|Year : 2017 | Volume
| Issue : 2 | Page : 101-103
Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||30-Mar-2017|
Department of Urology, Christian Medical College, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar S. Roundup. Indian J Urol 2017;33:101-3
In this issue of Round-up, I will review a few guidelines that have been published recently. Additionally, some of the recent clinically relevant manuscripts will be summarized.
In a systemic review on the various approaches to renal transplantation, 18 of 1954 publications over the period of half a century from 1966 to 2016, were included. The outcomes studied were graft survival, surgical site infection, incisional hernia, and cosmetic result. While the included studies had a low level of evidence, there was no difference in graft or patient survival. The Gibson incision was better than the hockey stick incision with respect to hernia, abdominal wall relaxation, and cosmesis. Surgical site infection, cosmesis, and hernia were better with minimally invasive techniques at the cost of prolonged warm and cold ischemia and total operative time.
The April issue of the European Journal of Urology will be coming out with guidelines on the treatment of relapsing, metastatic, and castration-resistant prostate cancer. This includes the literature of recent years (2013–15). Choline positron emission tomography/computed tomography (CT) is of limited importance if prostate-specific antigen (PSA) is <1 ng/ml. Bone scan and CT can be omitted in PSA <10 ng/ml. Multiparametric magnetic resonance imaging and biopsy should be included in biochemical failure after radiation therapy. Docetaxel combined with androgen deprivation therapy should be standard of care in fit, metastatic patients at presentation. A full version is available from the EAU office or online (http://uroweb.org/guideline/prostate-cancer/).
The results of distal hypospadias repairs are good; however, proximal hypospadias results are usually clubbed with these cases, often falsely improving the perception of their outcomes. This retrospective study reviewed a total of 167 boys with proximal hypospadias and observed a 56% complication rate at a follow-up of 31.7 months. More patients with single-stage repairs experienced at least two complications. This result from a high-volume center suggests that it may still be wiser to perform staged repairs in proximal hypospadias.
The need for lymphadenectomy with radical nephrectomy has always been debated. It adds to the operating time and blood loss with minimal benefit, if any. The oncological benefit is even more uncertain in patients undergoing cytoreductive nephrectomy for metastatic renal cell carcinoma. In this study, 305 patients with M1 disease were treated by cytoreductive nephrectomy, 62% underwent lymph node dissection, and 24% had N1 disease. Nodal metastasis was associated with aggressive primary histology and shorter cancer-specific survival. Lymphadenectomy was not associated with improved survival.
As the number of patients undergoing radical prostatectomy is high, their follow-up results in an increase in the burden and cost of health-care and stresses resources. In a study to assess the feasibility and efficacy of a shared care model for men after finishing treatment for prostate cancer, men with low and intermediate risk disease were enrolled. In the shared care model, two hospital visits were substituted with three visits in primary care, a survivorship care plan, recall and reminders, and screening for distress and unmet needs. Outcome measures included psychological distress, prostate cancer-specific quality of life, satisfaction and preferences for care, and health-care resource use. Eighty-eight men were randomized and no statistically significant differences were noted in the outcomes studied with high compliance with PSA monitoring in either group. The shared care model was cheaper by AUS$323 and patients were likely to prefer the shared care model to hospital follow-up.
Renal ischemia has always been a concern during partial nephrectomy. The strategies are main renal artery or selective renal artery clamping or zero ischemia. The advantage with any of these strategies in patients with normal renal function has been questioned. In an evaluation of these options in 665 patients, 589 underwent main renal artery clamping compared to 76 with selective clamping. The authors did not find any difference in positive surgical margins, complication rates, or renal functional outcomes. They concluded that if the expected warm ischemia time is low, selective renal artery clamping may not be necessary.
In a retrospective review evaluating the metabolic abnormalities in a contemporary pediatric population after the first stone episode, 113 children were evaluated over 15 years. Fourteen percent of patients had underlying genetic or systemic disease. The serum chemistry abnormalities were low. 24 h urinary evaluation showed low volume 89%, hypocitraturia 68%, and hypercalciuria in 11%. These findings suggested changing metabolic abnormalities contributing to modern pediatric stone disease.
It is a standard practice in most institutions to leave an external splint during a dismembered pyeloplasty to provide drainage, reduce urinary leak and for ease of removal in pediatric patients. In a parallel randomized study, thirty infants <6-month-old were enrolled with an intention to treat analysis. Forty percent of patients without splints had urinary leakage and required double J stent insertion. External urinary splint significantly reduced the hospital stay and complications.
The March issue of the World Journal of Urology has published the ICUD and SIU guidelines for upper tract urothelial carcinoma. There are five articles covering the issues of localized high-risk disease, treatment of low-risk upper tract urothelial carcinoma, treatment of metastatic cancer, epidemiology, diagnosis, preoperative evaluation, and prognostic assessment.
An ex vivo study was performed on caliceal and porcine ureteral models to find the optimal laser pulse energy and frequency to induce fragmentation and prevent retropulsion. Calcium oxalate monohydrate stones were fragmented using 200 μ laser fiber at settings of 0.6 J/5 Hz, 0.2 J/15 Hz, and 0.2 J/50 Hz. In caliceal stones, 0.6 J/5 Hz was similar to 0.2 J/50 Hz setting and both better than 0.2 J/15 Hz setting. In ureteric stones, 0.6 J/5 Hz setting produced higher fragmentation rates at the cost of retropulsion. Retropulsion was lower at 0.2 J and indifferent of the frequency used.
The prognosis of metastatic urothelial carcinoma which has failed platin-based chemotherapy is poor. There were no treatment options for these patients until recently. Nivolumab is a fully human IgG4 PD-1 immune checkpoint inhibitor antibody. A phase 2 trial was done to study the safety and activity in patients with metastatic or surgically unresectable urothelial carcinoma who failed treatment with at least one platinum-based chemotherapy regimen. Two hundred and sixty-five of the 270 patients who received the drug were evaluated. Median follow-up for overall survival was 7 months. Confirmed objective response was achieved in 19·6% of 265 patients. The response was better in patients with higher PD-1 expression. Grade 3–4 adverse reactions occurred in 18% with grade 3 fatigue and diarrhea being the most common. Three deaths were attributed to treatment (pneumonitis, acute respiratory failure, and cardiovascular failure).
The biggest problem in prostate cancer treatment is over-diagnosis and overtreatment. However, missing disease on an initial systemic biopsy of the prostate for an elevated PSA is a problem. The risk of disease-specific mortality in this group of patients is unknown. The data from the Danish Prostate Cancer Registry were evaluated from 1995 to 2011 with follow-up till 2015. Of the 64,430 patients referred for biopsy, 63,454 were included; the median follow-up was 5·9 years and maximum follow-up of 20 years. Thirty percent of patients with initial positive biopsy died of prostate cancer compared to 2% of those with first negative biopsy. The cumulative prostate cancer-specific mortality in this group was 5·2% versus 59·9% for all-cause mortality. The cumulative prostate cancer-specific mortality increased with increasing PSA (ng/ml), 0·7% for <10, 3·6% for men with a PSA higher than 10 ng/mL but 20 ng/mL or less and 17·6% for men with a PSA higher than 20 ng/mL. The authors based on this study question the need for re-biopsy and follow-up of individuals with a low PSA and a negative initial biopsy.
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| References|| |
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Intermediate-term followup of proximal hypospadias repair reveals high complication rate. J Urol 2017;197(3 Pt 2):852-8.
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Lymph node dissection is not associated with improved survival among patients undergoing cytoreductive nephrectomy for metastatic renal cell carcinoma: A propensity score based analysis. J Urol 2017;197(3 Pt 1):574-9.
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ProCare Trial: A phase II randomized controlled trial of shared care for follow-up of men with prostate cancer. BJU Int 2017;119:381-9.
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Selective arterial clamping does not improve outcomes in robot-assisted partial nephrectomy: A propensity-score analysis of patients without impaired renal function. BJU Int 2017;119:430-5.
Bevill M, Kattula A, Cooper CS, Storm DW. The modern metabolic stone evaluation in children. Urology 2017;101:15-20.
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Dismembered pyeloplasty in infants 6 months old or younger with and without external trans-anastomotic nephrostent: A prospective randomized study. Urology 2017;101:38-44.
Shariat SF ICUD guidelines for upper tract urothelial carcinoma: A state-of-the-art evidence-based guidance for clinical decisions regarding diagnosis, management and treatment. World J Urol 2017;35:325-6.
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High-frequency dusting versus conventional holmium laser lithotripsy for intrarenal and ureteral calculi. J Endourol 2017;31:272-7.
Sharma P, Retz M, Siefker-Radtke A, Baron A, Necchi A, Bedke J, et al.
Nivolumab in metastatic urothelial carcinoma after platinum therapy (CheckMate 275): A multicentre, single-arm, phase 2 trial. Lancet Oncol 2017;18:312-2.
Klemann N, Røder MA, Helgstrand JT, Brasso K, Toft BG, Vainer B, et al.
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