The latest medical research on Urology
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about urology gathered by our medical AI research bot.
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Qualitative exploration of the renal stone patients' experience and development of the renal stone-specific Patient-Reported Outcome Measure "Development of the Renal Stone PROM".BJU International
To investigate the experience of patients living with renal calculi via a qualitative methodology, aiming to develop and validate a disease-specific Patient-reported outcome measure (PROM) for renal stones, the Cambridge Renal Stone PROM (CReSP).
Patients with radiologically proven renal calculi who had undergone a range of management options were invited to focus groups or semi-structured interviews to elicit patient input and generate the PROM content. The developed renal stone PROM undergone validity studies included Cronbach's alpha for internal consistency, Spearman's and Pearson's correlation coefficients for test-retest reliability. Discriminant validity was assessed by Pearson's correlation coefficients versus EQ5D5L. Our project has Health and Social Care Research Ethics Committee approval.
A total of 106 subjects participated in creating the newly developed PROM. 36 patients were invited to 22 semi-structured interviews and 4 focus groups, until reaching saturation. Major issues reported, and themes selected for the renal stone PROM included pain, anxiety, limitations to social life and tiredness, urinary symptoms, dietary changes' impacts and gastrointestinal symptoms. Reliability analysis for 30 patients to determine internal consistency using Cronbach's alpha with a mean of 0.91 (range 0.90 to 0.93) within domains and Cronbach's alpha between domains was 0.92. Average inter-item Pearson's and Spearman's correlation within domains was performed, with Pearson's correlation mean of 0.77 (range 0.73 to 0.85) and Spearman's correlation mean of 0.72 (range 0.63 to 0.77). Test-retest Pearson's correlation mean was 0.85 (range 0.57 to 0.95). Validity assessment was performed for 20 patients versus 20 controls. Pearson's correlation with EQ5D5L was -0.74, showing the newly developed PROM successfully discriminated patients suffering from kidney stones. Our final renal stone PROM consists of 14 questions which are rated on a Likert scale. The higher the score, the worse the effect on a patient's quality of life.
Although pain was the most frequent symptom, other health-related and social well-being issues significantly impacted patients' lives. Our validated patient-derived CReSP is a new instrument, specifically tailored to measure renal stone disease health outcomes from the patient's point of view. This article is protected by copyright. All rights reserved.
Characterizing "Bounce-back" Readmissions After Radical Cystectomy.BJU International
To examine predictors of early readmissions following radical cystectomy. Factors associated with preventable readmissions may be most evident in readmissions that occur within 3 days of discharge, commonly termed "bounce-back" readmissions, and identifying such factors may inform efforts to reduce surgical readmissions.
We utilized the Healthcare Cost and Utilization Project's State Inpatient Databases to examine 1,867 patients undergoing cystectomy in 2009 and 2010 and identified all patients readmitted with 30 days of discharge. We assessed differences between patients experiencing bounce-back readmission compared to those readmitted 8-30 days after discharge using logistic regression models and also calculated abbreviated LACE scores to assess the utility of common readmissions risk stratification algorithms.
Thirty day and bounce-back readmission rates were 28.4% and 5.6%, respectively. Although no patient or index hospitalization characteristics were significantly associated with bounce-back readmissions in adjusted analyses, bounce-back patients did have higher rates of gastrointestinal (14.3% vs 6.7%, p=0.02) and wound (9.5% vs 3.0%, p<0.01) diagnoses as well as increased index and readmission length of stay (5 vs 4 days, p=0.01). Overall median abbreviated LACE score was 7, which fell into the moderate readmission risk category, and no difference was observed between readmitted and non-readmitted patients.
One in five readmissions following radical cystectomy occurs within three days of initial discharge, likely due to factors present at discharge. However, sociodemographic and clinical factors as well as traditional readmission risk tools were not predictive of this bounce-back. Effective strategies to reduce bounce-back readmission must identify actionable clinical factors prior to discharge. This article is protected by copyright. All rights reserved.
Teaching medical students digital rectal examination: a randomized study of simulated model vs rectal examination volunteers.BJU International
To determine if using a digital rectal examination (DRE) human volunteer improves medical students' confidence in performing DRE in comparison to using a simulated model alone.
Medical students underwent randomization into one of two groups: a control group who underwent standard teaching and an intervention group who underwent standard teaching plus further tuition involving a DRE volunteer. Standard teaching involved a 30-min lecture and a practice DRE on a simulation model. The intervention group additionally observed a tutor demonstrating DRE on a volunteer, then conducted a DRE themselves under supervision. Before and after teaching, both groups completed a survey comprised of three questions. The primary endpoint was confidence in performing a DRE, which was assessed according to the sum of the scores from the three questions.
In total, 48 students were randomized, 22 to the control group and 26 to the intervention group. The groups were well matched prior to teaching DRE (P = 0.76) After the DRE tutorial, students in the intervention group were more confident in knowing the indications for DRE (P = 0.001), more confident in their technique for performing DRE (P < 0.001) and more confident in their ability to assess findings accurately at DRE (P < 0.001). The primary outcome measure, overall confidence (sum of the scores from all three questions) in performing DRE, was significantly better in the intervention group (score 10/15 vs 14/15; P < 0.001).
This study showed that teaching DRE with the assistance of volunteer patients improves inexperienced students' confidence in performing DRE, and the incorporation of such training should be considered in the DRE education programme.
Robotic versus open radical cystectomy for bladder cancer in adults.BJU International
It has been suggested that in comparison with open radical cystectomy, robotic-assisted radical cystectomy results in less blood loss, shorter convalescence, and fewer complications with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits.
To assess the effects of robotic-assisted radical cystectomy versus open radical cystectomy in adults with bladder cancer.
This study was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (class III to V). Secondary outcomes were minor postoperative complications (class I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk of bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data.
Minor complications (Clavien grades 1 and 2): We are very uncertain whether robotic cystectomy may reduce minor complications (very low-certainty evidence). We downgraded the certainty of evidence for study limitations and for very serious imprecision. Transfusion rate: Robotic cystectomy probably results in substantially fewer transfusions than open cystectomy (RR 0.58, 95% CI 0.43 to 0.80; 2 trials; moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations. Hospital stay: Robotic cystectomy may result in a slightly shorter hospital stay than open cystectomy (mean difference (MD) -0.67, 95% CI -1.22 to -0.12); 5 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision. Quality of life: Robotic cystectomy and open cystectomy may result in a similar quality of life (standard mean difference (SMD) 0.08, 95% CI 0.32 lower to 0.16 higher; 3 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision. Positive margin rates: Robotic cystectomy and open cystectomy may result in similar positive margin rates (RR 1.16, 95% CI 0.56 to 2.40; 5 trials; low-certainty evidence). This corresponds to 8 more (95% CI 21 fewer to 67 more) positive margins per 1000 participants based on 48 positive margins per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision.
Time-to-recurrence: Robotic cystectomy and open cystectomy may result in a similar time to recurrence (hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.77 to 1.43); 2 trials; low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision. Major complications (Clavien grades 3 to 5): Robotic cystectomy and open cystectomy may result in similar rates of major complications (risk ratio (RR) 1.06, 95% CI 0.76 to 1.48); 5 trials; low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence for study limitations and imprecision.
Robotic cystectomy and open cystectomy may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness. This article is protected by copyright. All rights reserved.
The Natural History of Untreated Muscle Invasive Bladder Cancer.BJU International
To describe the natural history of untreated muscle invasive bladder cancer (MIBC) and compare the oncological outcomes of treated and untreated patients.
We utilized a database encompassing all patients with newly-diagnosed bladder cancer in Stockholm, Sweden between 1995-1996. The median follow-up for survivors was 14.4 yrs. Overall, 538 patients were diagnosed with BC of whom 126 patients had clinically localized MIBC. Patients were divided in two groups: those who received radical cystectomy or radiation therapy and those who did not receive any form treatment. Multivariable Cox or competing risks regressions were adopted to predict metastasis, overall survival (OS) and cancer specific mortality (CSM), when appropriate. Analyses were adjusted for age at diagnosis, sex, tumor stage, clinical N stage and treatment.
64 (51%) patients did not receive any definitive local treatment. In the untreated group, median (IQR) age at diagnosis was 79 (63-83) yrs versus 69 (63-74) in the treated group (p<0.001). Overall, 109 patients died during follow-up. At 6 mo after diagnosis, 38% of the untreated patients had developed metastatic disease and 41% experienced CSM. The 5-yr OS rate for untreated and treated patients was 5% (95%CI: 1,12%) versus 48% (95%CI: 36,60%), respectively. Patients not receiving any treatment had a 5-yr cumulative incidence of CSM of 86% (95%CI: 75,94%) versus 48% (95%CI: 36,60%) for treated patients. Untreated patients had a higher risk of progression to metastatic disease (HR: 2.40; 95% CI: 1.28,4.51; p=0.006), death from any cause (HR:2.63; 95%CI: 1.65,4.19; p<0.001) and CSM (SHR:2.02; 95%CI: 1.24, 3.30; p=0.004).
Untreated patients with MIBC are at very high risk for near term cancer specific mortality. These findings may help balance the risks versus benefits of integrating curative intent therapy particularly in older patients with MIBC. This article is protected by copyright. All rights reserved.
Water to prevent kidney stones: Tap vs. bottled; Soft vs. hard - Does it matter?BJU International
It is a question many patients ask in stone clinic - does it matter what water I drink? Often patients cite scaling up of their water pipes or kett...
Optimizing the number of cores for MRI guided targeted and systematic transperineal prostate biopsy.BJU International
To assess cancer detection rates of different target-dependent transperineal magnetic resonance (MR) / ultrasound (US) fusion-guided biopsy templates with reduced number of systematic cores.
Single-centre outcome of transperineal MR/US fusion guided biopsies of 487 men with a single target MRI lesion, prospectively collected between 2012 and 2016. All men underwent transperineal targeted biopsy (TB) with 2 cores followed by 18-24 systematic sector biopsies (SB) using the Ginsburg protocol. Gleason score (GS) ≥ 7 prostate cancer detection rates for 2-core TB, 4-core extended target biopsy (eTB), 10- to 20-core saturation target biopsy (sTB) including cores from sectors adjacent to the target, and 14 core ipsilateral biopsy (iTB) were compared to combined TB+SB.
Cancer was detected in 345 and GS 7-10 cancer in 211 men. TB alone detected 67%, eTB 76%, sTB 91% and iTB 91% of these GS 7-10. In the sub-group of 33 men (7% of cohort) with an anterior >0.5 cc highly suspicious MRI lesion and a prostate volume ≤45 cc, 4-core eTB detected 31 (97%) of 32 cancers and all 26 GS 7-10 cancers.
Saturation TB detected GS 7-10 cancer in 25% more of the men than a 2-core TB approach, and in almost as many men (91%) as the 20- to 26- core combined targeted and systematic transperineal biopsy, while needing only 10-20 cores. A 4-core extended TB may suffice for large, highly suspicious anterior in small or slightly enlarged prostates. This article is protected by copyright. All rights reserved.
"Single Port Robot-assisted Laparoscopic Radical Prostatectomy: Initial Experience and Technique With the da Vinci SP Platform".BJU International
To assess the safety and feasibility of the da Vinci SP (Intuitive Surgical, Sunnyvale, CA, USA) robotic platform for a consecutive series of patients who underwent single port robot-assisted laparoscopic radical prostatectomy (SP-RALP).
Ten consecutive patients with biopsy-confirmed prostate cancer underwent SP-RALP at our institution. Pre, peri, and postoperative data were prospectively collected regarding key outcomes including estimated blood loss, operative time, postoperative pain requirements, duration of hospital stay, and complications.
Patients were between 52 and 77 years of age with BMI between 24.4 and 36.7 kg/m2 . Prostate volumes ranged from 26 to 136 cc with an average PSA 11.0 ng/mL (SD 10.6). Lymph node dissection was performed in 4 cases and nerve sparing performed in 5 cases. No intra-operative complications occurred, and no patients required conversion to open approach. Estimated total blood loss was 20 to 150 cc with median console time of 189 (IQR 171 - 207) minutes and operative time of 234 minutes (IQR 216 - 247). No patients were readmitted or required intervention. Urethral catheters were removed a median 10 days (IQR 8-11) following surgery.
SP-RALP appears to be a safe and feasible approach to performing robotic radical prostatectomy. Long term follow-up will be necessary to assess initial oncological and functional results. This article is protected by copyright. All rights reserved.
Changing clinical trends in 10,000 robot-assisted laparoscopic prostatectomy patients and impact of the 2012 USPSTF statement against PSA screening.BJU International
To evaluate the clinical trend changes in our robot-assisted laparoscopic prostatectomy (RALP) practice and to investigate the effect of 2012 US Preventive Services Task Force (USPSTF) statement against PSA screening on these trends.
Data of 10,000 RALPs performed by a single surgeon between 2002 and 2017 were retrospectively analyzed. Time trends in successive 1,000 cases for clinical, surgical and pathological characteristics were analyzed with linear and logistic regression. Time-trend changes before and after USPSTF statement were compared using a logistic regression model and likelihood-ratio test.
Unfavorable cancer characteristics rate, including D'Amico high risk, pathological non-organ confined disease and Gleason score ≥4+4 increased from 11.5% to 23.3%, 14% to 42.5% and 7.7% to 20.9% over time, respectively (p<0.001 for all). Significant time-trend changes were detected after USPSTF statement with an increase in the positive trend of Gleason ≥4+4 and increase in the negative trends of Gleason ≤3+4 tumors. There was a significant negative trend in the rate of Full NS (nerve-sparing) with a decrease from 59.3% to 35.7%, and a significant positive trend in Partial NS with an increase from 15.8% to 62.5% over time (p<0.001 for all). Time-trend slope in "high-grade" Partial NS significantly decreased and "low-grade" Partial NS significantly increased after USPSTF statement. Overall positive surgical margin (PSM) rate increased from 14.6% to 20.3% in the first vs. last 1,000 cases (p<0.001), with a significantly positive slope after USPSTF statement.
The proportion of high-risk patients increased in our series over time with a significant impact of USPSTF statement on pathological time-trends. This stage migration resulted in decreased utilization of high-quality NS and increased performance of poor-quality NS. This article is protected by copyright. All rights reserved.
Cost-utility analysis of focal HIFU versus active surveillance for low- to intermediate-risk prostate cancer using a Markov multi-state Model.BJU International
To estimate the relative cost-effectiveness of focal high intensity focused ultrasound (F-HIFU) compared to active surveillance (AS) in patients with low- to intermediate-risk prostate cancer (PCa), in France.
A Markov multi-state model was elaborated for this purpose. Our analyses were conducted from the French National Health Insurance perspective, with a time horizon of 10 years and a 4% discount rate for cost and effectiveness. A secondary analysis used a 30-year time horizon. Costs are presented in € 2016, and effectiveness is expressed as Quality-Adjusted Life Years (QALY). Model parameters' value (probabilities for transitions between health states, and cost and utility of health states) are supported by systematic literature reviews (PubMed) and random effect meta-analyses. The cost of F-HIFU in our model was the temporary tariff attributed by the French Ministry of Health to the global treatment of PCa by HIFU (6047€). Our model was analysed using Microsoft Excel 2010. Uncertainty about the value of the model parameters was handled through probabilistic analyses.
The five health states of our model were: initial state (AS or F-HIFU), radical prostatectomy, radiation therapy, metastasis and death. Transition probabilities from the initial F-HIFU state relied on four articles eligible for our meta-analyses. All were non-comparative studies. Utilities relied on a single cohort in San Diego, CA, USA. For a fictive cohort of 1000 individuals followed for 10 years, F-HIFU would be 207 520 € more costly and would yield 382 less QALYs than AS, which means that AS is cost-effective when compared to F-HIFU. For a threshold value varying from 0 to 100,000 €/QALY, the probability of AS being cost-effective compared to F-HIFU varied from 56.5% to 60%. This level of uncertainty was in the same range with a 30-year time horizon.
Given existing literature data, our results suggest that AS is cost-effective compared to F-HIFU in patients with low- and intermediate-risk PCa, but with high uncertainty. This uncertainty must be scaled down by continuing to supply the model with new literature data and ideally through a randomized clinical trial that includes cost-effectiveness analyses. This article is protected by copyright. All rights reserved.
Detrusor overactivity is missed by stopping urodynamic investigation at a bladder volume of 500 mL.BJU International
To investigated whether detrusor overactivity is missed in a relevant percentage if the urodynamic investigation (UDI) is stopped at a filling volume of 500 mL due to the fear of bladder overdistention in patients with lower urinary tract symptoms and high bladder capacity.
A consecutive series of 1598 patients with a bladder capacity of >500 mL in the bladder diary undergoing UDI due to lower urinary tract dysfunction was prospectively investigated. UDI was performed according to Good Urodynamic Practices recommended by the International Continence Society. UDI was stopped at strong desire to void or in case of autonomic dysreflexia, vesico-uretero-renal reflux, bladder pain or discomfort.
Of the 1598 patients (594 women, 1004 men), 1282 (80%) and 316 (20%) suffered from neurogenic and non-neurogenic lower urinary tract dysfunction (LUTD), respectively. Overall, detrusor overactivity was detected in 66% (1048/1598), in 71% (910/1282) with neurogenic and in 44% (138/316) with non-neurogenic LUTD. Detrusor overactivity occurred in 16% (263/1598, 95% CI 14.7-18.4%) only at a bladder volume above 500 mL. This phenomenon was significantly (p<0.0001) more frequent in patients with neurogenic (18% (236/1282), 95% CI 16.4-20.6%) compared with non-neurogenic (9% (27/316), 95% CI 5.9-12.1%) LUTD.
In both neurological and non-neurological patients with high bladder capacity, we strongly recommend not to stop UDI at a bladder volume of 500 mL, since detrusor overactivity might be missed in a relevant percentage leading to inappropriate patient treatment. This article is protected by copyright. All rights reserved.
Guideline adherence for the surgical treatment of T1 renal tumours correlates with hospital volume: an analysis from the British Association of Urological Surgeons Nephrectomy Audit.BJU International
To assess European Association of Urology (EAU) guideline adherence on the surgical management of patients with T1 renal tumours and the effects of centralization of care.
Retrospective data from all kidney tumours that underwent radical nephrectomy (RN) or PN in the period 2012-2016 from the BAUS nephrectomy audit were retrieved and analysed. We assessed total surgical hospital volume (HV; RN and PN performed) per center, PN rates; complication rates, and completeness of data. Descriptive analyses were performed and confidence intervals was used to illustrate the association between hospital volume and proportion of PN. Chi2 and Cochran-Armitage trend tests were used to evaluate differences and trends.
In total, 13045 surgically treated T1 tumours were included in the analyses. Over time, there was an increase in PN use (39.7% in 2012 to 44.9% in 2016). Registration of the PADUA complexity score was included in March 2016 and documented in 39% of cases. Missing information on post-operative complications appeared constant over the years (8.5-9%). A clear association was found between annual HV and the proportion of T1 tumours treated with PN rather than RN (from 18.1% in centres performing <25 cases/year [Lowest volume] to 61.8% in centres performing >100 cases/year [high volume]), which persisted after adjustment for PADUA complexity. Overall and major (Clavien Dindo ≥3) complication rate decreased with increasing HV (from 12.2% and 2.9% in low volume centres to 10.7% and 2.2% in high volume centres, respectively), for all patients including those treated with PN.
Closer guideline adherence was exhibited by higher surgical volume centers. Treatment of T1 tumours using PN increased with increasing HV, and was accompanied by an inverse association of HV with complication rate. These results support the centralization of kidney cancer specialist cancer surgical services to improve patient outcomes. This article is protected by copyright. All rights reserved.