 patients with transitional cell carcinoma of the bladder were analyzed by immunohistochemistry for expression of EGFR, EGF, and TGF-alpha. Disease-related events were recorded during a routine clinical follow-up and analyzed for possible correlation with the expression status of the above-mentioned proteins. RESULTS: All Stage pT1 transitional cell carcinomas expressed EGFR, and 10 of 21 (48%) tumors showed focal areas of strong EGF and/or TGF-alpha expression. Of these, 80% with EGF positivity (8 of 10) had recurrences, whereas only 9% of patients without EGF staining (1 of 11) did so. The same pattern was observed with TGF-alpha. A strong association was confirmed between EGF/TGF-alpha positivity and tumor recurrence (P <0.005). We also found that EGF and TGF-alpha were expressed in stroma and/or around the vessels of tumor tissue in 48% and 38% of the tumors, respectively. No association was found between the recurrence rate/vascular invasion and the stromal/vascular wall expression of the growth factors. CONCLUSIONS: Expression of EGF and TGF-alpha is correlated with tumor recurrence. Also, there is the ability of vessel walls to express EGF and TGF-alpha in superficial bladder cancer. Further clarification of the impact of this expression on angioinvasion of tumor cells may be helpful in understanding the nature of local invasion and metastasis.

Transrectal periprostatic lidocaine injection anesthesia for transrectal prostate biopsy: a prospective study.

Transrectal ultrasound (TRUS)-guided biopsy remains the mainstay of the diagnosis of prostate cancer. Although this diagnostic method is a safe procedure and well tolerated by most patients a significant number of patients report discomfort and pain during prostate biopsy. In order to define the best method of anesthesia, many studies, in which different methods were compared, have been performed. To determine the effectiveness of local injection anesthesia in TRUS-guided prostate biopsy, we designed and performed this prospective study in order to evaluate the utility of periprostatic nerve block for pain management. A total of 100 patients who had elevated total prostate-specific antigen (tPSA) and/or abnormal digital rectal examination (DRE) were included in this study. Half of the patients received periprostatic injection anesthesia (group I) and the remaining half received placebo (group II). Patients received 10 cm3 (5 cm3 each side) 1% lidocaine injected into the periprostatic nerve plexus under transrectal ultrasonic guidance. Pain during biopsy was assessed using a 10-point modified visual analog scale (VAS). In groups I and II, mean patient age was 66.8+2.5 and 65.6+11.5 y, mean tPSA was 7.87+/-3.6 and 11.3+/-1.7 ng/ml, mean biopsy duration was 6.5+/-2.5 and 6.6+/-2.2 min and mean pain score during TRUS-guided biopsy was 1.46+/-2.2 and 4.5+/-2.1, respectively. No statistically significant difference was observed with respect to age, tPSA and mean biopsy duration between these groups. Mean pain VAS score was statistically or significantly better (P=0.0001) in the lidocaine injection group (group I), and furthermore no patient had a VAS pain score > or =5 in this group. Only minor and transient complications occurred in both groups. This study reinforces the usage of periprostatic nerve block as a standard method of pain management during TRUS-guided prostate biopsy, because it is simple, safe, uncostly and significantly effective without requiring additional time.

When should one perform shockwave lithotripsy for lower caliceal stones?

Extracorporal shockwave lithotripsy of lower caliceal stones is often unrewarding because of the difficulty of passing stone fragments. We report our results in SWL of lower pole stones in 219 patients and compare them with the results of SWL of middle (82 patients) and upper pole (85 patients) stones. The stone-free rate of SWL monotherapy was found to be 59%, 77%, and 64% in lower, middle, and upper caliceal stones, respectively. In lower pole stones, SWL was unsuccessful in 41% of the patients, of whom 9% had minimal residual asymptomatic stones (less than 4 mm in greatest diameter). In comparison with the results of percutaneous nephrolithotomy (PCN) of lower pole urolithiasis in the literature, SWL was unsuccessful in large stones, with stone-free rates of 13% and 0 when the stone size was 3 to 4.9 cm2 and > 5 cm2, respectively. A stone-free rate of 82% when the stone burden was < 1 cm2 is similar to the PCN results of other centers, suggesting that SWL may be the first choice of treatment in lower pole stones of this size. We achieved a stone-free rate of 59% when the stone size was between 1 and 3 cm2, which is lower than the stone-free rates of PCN in the literature. In spite of its lower stone-free rates, SWL, with its lower morbidity, may still be considered an acceptable treatment modality in this range of moderate stone burden, especially when there is a patient desire for conservative treatment.

Short-term bioeffects of extracorporeal shockwave lithotripsy.

Safety guidelines for shockwave delivery during extracorporeal shockwave lithotripsy (SWL) are not yet clear. Renal functions were assessed by using urinary N-acetyl-beta-D-glucosaminidase (NAG), lactate dehydrogenase (LDH), alanine aminotransferase (ALT; EC.2.6.1.2), aspartate aminotransferase (AST; EC. 2.6.1.1), and gamma-glutamyltransferase (GGT) as well as sodium, potassium, and calcium concentrations in respect to tubular functions after SWL with the Dornier MFL 5000 unit in 32 patients. In order to monitor glomerular function, we determined microalbuminuria. Transient glomerular and tubular damage occurs in SWL-treated kidneys. The minimum interval between two shockwave treatments should be at least 7 days.

Ureteral extracorporeal shock wave lithotripsy utilizing Dornier MFL 5000.

Early reports indicated that stones in the upper ureter that have been manipulated back into the kidney have a higher success rate with SWL than those treated in situ. Difficulties in detecting stones in the mid and lower ureter with lithotripters using ultrasonographic localization also limit in situ SWL of ureteral calculi. We treated 254 patients with ureteral calculi (85 upper, 72 mid, and 97 lower) using in situ SWL on the Dornier MFL 5000. The mean stone volume was 1.4 cm2. Approximately one third of the patients required more than one session. The mean number of shock waves was 2010 (range 1400-3000) with a mean voltage of 20 kV (range 14-30 kV). Fragmentation was achieved in 92.6% of the patients. Only 0.4% of the sessions involved general anesthesia. At 3-month follow-up, available in 75% of the patients, the stone-free rate was 82.6%. Ureteral calculi can be treated effectively in situ by means of SWL.

Extracorporeal shock wave lithotripsy monotherapy of staghorn calculi with Dornier MFL 5000.

A retrospective study was conducted of the efficacy of extracorporeal shock wave lithotripsy (SWL) monotherapy for the management of 31 patients with staghorn calculi (mean size 5.2 cm2). Five patients were lost to follow-up, 10 were stone-free in the end, and 11 had effective disintegration with small residual fragments. The remaining five patients required open surgery because of insufficient stone fragmentation. According to our data, SWL monotherapy is not sufficient for achieving stone-free status in patients with staghorn calculi, but it relieves obstruction and decreases the stone bulk in the majority of them.

Effects of single-shot and twin-shot shockwaves on urinary enzyme concentrations.

BACKGROUND AND OBJECTIVE: Extracorporeal shockwave lithotripsy (SWL) remains the first-line treatment of urinary calculi. However, a number of studies have shown that adverse effects on the kidneys and the surrounding tissues may be encountered in short- and long-term follow-up. The aim of this study was to compare the effects of single-shot and twin-shot SWL techniques to identify the safest modality in terms of urinary enzyme excretion. PATIENTS AND METHODS: In this prospective, investigator-blinded, randomized study, urinary enzymes, beta2-microglobulin, microalbumin, Na, K, Ca, and creatinine concentrations were analyzed in 59 consecutive patients. Measurements were performed in urine specimens collected immediately before and after the SWL procedure and also on the 3rd and 7th days after treatment, which was performed on a Dornier MFL-5000 lithotripter utilizing the twin-shot technique (Group 1; N = 30) or the single-shot technique (Group 2; N = 29) with 3000 shockwaves at 18 kV per treatment. RESULTS: Although there was no statistically significant difference in the results between the groups, urinary levels of microalbumin, alanine and aspartate aminotransferases, beta-2-microalbumin, gamma-glutamyltranspeptidase, Na, K, and Ca rose acutely after SWL, reaching maximum levels on the 3rd day, and returned to the baseline by the 7th day following the treatment in both groups. CONCLUSION: This study demonstrates that SWL performed by either a single-shot or twin-shot shockwave technique has a transient detrimental effect on renal function, as assessed by urine enzyme concentrations. It is recommended that the twin-shot shockwave technique be used in routine lithotripsy in consideration of the cost-effectiveness provided by the shorter treatment time.

Effect of urinary stone disease and extracorporeal shockwave lithotripsy on excretion of glycosaminoglycans.

BACKGROUND AND PURPOSE: The effect of glycosaminoglycans (GAGs) in urinary crystal inhibition has been shown in vitro, but their inhibitor role in vivo has not been precisely determined in stone-forming patients. The aim of this study was to compare the levels of total GAGs and their components in primary stone-forming patients and a healthy control group and to investigate the impact of shockwave lithotripsy (SWL). PATIENTS AND METHODS: Thirty-eight patients with primary kidney stones and 31 healthy controls were included in this prospective study. Total urinary GAG concentrations were determined by the dimethylene blue assay (DMB), and GAG fractions (chondroitin sulfate, heparan sulfate, and dermatan sulfate) were studied by cellulose acetate electrophoresis. Analysis was repeated after SWL in the stone patients. RESULTS: Chondroitin sulfate was the major component secreted in the urine of the control subjects. Heparan sulfate was the major component in the urine of the stone patients with less chondroitin sulfate and dermatan sulfate (48%, 35%, 16.5%, respectively). Our study showed a significant increase in total urinary GAGs (4.75 v. 7.43 microg/mg of creatinine; P<0.0001) after SWL. Dermatan sulfate was the main component in this group (P<0.0001). The total urinary GAG concentrations remained high for at least 2 days after SWL. CONCLUSION: The elevation in total GAGs after SWL indicates the presence of tissue injury, which also renders dermatan sulfate the principal excreted component. Studies with longer follow-up periods are needed to determine whether these changes in the excretion of GAG components persist.

The impact of squamous metaplasia in transitional cell carcinoma of the bladder.

The authors report a case of squamous cell carcinoma of the bladder induced by radiation therapy for transitional cell carcinoma, possibly from sites of squamous metaplasia, which were present at the time of initial diagnosis. Although data in the literature are not sufficient at the moment in terms of implication on prognosis, foci of squamous metaplasia during the initial diagnosis of transitional cell carcinoma must be carefully sought and their presence warrants caution in utilizing irradiation in the management of the disease.

Economics of different treatment options of benign prostatic hyperplasia in Turkey.

Benign prostatic hyperplasia (BPH) has an important impact on the national health economics and can be managed in a large spectrum of modalities from simple follow-up to surgery. In this study, we aimed to compare different treatment options of BPH in terms of cost effectiveness in Turkey. The first evaluation of a BPH patient has a cost of $200. The cost of TURP or open prostatectomy (OP) in our hospital including all the expenses is $740. Finasteride has an annual cost nearly equal to TURP and OP. Considering the expenses of the close follow-up studies and regular visits, one-year lasting Finasteride treatment is two times more expensive than surgery. In comparison with medical treatment options, TURP as the gold standard of treatment of BPH is cost effective when long-term expenses are considered.

The effect of ergobromocriptine on serum testosterone and prolactin levels in patients with carcinoma of the prostate.

The effect of Ergobromocriptine treatment on serum testosterone and prolactin levels in 15 patients with prostatic carcinoma and 15 patients with benign prostatic hyperplasia was examined. The prolactin levels which were elevated in patients with prostatic carcinoma showed a significant decrease after suppression with Ergobromocriptine. The selective effect of Ergobromocriptine on prolactin levels of patients with prostatic carcinoma may control the progression of the disease.

The role of delay in stage III testicular tumours.

Twenty-nine patients with stage III testicular tumours seen between 1979 and 1984 were analysed for the relation between delay in both diagnosis and chemotherapy, and prognosis. The complete response (CR) rate was 40% for patients who were treated within 6 months from onset of symptoms, and 26.3% for patients who had an interval longer than 6 months. We believe that delay in diagnosis and chemotherapy may affect the response to treatment. Health education of the male population for self-examination of the testes is an important factor to minimize this delay.

Serum and urine levels of tumour necrosis factor in patients with genitourinary cancer and their relevance to disease status.

Serum and urine levels of tumour necrosis factor (TNF) which is a lymphokine was measured in patients with genitourinary cancer (either prostatic, bladder or testicular carcinoma) in order to find out whether there were elevated levels of TNF in those patients and if it was related to disease status. Although the preliminary results are not conclusive, further research on TNF may prove this immunoprotein to be a potential diagnostic and therapeutic agent.

Bladder agenesis.

Agenesis of the bladder is an extremely rare anomaly with only approximately 40 such cases reported in the literature. We report on a 30-year-old female patient who also had right renal agenesis.

Correction of primary and secondary vesicoureteral reflux by subureteric Teflon injection.

Polytetrafluoroethylene (Teflon) has been used for various purposes since 1963 and in urologic practice for the treatment of vesicoureteral reflux (VUR) since the 1980s. In this study we report on our experience with Teflon injection for the treatment of 28 children with primary or secondary reflux. An overall success rate of 91.3% was achieved in the treatment of primary and 66.6% in secondary reflux. With these results we conclude that Teflon injection is a good alternative in the treatment of VUR.

The cost and availability of therapeutic options in advanced prostatic carcinoma in Turkey.

Advanced prostatic carcinoma may be treated by a variety of methods of endocrine manipulation which affect the production of androgens. This can either be done by bilateral orchiectomy or by a number of drugs. Orchiectomy has two advantages: low cost and being a once-only procedure. This report outlines the costs of various methods of hormonal treatment and compares them with each other in Turkey.

Single dose of ofloxacin treatment in women with dysuria and frequency.

The efficacy of single dose ofloxacin in lower urinary tract infections was investigated in this study. Fifty-one women with complaints of dysuria and frequency were treated with a single dose of 400 mg ofloxacin orally. The results of urinalysis and urine culture which were performed 4-7 days after the administration of the drug were evaluated. Thirty-eight of the 47 evaluable patients (80.85%) were asymptomatic with normal urinalysis and sterile urine, thus cured. The data of the study suggest that single dose ofloxacin may be the first treatment option in the particular group of women with uncomplicated urinary tract infection.

Neoadjuvant (induction) chemotherapy in advanced bladder carcinoma.

Traditional approaches for the treatment of locally advanced bladder tumours may not be sufficient enough. Neoadjuvant chemotherapy, a new modality, may be beneficial by enhancing the local and systemic control of the disease. The background of this new modality and early results of various trials are discussed.

Spontaneous fracture of indwelling ureteral stents in patients treated with extracorporeal shock wave lithotripsy: two case reports.

Placement of indwelling ureteral stents adjunctive to ESWL treatment has been a widespread practice. We herein present two cases of spontaneous breakage of double pigtail ureteral stents and their management. Prevention of this complication may be possible by careful examination of the stents prior to insertion, by following the instructions of manufacturers on maximum time limits and by using stent logs to keep track of patients.