Year : 2017 | Volume
: 33 | Issue : 3 | Page : 183--185
Department of Urology, King George's Medical University, Lucknow, Uttar Pradesh, India
Department of Urology, King George's Medical University, Lucknow, Uttar Pradesh
|How to cite this article:|
Goel A. Round-up.Indian J Urol 2017;33:183-185
|How to cite this URL:|
Goel A. Round-up. Indian J Urol [serial online] 2017 [cited 2021 Jun 18 ];33:183-185
Available from: https://www.indianjurol.com/text.asp?2017/33/3/183/209250
The role of intravesical Bacillus Calmette–Guerin (BCG) instillation is well established in the management of high-grade and some low-grade nonmuscle invasive bladder tumors. Mostly, it is instilled after complete resection of all visible tumors. BCG strains are derived from a virulent strain of Mycobacterium bovis. Calmette and Guerin developed the original BCG that provided protection against different strains of tuberculosis. The original BCG was distributed throughout the world for clinical use. However, BCG produced in different laboratories started to diversify genetically over a period of time. Boehm et al. performed a systematic review to assess the efficacy of various strains of BCG for the treatment of nonmuscle invasive bladder tumor. Data were retrieved from literature available on MEDLINE from inception to October 2016. The primary outcome measure was bladder cancer recurrence. The authors found that with chemotherapy as the common comparator (28 trials, 5757 patients, 5 strains) Tokyo 127 (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.16–0.93), Pasteur (OR 0.49, 95% CI 0.28–0.86), and TICE (OR 0.61, 95% CI 0.40–0.93) strains were significantly better than chemotherapy at preventing recurrence. The authors concluded that BCG strains exhibited significant differences in efficacy compared to chemotherapy. However, no definitive conclusions could be reached regarding strain superiority, and head-to-head trials are greatly needed to further understand the importance of strain selection in determining BCG efficacy.
Treating recurrent urinary tract infections (UTI) is a difficult clinical problem and cranberry extracts are often used in such patients. In a systematic review and meta-analysis, Luís et al. tried to clarify the association between cranberry intake and prevention of UTI. Twenty-eight studies were included in the meta-analysis. The authors reported that cranberry products significantly reduced the incidence of UTIs as indicated by the weighted risk ratio (0.67, 95% CI 0.55-0.79, P < 0.0001). Based on this review, the authors suggest the use of cranberry products in patients of recurrent UTI.
The technique of radical prostatectomy is continuously evolving. Recent observational studies have suggested that preservation of seminal vesicles may improve functional outcomes after this surgery by reducing the risk of neurovascular bundle injury., In a phase II randomized controlled trial, Gilbert et al. looked at functional and cancer control outcomes between nerve-sparing prostatectomy augmented with seminal vesicle sparing and standard nerve-sparing prostatectomy. Of the 140 men with early-stage prostate cancer enrolled, the authors noted that the recovery of continence and sexual function was similar between the two groups. Seminal vesicle sparing did not negatively affect margin status or 12-month biochemical recurrence as documented by serum prostate-specific antigen levels. These results suggest limited usefulness of seminal vesicle prostatectomy.
Metastatic cancer prostate is primarily treated by androgen deprivation therapy. However, over time, the cancer escapes hormone regulation and there may be local disease progression giving rise to complications such as bladder outlet obstruction, ureteric obstruction, and hematuria. In patients with metastatic renal cell carcinoma, the role of radical nephrectomy is well established. Some retrospective studies have shown some benefit of local treatment in men with metastatic cancer prostate.,, Being retrospective, there is bias in the data. Therefore, the Local Treatment of Metastatic Prostate cancer trial was initiated to identify the role of cytoreductive radical prostatectomy (cRP) in men with newly diagnosed metastatic cancer prostate. The authors compared the data of 17 men who underwent cRP with 29 men who were given standard of care (SoC). The authors noticed that in a group of well-selected patients, cRP is safe. These patients have more favorable characteristics compared with patients treated with only SoC. If only SoC can be offered, patients are at risk of suffering from local symptoms.
In men with carcinoma penis, surgical removal of both the primary and regional disease is recommended treatment in high-risk localized cancer comprising men with cN0 and node-positive malignancy. Inguinal lymph node dissection (ILND) performed either prophylactically or for early disease is associated with significant survival advantage but is associated with significant complications.,,, Recently, endoscopic ILND (E-ILND) has been described encompassing video endoscopic inguinal lymphadenectomy (VEIL) and robot-assisted inguinal lymphadenectomy (RAIL). The authors report the outcomes of E-ILND, inclusive of VEIL and RAIL approaches, in the largest reported series to date. In this article involving 34 men, the authors concluded that lymph node counts are comparable with an open approach. Importantly, E-ILND has the potential to reduce complication rates and time to convalescence when compared with open ILND.
Suskind et al. sought to evaluate the relationship between age, frailty, and overactive bladder (OAB). All individuals aged ≥65 years underwent a Timed Up and Go Test, a parsimonious measure of frailty. The cohort included 201 and 1162 individuals with and without OAB, respectively. The authors noted that patients with OAB had significantly greater frailty than individuals seeking care for other nononcologic urologic diagnoses. Frailty, when adjusted for age, race, and gender, was a significant predictor of OAB. Furthermore, frailty should be considered when caring for older patients with OAB and OAB should be assessed when caring for frail older patients.
Eredics et al. performed a meta-analysis evaluating the effect of placebo on lower urinary tract symptoms and maximum flow rates in men with lower urinary tract symptoms due to benign prostate enlargement. Twenty-five RCTs involving 10,587 men were included in this study. The authors concluded that there was placebo effect on lower urinary tract function, particularly concerning subjective improvement. The degree of the placebo effect varies considerable between studies even at 12 months.
Khandwala et al. reported the racial variations in semen parameters in men presenting at a fertility center for infertility evaluation or treatment. Data collected included height, weight, body mass index (BMI), age, and race. The authors found that white men produced greater volumes of semen while Asians had higher sperm concentrations and total sperm count. Compared to white men, lower proportion of Asian men had semen quality in the suboptimal range for most semen parameters. Azoospermia was more common in whites. On stratifying the semen results based on BMI, the authors noted attenuation of the observed differences between whites and Asians, yet Asian male semen quality remained higher.
In a systematic review, Jones et al. investigated outcomes of percutaneous nephrolithotomy (PCNL) in patients with chronic kidney disease (CKD) showing an overall renal function improvement of 10%. The authors included nine studies in their review involving treatment of 1851 patients. Some studies utilized glomerular filtration rate (GFR) to measure changes in renal function and reported the mean pre-, post-operative, and follow-up estimated GFR (eGFR) as 31.4, 35.1, and 36.9 mL/min/1.73 m2, respectively. Other studies reported changes in serum creatinine. Mean pre-, post-operative, and follow-up serum creatinine were 3.48, 2.4, and 3.0 mg/dL, respectively. The authors also sought to answer if there is improvement based on the stage of CKD. In patients with established CKD 5, most patients had deterioration of renal function after PCNL. However, PCNL in patients with CKD 3 and 4 led to a stabilization or improvement in renal function, and this improvement was maintained at long-term follow-up. The authors also noted that PCNL in the setting of CKD was associated with higher complications as compared with normally functioning kidneys.
In an interesting report, Purohit et al. reported the natural history and rate of progression of incidental wide-caliber, anterior urethral strictures in men utilizing a validated stricture staging system. These urethral strictures were detected incidentally on cystoscopy for other conditions. Based on cystoscopic finding, the strictures were staged as: Stage 0 - no stricture; Stage 1 - wide-caliber stricture; Stage 2 - requires gentle dilation with a flexible cystoscope; Stage 3 - impassable stricture with a visible lumen; and Stage 4 - no visible lumen. Using this staging system, the authors assessed the change over time in stricture in patients found to have a Stage 1 stricture. The primary outcome was the urethral stricture grade at time of follow-up. Thirty-two men with 42 separate strictures were followed, and at a median length of follow-up of 23 months, a median of 4 cystoscopies per patient were performed. Fifteen of 42 strictures regressed to Stage 0 (36%), 22 remained as Stage 1 (52%), while 5 (12%) advanced to Stage 2. The authors concluded that the majority of low-stage strictures do not progress and suggest the notion that strictures are a graded phenomenon and not all need surgery.
In another study, Blute et al. assessed if reduced eGFR (<60 ml/min) at first transurethral resection of bladder tumor was a significant predictor of subsequent recurrence and progression. They analyzed the multi-institutional database and identified patients with serum creatinine values before first TURBT. CKD-epidemiology collaboration formula was used to calculate the eGFR. Six hundred and thirty-two patients with complete data were included for analysis. During a median follow-up of 3.7 (interquartile range 1.5–6.5) years, 400 (55%) patients had recurrence and 145 (19.9%) patients had progression of tumor stage or grade. Moderate or severe CKD was present in 183 patients. Multivariable analysis identified eGFR <60 (hazard ratio [HR] 1.5, 95% CI 1.2–1.9; P = 0.002) as a predictor of tumor recurrence. The 5-year recurrence-free survival (RFS) rate was 46% for patients with an eGFR ≥ 60 ml/min and 27% for patients with an eGFR <60 ml/min (P = 0.0004). Multivariable analysis also demonstrated that eGFR <60 ml/min (HR 3.7, 95% CI 1.75–7.94; P = 0.001) was associated with progression to muscle-invasive disease. The 5-year PFS rate was 83% for patients with an eGFR ≥60 ml/min and 71% for patients with an eGFR <60 ml/min (P = 0.01). The authors suggested that as moderate CKD at first TUR was associated with reduced RFS and PFS, patients with reduced renal function should be considered for increased surveillance.
Financial support and sponsorship: Nil.
Conflicts of interest: There are no conflicts of interest.
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