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  Table of Contents 
EDITORIAL
Year : 2017  |  Volume : 33  |  Issue : 4  |  Page : 261-263
 

Roundup


Department of Urology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India

Date of Web Publication27-Sep-2017

Correspondence Address:
Arabind Panda
Department of Urology, Krishna Institute of Medical Sciences, Secunderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/iju.IJU_283_17

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How to cite this article:
Panda A. Roundup. Indian J Urol 2017;33:261-3

How to cite this URL:
Panda A. Roundup. Indian J Urol [serial online] 2017 [cited 2017 Dec 12];33:261-3. Available from: http://www.indianjurol.com/text.asp?2017/33/4/261/215709



   Urological Oncology Top


The risk of overall and differential 30 days mortality (TDM) after nephrectomy was retrospectively audited in 21,380 patients in the British association of urological surgeons national nephrectomy audit.[1] There were 110 (0.5%) deaths overall within 30 days of surgery. The TDM rates were 0.6% (63/11057) for radical, 0.1% (4/3931) for partial, and 0.4% (28/3091) for nephroureterectomy. Age, stage, estimated blood loss, and performance status was associated with a greater TDM as was a conversion from minimally invasive surgery and a greater surgical volume. Curative surgery was deemed safer than cytoreductive surgery. However, a modest estimated blood loss of 1–2 L had a greater risk than a loss of 2–5 L.[1]

Partial nephrectomy offers better functional outcomes than radical nephrectomy with almost similar oncological control in properly selected cases. The functional outcome is related to the parenchymal mass loss. This has two components – the excised parenchymal mass (EPM) and the devascularized parenchymal mass (DPM) which is total parenchymal mass loss minus EPM. Dong et al. measured parenchyma mass loss with contrast enhanced computed tomography scans <2 months prior and 3–12 months after partial nephrectomy in predominantly T1 tumors with a mean RENAL score of 7. EPM had a weak association with functional outcomes while total parenchymal mass loss and the DPM had a strong association with preserved glomerular filtration rate. While this is not unexpected, these results make it imperative for the surgeon to preserve uninvolved parenchyma without compromising oncological clearance.[2]

While radical cystotomy remains the cornerstone of management of invasive bladder cancer, the optimal extent of lymphadenectomy has been debatable. Aljabery et al. evaluated the value of radio-guided sentinel lymph node detection and lymph node mapping in invasive bladder cancer. A total of 103 patients with invasive bladder cancer who had radical cystectomy and pelvic lymph node dissection had a blue dye, and radioactive tracer injected into the bladder wall around the primary tumor. A handheld Geiger probe was used to detect senile lymph nodes, which were found in 83/103 patients out of which 20 patients (25%) had metastases. The sensitivity and specificity for detecting metastatic disease by this technique was between 67%–90%.[3] The bladder drains into multiple lymph node areas depending on the location. Moreover, the presence of multiple tumor sites on the bladder wall makes sentinel lymph node biopsy an unreliable technique to assess lymphatic spread. Till a viable alternative technique is available, conventional lymph node dissection remains necessary.

Multiparametric magnetic resonance imaging (MRI) has been used to characterize prostatic malignancy. Canvasser et al. attempted to evaluate its utility in diagnosing clear cell renal cell carcinoma in small renal masses. One hundred twenty-one masses were retrospectively reviewed by radiologists, and a clear cell likelihood score (1–5) was assigned to each tumor mass. Defining clear cell scores of >4 had a sensitivity of 78% and a specificity of 80%.[4] While adoption of such a score may reduce the number of diagnostic renal mass biopsies, multiparametric MRI remains a technique in evolution with no standard guidelines for renal imaging. In addition, the learning curve for reporting specific cancers has to be overcome.

Chiu et al. evaluate the additional benefit of a risk-based selection for prostate biopsy from the data of the Rotterdam section of the European Randomised study of Screening for Prostate Cancer. In 10,747 biopsies, 7294 complications were noted with 0.9% (92/10747) requiring hospital admission. Risk calculators (RC) which are individual multivariate risk assessors, were applied; RC3 for the first round of screening and RC4 for subsequent screening. With a cutoff of 12.5% for prostate cancer and 3% for high-grade prostate cancer 35.8% of biopsies, 37.4% complications, and 42.3% of admissions could have been avoided with a significant saving on biopsies and treatment of complications.[5] This article reiterates the importance of multivariate risk assessment rather than relying on prostate-specific antigen alone.


   Reconstructive Urology Top


Levy et al. assessed if age is an independent factor that predicts urethroplasty success. In a retrospective multicenter analysis from 11 institutions in 322 cases (258 <60 years and 64 >60 years) they assessed functional success (freedom from posturethroplasty procedures) 1 year from surgery. The patients were matched in terms of strict length and location, number of previous direct visual internal urethrotomy/dilatation, smoking status, and urethroplasty type. Comorbid illnesses were more common in the >60 years cohort. Using multivariate logistic regression, they found no difference with respect to age, but the stricture length remained a statistically significant clinical factor.[6] The study is significant in that urethroplasty can be offered to elderly patients with strictures that remain amenable to reconstructive surgery rather than repeated endoscopic procedures that have a poorer success rate and need self-calibration or regular dilatation.


   Urinary Stone Disease Top


The perceived association of diet and lifestyle with urinary stones has long fascinated urologists. Yet the evidence for rigorous dietary modification is poor, and compliance to such a modified diet is difficult. Ferraro et al. estimate the population attributable fraction (PAF) and the number need to prevent for modifiable risk factors- including body mass index, fluid intake, diet, dietary calcium intake, and sugar-sweetened beverages. The data were obtained from validated questionnaires. This study is significant for its size (192,126 participants in 3 prospective cohorts, 3,259,313 person-years of follow-up with 6449 participants developing an incident kidney stone). The PAF was 4.4% for high sweetened beverages intake to 26% for lower fluid intake. The five modifiable risk factors accounted for more than 50% of incident stones in the 3 cohorts.[7]

Despite the numbers there remain certain concerns-the authors did not take into account the salt or protein intake. This has been shown to affect the formation urinary stones.[8] The data are gathered from self-reported questionnaires which have limitations.


   Benign Prostatic Hyperplasia Top


Combination therapy for benign prostatic hyperplasia has more side effects compared to monotherapy. While the effect of alpha blockers is immediate and may decrease over time, the effects of 5-alpha reductase inhibitors start slowly and persist. Attempts to discontinue with a component of combination therapy may result in disease progression and risk of resuming medication and TURP in the 5-ARI group.[9] Adding to this evidence Matsukawa et al. compared the effects of switching to 5 alpha-reductase inhibitor monotherapy from combination therapy after 1 year. In a randomized controlled trial 132 patients on combination therapy were randomized to either continue dutasteride and silodosin or allotted to the silodosin group alone. While no significant differences in the subjective symptoms and bladder outlet obstruction were observed between the two groups, lower urinary tract symptoms deteriorated significantly in the dutasteride monotherapy group in patients with higher body mass index.[10] While the last conclusion may need to be supported by larger trials, the evidence seems to be in favor of continuing combination therapy rather than switching to a single agent.


   Evidence-Based Urology Top


Altmetrics versus conventional metrics is a perineal debate. O'Connor et al. evaluated nontraditional measures of impact and media attention compared to its actual scientific impact. The top 5 cited articles from the top 10 ranked urology journals were compared to the top 50 articles in the altimetric ranking for 2014–2015. There was a weak positive correlation between citations and the altimetric score. The highest altimetric scores were for articles related to sexual medicine while the oncology guidelines had the highest impact factor.[11] While the findings are not entirely unexpected, it is important to remember that the articles most widely commented on in the lay press or shared on social media may not be the most scientific.


   Pediatric Urology Top


Children are often prescribed anticholinergics for neurogenic detrusor overactivity. For long, the only approved anticholinergic that could be used in children was oxybutynin. Long-term data about newer anticholinergics and their safety in children is lacking. Newgreen et al.[12] evaluated the safety and efficacy of solifenacin in children and adolescents with overactive bladder over a period of 2 years. While the drug is safe, it does had a 8%–14% incidence of ECG QT prolongation, the incidence of which increases with the increase of the dose from 5 to 10 mg/day. There was also a higher incidence of constipation and children may need a concomitant bulk laxative. The other adverse effects were similar to other anticholinergics.

 
   References Top

1.
Fernando A, Fowler S, Van Hemelrijck M, O'Brien T; British Association of Urological Surgeons (BAUS). Who is at risk of death from nephrectomy? An analysis of thirty-day mortality after 21 380 nephrectomies in 3 years of the British Association of Urological Surgeons (BAUS) National Nephrectomy Audit. BJU Int 2017;120:358-64.  Back to cited text no. 1
    
2.
Dong W, Wu J, Suk-Ouichai C, Caraballo Antonio E, Remer E, Li J, et al. Devascularized parenchymal mass associated with partial nephrectomy: Predictive factors and impact on functional recovery. J Urol 2017;198:787-94.  Back to cited text no. 2
    
3.
Aljabery F, Shabo I, Olsson H, Gimm O, Jahnson S. Radio-guided sentinel lymph node detection and lymph node mapping in invasive urinary bladder cancer: A prospective clinical study. BJU Int 2017;120:329-36.  Back to cited text no. 3
    
4.
Canvasser NE, Kay FU, Xi Y, Pinho DF, Costa D, de Leon AD, et al. Diagnostic accuracy of multiparametric magnetic resonance imaging to identify clear cell renal cell carcinoma in cT1a renal masses. J Urol 2017;198:780-6.  Back to cited text no. 4
    
5.
Chiu PK, Alberts AR, Venderbos LD, Bangma CH, Roobol MJ. Additional benefit of using a risk-based selection for prostate biopsy: An analysis of biopsy complications in the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer. BJU Int 2017;120:394-400.  Back to cited text no. 5
    
6.
Levy M, Gor RA, Vanni AJ, Stensland K, Erickson BA, Myers JB, et al. The impact of age on urethroplasty success. Urology 2017;107:232-8.  Back to cited text no. 6
    
7.
Ferraro PM, Taylor EN, Gambaro G, Curhan GC. Dietary and lifestyle risk factors associated with incident kidney stones in men and women. J Urol 2017;198:858-63.  Back to cited text no. 7
    
8.
Borghi L, Schianchi T, Meschi T, Guerra A, Allegri F, Maggiore U, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med 2002;346:77-84.  Back to cited text no. 8
    
9.
Lin VC, Liao CH, Kuo HC. Progression of lower urinary tract symptoms after discontinuation of 1 medication from 2-year combined alpha-blocker and 5-alpha-reductase inhibitor therapy for benign prostatic hyperplasia in men – A randomized multicenter study. Urology 2014;83:416-21.  Back to cited text no. 9
    
10.
Matsukawa Y, Takai S, Funahashi Y, Majima T, Kato M, Yamamoto T, et al. Effects of withdrawing α1-blocker from combination therapy with α1-blocker and 5α-reductase inhibitor in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: A prospective and comparative trial using urodynamics. J Urol 2017;198:905-12.  Back to cited text no. 10
    
11.
O'Connor EM, Nason GJ, O'Kelly F, Manecksha RP, Loeb S. Newsworthiness vs. scientific impact: Are the most highly cited urology papers the most widely disseminated in the media? BJU Int 2017;120:441-54.  Back to cited text no. 11
    
12.
Newgreen D, Bosman B, Hollestein-Havelaar A, Dahler E, Besuyen R, Snijder R, et al. Long-term safety and efficacy of solifenacin in children and adolescents with overactive bladder. J Urol 2017;198:928-36.  Back to cited text no. 12
    




 

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