This Month in Adult Urology

Article Outline

• Medical Stone Management
• Importance of Definitions of Success of Sling Surgery
• Effect of Lidocaine Jelly in Preventing Inadvertent Retrograde Stone Migration
• Results of Long-Term Treatment With Finasteride on Prostate Volume
• Von-Hippel Lindau Gene Status and Response to Targeted Therapy for Metastatic Clear Cell Renal Cell Carcinoma
• Phase II Trial of Gemcitabine Plus Capecitabine for Metastatic Renal Cell Cancer
• The Role of Lymphovascular Invasion in Predicting the Prognosis of Upper Tract Urothelial Carcinoma
• Validation of the Fournier's Gangrene Severity Index
• The Presacral Space and Its Impact on Sacral Neuromodulator Implantation
• Assessment of Early Continence After Reconstruction of the Periprostatic Tissues
• Copyright

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Medical Stone Management 

Pak (page 813) from Dallas, Texas reviews the history and rationale for medical management of calculus disease during the last 35 years. The author, a world leader in this area, identifies the key individuals responsible for the advancements in this field. Directing therapy to the specific pathophysiology identified by serum and urine tests represented a paradigm shift for clinicians. Recently these tests and categories have been simplified, making it easier for urologists to differentiate categories and tailor treatments. It is no overstatement that Pak and his progeny have altered the way stone disease is managed.

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Importance of Definitions of Success of Sling Surgery 

Significant variation exists in surgical outcomes for stress urinary incontinence depending on whether success is defined by dry rate, pad usage rate, percent improvement or degree of satisfaction. Rapp and Kobashi (page 998) from Seattle, Washington assessed the outcomes for 271 women 1 year after undergoing either a SPARC™ or pubovaginal sling (PVS). Validated continence questionnaires (UDI-6 and IIQ-7) were used, and parameters included dry rate, frequency of incontinence episodes, patient perceived improvement, patient satisfaction and the likelihood of recommending the treatment to a friend. The success rates ranged from 33% to 87% for SPARC vs 40% to 79% for PVS. The response rates to the question of willing to undergo the surgery again were 74% for the SPARC group and 66% for the PVS group. There was no significant difference over the range of various outcome measures between the groups. These data suggest that success rates are sensitive to the measures used. Investigators need to use multiple measures of success to provide an adequate assessment of outcomes from surgical procedures for incontinence.

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Effect of Lidocaine Jelly in Preventing Inadvertent Retrograde Stone Migration 

Zehri et al (page 966) from Pakistan reported a prospective randomized trial of proximal injection of lidocaine jelly to prevent ureteral stone migration during pneumatic lithotripsy. A total of 50 patients with 5 to 18 mm stones undergoing ureteroscopy and pneumatic lithotripsy were randomized into 2 groups of 25. Lidocaine jelly was instilled proximal to the stone before the start of fragmentation in 1 group. Ureteroscopy was performed using an 8 or 6.4Fr rigid ureteroscope and a 5Fr stent. Two ml of lidocaine jelly were instilled. Stone migration occurred in 4% of the subjects in the lidocaine group and in 28% of those in the control group. Stone-free rates were 96% in the lidocaine group and 72% in the control group, which was statistically significant. The authors conclude that lidocaine is useful for preventing stone migration during ureteral lithotripsy and improves stone-free rates. The extent to which this is a mechanical effect of the jelly or an effect of lidocaine on ureteral motility was not addressed in this rather small study.

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Results of Long-Term Treatment With Finasteride on Prostate Volume 

In a long-term followup of the MTOPS (Medical Therapy of Prostatic Symptoms) trial Kaplan et al (page 1030) found that finasteride, either alone or combined with doxazosin, resulted in a consistent 25% reduction in prostate size compared to placebo over a full range of prostate sizes in men with lower urinary tract symptoms or benign prostatic hyperplasia. The authors suggest that this size independent effect explains a finding in the MTOPS trial in which the combination of doxazosin and finasteride reduced the risk of clinical progression of BPH in men with small to moderately sized prostates. Presumably this 25% reduction in prostate volume in finasteride treated patients vs placebo had an impact that contributed to the beneficial effect of combination therapy compared to doxazosin alone in these men.

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Von-Hippel Lindau Gene Status and Response to Targeted Therapy for Metastatic Clear Cell Renal Cell Carcinoma 

In this era of personalized medicine the ultimate goal is often to link genetic defects predisposing to evolving diseases such as malignancies to targeted therapies or prevention measures. In this regard Choueiri et al (page 860) examined the Von Hippel Lindau (VHL) gene status in 123 patients with metastatic clear cell renal cell carcinoma who received vascular endothelial growth factor (VEGF) therapy. Patients with VHL inactivation, which affects the VEGF pathways, had a response rate of 41% to a VEFG regimen vs 31% for patients with wild-type VHL. Patients with loss of function (LOF) mutations had a 52% response rate vs 31% for patients with wild-type VHL. In multivariate analysis the presence of a LOF mutation remained an independent prognostic indicator of improved response. However, progression-free survival and overall survival were not significantly different based on VHL status. To my knowledge this is the largest analysis to date investigating the impact of VHL gene status on outcomes after VEGF targeted therapy for renal cell carcinoma. The response of patients with VHL activation did not show a statistically significant increase. However, patients with LOF mutations appeared to have a somewhat greater response.

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Phase II Trial of Gemcitabine Plus Capecitabine for Metastatic Renal Cell Cancer 

Tannir and associates (page 867) from Dallas, Texas evaluated the clinical activity and safety of gemcitabine plus capecitabine in 83 patients with renal cell carcinoma previously treated with immunotherapy. Median progression-free survival and overall survival were 4.6 months (95% CI 3.7–7.3) and 17.9 months (95% CI, 13.2–23.6), respectively in patients with a poor risk prognosis. There was 1 complete response and 6 partial responses. On multivariate analysis more than 3 disease sites were significantly associated with shorter progression-free survival time, and patients with thrombocytosis, more than 3 disease sites or anemia had a significantly increased risk of death. Adverse events primarily included grade 3 neutropenia, which occurred in 83% of patients. At the doses and schedule tested gemcitabine plus capecitabine showed modest clinical activity after cytokine failure and produced significant neutropenia. A modified regimen may be of benefit in patients with renal carcinoma after failure of approved targeted therapies.

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The Role of Lymphovascular Invasion in Predicting the Prognosis of Upper Tract Urothelial Carcinoma 

Patients with upper tract urothelial carcinoma often have a poor prognosis. Previously it has been shown that tumor stage and grade are predictive of recurrence-free survival rate. Lin et al (page 879) from Taiwan, Province of China evaluated lymphovascular invasion as an additional factor in determining disease-free survival. In 106 patients treated surgically for clinically localized upper tract urothelial carcinoma the 5-year recurrence-free survival rate of those with lymphovascular invasion was 65.3% vs 91.9% of patients without lymphovascular invasion (p <0.001). Lymphovascular invasion status as well as pT3 stage and ureteral involvement were predictive of recurrence-free survival, and lymphovascular invasion was also predictive of higher stage. The authors conclude that lymphovascular invasion is a diagnostic indication of higher risk of recurrence, and postulate that lymphovascular invasion may help guard against chemotherapeutic regimens in patients with upper tract urothelial carcinoma.

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Validation of the Fournier's Gangrene Severity Index 

In general Fournier's gangrene is often associated with a high mortality rate but it is difficult to predict which specific patients will do poorly. Corcoran et al (page 944) from Pittsburgh, Pennsylvania and San Francisco, California developed a Fournier's Gangrene Severity Index which they applied to 68 patients. Their index score for survivors was 5.4 ± 3.5 compared to 10.9 ± 4.7 for nonsurvivors. Index and laboratory parameters associated with mortality included heart rate, respiratory rate, serum creatinine, serum bicarbonate, serum lactate and serum calcium. Total body surface area was only suggestive of an association, as was abdominal wall and lower extremity involvement. The Fournier's Gangrene Severity Index score threshold of 9 (sensitivity 71.4%, specificity 90%) was predictive of a 96% survival rate. However, the mortality rate for patients with a score of 9 or higher was 46%. This index may be useful for stratifying and targeting patients at higher risk for more aggressive management.

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The Presacral Space and Its Impact on Sacral Neuromodulator Implantation 

The InterStim® sacral neurostimulator has been used since 1997 for a variety of urinary dysfunctions and pelvic pain syndromes. Reported rare complications include injury to bowel and lead extrusion into the rectum. Although the implanters used fluoroscopy, the distance between the sacrum and bowel is variable. On 45 magnetic resonance images Saint Clair et al (page 988) from Portland, Oregon measured the distance between the sacrum and the first presenting abdominal organ which was 7.4 mm. This presacral space was larger than previously reported. It is clear from these measurements and from previous reports that it is entirely possible to inadvertently place an InterStim trocar needle through the presacral space and encounter bowel or other intra-abdominal organs. The authors suggest that multiplane fluoroscopy be used for all InterStim placements to avoid bowel injury. Preoperative bowel preparation could also decrease bowel distension but additional studies are needed to determine if this would be of clinical benefit.

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Assessment of Early Continence After Reconstruction of the Periprostatic Tissues 

Prospective randomized trials of robotic prostatectomy surgery are rare. Recent reports have suggested that reconstruction of the periprostatic tissues in patients undergoing computer assisted robotic prostatectomy improves continence rates or at least early return to continence based on retrospective analysis and case reports. Menon et al (page 1018) from Detroit, Michigan tested the hypothesis whether posterior and anterior reconstruction independently improved early continence. A 2-group randomized clinical trial was performed in 116 consecutive patients undergoing prostatectomy. There was no significant difference in early urinary continence with either the single or double urethrovesical fascial anastomosis technique. There was no improvement in continence rates with reconstruction of the posterior rhabdosphincter and puboprostatic collar. Overall continence rates were defined based on pads per day and pad weight at days 1, 2, 7 and 30 after catheter removal. Using the definition of 0 to 1 pad a day as continent, the 30-day continence rate for single vs double anastomosis was 74% vs 80%. Using no pads and no leakage as the definition, 47% and 42% of patients treated with single or double anastomosis were continent, respectively. These differences were not statistically significant. Interestingly, the continence rate for single anastomosis was slightly higher at 30 days using the more restrictive definition of continence.