This Month in Adult Urology

Article Outline

• Inadequacy of Urinary Dipstick and Microscopy as Markers of Urinary Tract Infection
• Central Nervous System Findings Before and After Anticholinergic Medication
• Urethroplasty With Abdominal Skin Grafts for Long Segment Urethral Strictures
• Reporting of Harm in Randomized Controlled Trials Published in the Urological Literature
• Prostate Cancer Screening in Men 75 Years Old or Older
• Impact of Previous Radiotherapy for Prostate Cancer on Clinical Outcomes of Bladder Cancer
• Medical Malpractice Claims Risk in Urology
• Copyright

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Inadequacy of Urinary Dipstick and Microscopy as Markers of Urinary Tract Infection 

Most urinary tract infections are diagnosed based on urinalysis. Khasriya et al (page 1843) from London, United Kingdom investigated limitations of the dipstick urinalysis to adequately screen patients who have no urinary tract infection symptoms, eg those with dysuria. The authors performed a blinded study of a cohort of urological outpatients with painless lower urinary tract symptoms (LUTS). Midstream urine cultures and catheter urine samples were compared with leukocyte esterase, nitrite dipstick and urine microscopy. For cases with a midstream urine culture of 10⁵ colony forming units, sensitivity and specificity, respectively, were 56% and 66% for leukocyte esterase, 10% and 99% for nitrite, and 56% and 72% for microscopy. For cases with a catheter urine culture of 10⁵ cfu, sensitivity and specificity, respectively, were 59% and 84% for leukocyte esterase, 20% and 97% for nitrite, and 66% and 73% for microscopy. Despite common practice, the authors warn that urinalysis in patients with LUTS but without dysuria may not detect infections, and suggest a ratio of 10² cfu/ml in those patients as this threshold did have a higher yield. Routine analysis relies on nitrite generation which assumes dominant pathogenicity from the Enterobacteriaceae. However, recent shifts in sensitivities raise questions about the sensitivity of nitrite positive urinalysis. Thus in patients with LUTS a urine culture may be warranted even with a nitrite negative urinalysis.

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Central Nervous System Findings Before and After Anticholinergic Medication 

Investigators have been searching for diagnostic imaging that correlates with treatment efficacy of such conditions as urge incontinence and overactive bladder. Pontari et al (page 1899) from Philadelphia, Pennsylvania randomized 20 patients with urinary frequency to 4 weeks of tolterodine or placebo. Functional magnetic resonance imaging based on blood oxygenation dependent imaging of the brain was performed before and after treatment. In each patient the bladder was filled by urethral catheter and emptied 5 times. Activation and deactivation in areas of the brain with filling were compared to the empty state. After treatment with tolterodine 2 areas of the parietal cortex showed greater activity compared to placebo. Whereas 2 areas of the cerebellum showed greater activation in the placebo group, those same areas showed deactivation in the tolterodine group. Thus patients treated with an anticholinergic or placebo appear to activate and deactivate different areas of the brain. Whether these findings correlate with efficacy remains to be determined.

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Urethroplasty With Abdominal Skin Grafts for Long Segment Urethral Strictures 

Grafts for long urethral strictures often require nonbuccal sources, especially in patients with a history of buccal harvest. Meeks et al (page 1880) from Chicago, Illinois used full thickness abdominal wall skin for urethroplasty in 21 men with strictures averaging 11 cm long. Grafts were placed as a ventral onlay in the pendulous urethra and either ventrally or dorsally for augmented anastomotic repairs. Mean followup was 28 months. Stricture recurrence rates were 19% overall, 29% in patients with an abdominal skin graft used as a ventral onlay, only 12.5% in those treated with a staged procedure and 25% in patients who underwent an augmented anastomotic repair. Based on these findings, the authors recommend selective use of full thickness abdominal skin limited to staged procedures. They postulate that the higher failure rate seen with a single stage procedure is due to failure of the graft to take because of impaired vascularity.

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Reporting of Harm in Randomized Controlled Trials Published in the Urological Literature 

Breau et al (page 1693) performed a multi-institutional investigation of the prevalence and completeness of analysis of potential benefits vs adverse events in health care interventions. Source material was obtained from randomized controlled trials reported in a systematic literature search of The Journal of Urology®, Urology®, European Urology and BJU International from 1996 and 2004. A total of 152 randomized controlled trials were scrutinized, of which 72% reported at least 1 harm outcome. In these studies few specified which adverse events were evaluated (14%), how the harm information was collected or how the harm was attributed to the interventions (3%). The authors conclude that the trials analyzed contained significant deficiencies in adverse event reporting, and suggest the need for standardized reporting requirements for harm in urological journals.

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Prostate Cancer Screening in Men 75 Years Old or Older 

The US Preventative Services Task Force guidelines recommend against screening men older than 75 years for prostate cancer regardless of life expectancy. Hoffman et al (page 1798) from Houston, Texas and Boston, Massachusetts postulate that before these 2008 guidelines physicians were appropriately using health status and life expectancy to tailor prostate specific antigen (PSA) screening for older men in the United States. They examined the records of 718 men 75 years old or older diagnosed with prostate cancer in 2005. Overall, 19% of the men were older than 85 years and 27% reported fair or poor health. In the previous 2 years 52% of the men had undergone a PSA screening test. Of those reporting recent PSA screening only 42% were expected to live longer than 10 years. The authors also reported that many men expected to live only 5 years had undergone PSA screening. The strict recent cutoff at age 75 years reduces unnecessary screening and yet prevents healthy older men with a life expectancy of greater than 10 years from the benefits of screening.

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Impact of Previous Radiotherapy for Prostate Cancer on Clinical Outcomes of Bladder Cancer 

An increased incidence of higher grade and stage of bladder cancer has been noted in patients who received radiotherapy for prostate cancer compared to those who did not undergo radiation. Yee et al (page 1751) from New York, New York update their cohort series to review the pathological features and survival outcomes of 144 patients with bladder cancer diagnosed between January 1992 and June 2007 who had a previous prostate cancer diagnosis. Median time between prostate and bladder cancer diagnoses was longer in irradiated than nonirradiated patients (59 vs 24 months, respectively). As predicted, irradiated vs nonirradiated patients presented with higher grade tumor (92% vs 77%), had higher stage disease progression (muscle invasive 70% vs 43%) and had a higher rate of nonorgan confined disease. Future studies are needed to determine if causality is associated with radiation rather than biological differences.

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Medical Malpractice Claims Risk in Urology 

It seems intuitive that physicians whose patients complain are more likely to be sued. Stimson et al (page 1971) from Nashville, Tennessee evaluated 1,516 unsolicited complaints against 268 urologists categorized by subspecialty. Overall 47% of urologists (125) had 0 complaints and 11% (30 urologists) of the cohort were associated with 50% of the complaints. Calculi and oncology subspecialists were at greater risk for patient complaints. Monitoring patient complaints may allow for early identification and intervention with high risk urologists before malpractice claims accumulate.