Insight Urology

Comparative outcomes between adjuvant and salvage radiotherapy in prostate cancer after minimally invasive radical prostatectomy

Naphon Sriwachirawat — 2024-06-28

Objective: Radical prostatectomy (RP) is the standard treatment in clinically localized prostate cancer. However, the timing of postoperative radiotherapy (RT) in patients with adverse pathologic features or PSA persistence remains controversial. The objective of this study is to compare the survival outcomes and treatment complications between adjuvant radiotherapy (aRT) and salvage radiotherapy (sRT) in patients after minimally invasive RP.

Materials and Methods: This retrospective study reviewed the clinical data in patients who underwent minimally invasive RP in our institution between January 2012 and April 2021. The patients were divided into three groups: no RT, aRT, and sRT. Patient demographic data, pathological reports, RTOG/EORTC toxicity scores, functional outcomes, and survival outcomes were compared between aRT and sRT groups.

Results: A total of 487 patients were included in the study. One-hundred and thirty-three patients (27.3%) received postoperative RT. The pathological stage and positive margin rate were significantly higher in the aRT group. Five-year ADT-free survival (78.8% vs 80%, p = 0.68), 5-year metastasis-free survival (80.2% vs 92.2%, p = 0.38), and 5-year overall survival (97.1% vs 100%, p = 0.68) were no different between groups. There were no significant differences in continence, potency, genitourinary or gastrointestinal toxicities between groups.

Conclusions: Timing of postoperative RT does not affect survival. Functional outcomes and radiation toxicity were comparable between patients undergoing aRT and sRT.

Effect of implementation of Enhanced Recovery After Surgery Protocol on elective open simple nephrectomy in urolithiasis

Krit Santanapipatkul — 2024-06-28

Objective: To assess the impact of the implementation of an Enhanced Recovery After Surgery (ERAS) protocol in elective open simple nephrectomy in urolithiasis patients.

Materials and Methods: Data from 43 patients were collated. Sixteen were in the ERAS group and 27 in the pre-ERAS group, the division created by date of the procedure. The ERAS protocol included preoperative education, standardized perioperative care, early mobilization, and postoperative pain management. Outcomes, including length of hospital stay (LOS), first flatus, first defecation, complications, pain scores, creatinine level (Cr), glomerular filtration rate (GFR) and associated costs, were compared.

Results: The ERAS group exhibited significantly lower total LOS (3.19±0.40 days vs. 6.22±1.55 days, p < 0.001), earlier first flatus (1.19±0.40 days vs. 2.66±1.11 days, p < 0.001), first defecation (1.56±0.73 days vs. 3.11±1.28 days, p < 0.001), and lower postoperative ileus rates (12.5% vs. 71.43%, p = 0.01) than the control group. Lower pain scores at 1, 6, 24, and 48 hours post-surgery (p < 0.05) were also recorded in comparison to the control group. No significant differences in Cr and GFR were observed (p > 0.05). Although ERAS treatment costs were marginally lower, the difference was not statistically significant (23,833±3731.48 Baht vs. 23,930±3068.45 Baht, p = 0.927).

Conclusion: ERAS implementation in elective open simple nephrectomy for urolithiasis reduces LOS, and postoperative pain, accelerates recovery of bowel function, and allows quicker resumption of normal activities. These benefits come without increased risk of readmission or complications, and without compromising postoperative renal function. All these advantages may also result in cost savings.

Diagnostic properties of percent-free PSA as a predictor of prostate cancer in Thai men with total serum PSA level of 4-10 ng/ml

Thanabordee Phongthanyawiriya — 2024-06-28

Objective: The percent-free prostate specific antigen (%fPSA) could enhance total PSA (tPSA) with regards to early prostate cancer detection by increasing its specificity. However, due to significant physiologic differences across races, the optimal cut-off level for %fPSA may vary. We aimed to determine optimal %fPSA cut-off level for Thai men aged between 50 to 80 years whose tPSA score ranged from 4-10 ng/mL and to evaluate its corresponding diagnostic properties, specifically sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The secondary endpoint is the relationship between Gleason Grade Group and %fPSA value.

Materials and Methods: A total of 184 male patients from age 50-80 years whose tPSA was between 4-10 ng/ml were enrolled onto the study. Their %fPSA were measured before undergoing transrectal ultrasonography (TRUS) guided prostate biopsy, which procured at least 10 cores. All histologic reports were reviewed and confirmed for further analysis.

Results: Out of the 184 patients registered the final diagnoses were 31 (16.84%) were positive for prostate cancer and the other 153 (83.16%) had benign prostate hypertrophy (BPH). At %fPSA cut-off of ≤ 10%, the sensitivity would be 22.6%, specificity 95.4%, PPV 50.0% and NPV 85.9%. However, at a %fPSA cut-off of ≤ 20%, the sensitivity was 77.4%, specificity 32.7%, PPV 18.9%, and NPV 87.7%. The %fPSA value has a direct relationship with sensitivity and NPV whereas it is inversely proportional to specificity and PPV. Lower %fPSA is associated with higher risk of prostate cancer. The area under the curve (AUC) of ROC curve was 0.65. The incidence of prostate cancer among patients with Gleason Grade Groups 1, 2, 3, 4, and 5 were 41.94%, 32.26%, 16.13%, 6.45%, and 3.23% respectively. The mean %fPSA scores among those groups were 14.75%, 17.64%, 10.19% ,13.33%, and 15.65% respectively.

Conclusion: The decision to undergo prostate biopsy in Thai males with a tPSA score between 4-10 ng/ml can be guided by %fPSA, which proved to be an effective and useful predictive tool. The cut-off level of %fPSA ≤ 20% had the highest diagnostic properties in Thai men in our study which yielded a sensitivity of 77.4%, specificity of 32.7%, PPV of 18.9%, and NPV 87.7%. If %fPSA was ≥ 30%, there was no risk of prostate cancer in this cohort. In addition, with regard to disease severity, we found that %fPSA level is not associated with the Gleason Grade Grouping.

Evaluation of therapeutic outcomes in emphysematous pyelonephritis: a single-center experience at Siriraj Hospital

Kitipat Wijarn — 2024-06-28

Objective: Emphysematous pyelonephritis (EPN) is an acute, severe, necrotizing parenchymal and perirenal infection associated with high morbidity and mortality. The radiographic classifications, which determine the treatment strategies, however, remain controversial. Our study aimed to evaluate and compare the clinical parameters related to nephrectomy and the treatment outcomes in current practices.

Materials and Methods: We retrospectively reviewed the data from 21 EPN patients who had been diagnosed using computed tomography (CT) scans, who were admitted to Siriraj Hospital from January 2009 to December 2019. The clinical manifestations, imaging results, laboratory findings, treatment methods, and overall outcomes of each patient were reviewed and analyzed. Huang–Tseng’s and Wan’s classifications were used to classify the images obtained from the CT scans.

Results: Among the 21 patients with EPN, all had at least one comorbidity associated with a compromised immune response. Common manifestations included fever (74%) and initial laboratory findings showed hyperglycemia (66%), acute kidney injury (72%), and metabolic acidosis (76%). Inotropes were used in 13 patients for hemodynamic support. Eleven patients were treated with a non-nephrectomy approach, while 10 patients underwent nephrectomy. No statistical difference in treatment outcomes was observed between groups in both classification systems. Overall survival was 100% with a minimum one-year follow-up.

Conclusion: Our study demonstrated that the current treatment approach has resulted in a zero mortality rate of EPN most probably due to advancements in antibiotics, surgical techniques, and postoperative intensive care over the years. However, refining treatment strategies, considering radiographic criteria, clinical parameters, and initial treatment response, is essential in future studies to further decrease disease morbidity.

The impact of musical intervention on pain and anxiety levels during percutaneous nephrostomy tube replacement: a randomized controlled trial

Krit Santanapipatkul — 2024-06-28

Objective: Percutaneous nephrostomy tube replacement (PNTR) is a significant and frequently performed outpatient urological procedure. Patients undergoing this procedure often experience pain and anxiety. Various non-pharmacological methods are currently utilized to alleviate pain and anxiety. The objective of this study is to investigate the effects of music on pain and anxiety during PNTR .

Materials and Methods: A prospective randomized controlled trial was conducted in patients undergoing PNTR at Loei Hospital from May 1, 2023, to September 30, 2023. A total of 104 patients were randomly assigned to two groups: group 1, where patients did not listen to music during the procedure, and group 2, where patients listened to their preferred choice of music. Demographic data, vital signs, Visual Analog Scale (VAS) pain levels, State-Trait Anxiety Inventory-State Anxiety (STAI-SA), and willingness to repeat procedures were compared.

Results: The VAS pain scores in the music group were significantly lower than in the non-music group during and after PNTR (2.5 vs 5, p < 0.005 and 0 vs 3, p < 0.001, respectively). Moreover, the STAI-SA levels in the music group were significantly lower post-procedure (32.98±5.61 vs 39.98±6.18, p < 0.001), and the willingness to repeat the procedure was significantly higher (41 vs 22, p < 0.001).

Conclusion: The results of this study indicate that listening to a preferred choice of music during PNTR has the potential to reduce pain, and anxiety, and increase the willingness of patients to repeat procedure. The intervention of music serves as a cost-effective, safe, and side effect-free non-pharmacological approach to facilitate patient outcome in PNTR.

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Phitsanu Mahawong — 2024-06-28

Cardiovascular risk and urolithiasis: underestimated or unknown relationship?

Valentina Melo Pedroza — 2024-06-28

Objective: Urolithiasis, a multifactorial disease, is increasingly recognized for its association with cardiovascular disease (CVD), a leading global cause of morbidity and mortality. Despite the establishment of links between urolithiasis and CVD risk factors such as diabetes, obesity, and hypertension, this relationship remains underexplored. This study aims to characterize the trend of information regarding cardiovascular risk and urolithiasis through comprehensive bibliometric analysis, highlighting the importance of investigating this association further.

Materials and Methods: We searched publications between 2002 and 2022 on the Web of Science (WOS) database, filtered by exclusion criteria. Impact factor (IF) 2021 and Journal Citation Reports (JCR) were evaluated and analyzed by mapping using VOSviewer.

Results: We obtained 63 articles from 49 journals over the last two decades, identifying an increase in publications in the last two years without a rising annual trend. Gambaro G is the author of most citations (12,317), underscoring the extent of the global and interdisciplinary effort in understanding the cardiovascular implications of urolithiasis. Our findings highlight the varied impact of journals, with IFs ranging from 1 to 10.6, and point to a significant yet overlooked global research interest in the intersection between urolithiasis and cardiovascular risk. The USA was the country with the most publications (20.6%) followed by Taiwan (12.6%) and Spain (9.5%). Despite the observed increase, the rate of publications especially in high-impact journals remains low, particularly in Latin America, indicating a need for heightened research efforts in this important field.

Conclusion: This bibliometric analysis underscores a growing yet insufficient global scholarly interest in the relationship between urolithiasis and cardiovascular risk. Despite some high-impact publications, the overall scarcity points to a need for increased research efforts, particularly in underrepresented regions such as Latin America. The study calls for a broader interdisciplinary collaboration to further understand and address the cardiovascular implications of urolithiasis, aiming to improve patient care and outcomes in this significant public health intersection.

Transforming urology: exploring the innovations and utilizations of robotic systems

Tanan Bejrananda — 2024-06-28

Robot-assisted surgery represents the pinnacle of minimally invasive surgical techniques, surpassing laparoscopic surgery in its efficacy. This study aimed to evaluate the current status of robotic surgery in urological practice, examining its advantages and disadvantages. A literature review was conducted using PUBMED and the pertinent articles in the field of urology selected. Various single-port and multiport robotic platforms, such as Da Vinci, Versius, Hugo RAS, Revo-I, Senhance, Mantra, Avatera, hinotori, and MicroSurge, are discussed along with their respective pros and cons. Details of the 4 robotic platforms used in our centers are also included. With an influx of diverse medical surgical robots entering the market and a competitive drive to establish the next standard of care in robotic surgery, it is inevitable that robotic surgery will soon become economically comparable to laparoscopic procedures.

Editorial Board

Phitsanu Mahawong — 2024-06-28

Editorial

Phitsanu Mahawong — 2024-06-28

Instructions for Authors

Phitsanu Mahawong — 2024-06-28

An intravesical ureterocele with a large impact stone: a case report

Pises Insuan — 2024-06-28

Ureteroceles may be asymptomatic, or they may produce a wide range of clinical signs and symptoms. Stasis of urine in the dilated distal segment leads to recurrent urinary tract infection and stone formation. This case study concerns 51-year-old women presenting with intermittent left flank and left lower quadrant pain for 6 months from an intravesical ureterocele with a large impact stone. A diagnosis was based on ultrasonography, CT scan and cystoscopic examination. Transurethral incision left ureterocele, then cystolitholapaxy using 26 Fr Resectoscope and hook electrode with U-shaped incision and stone fragmentation with a stone punch. The procedures were performed with successful resolution of symptoms. Voiding cystourethrogram; VCUG at 10 weeks later after surgery showed none of vesicoureteral reflux; VUR.

Insight Urology

Comparative outcomes between adjuvant and salvage radiotherapy in prostate cancer after minimally invasive radical prostatectomy

Effect of implementation of Enhanced Recovery After Surgery Protocol on elective open simple nephrectomy in urolithiasis

Diagnostic properties of percent-free PSA as a predictor of prostate cancer in Thai men with total serum PSA level of 4-10 ng/ml

Evaluation of therapeutic outcomes in emphysematous pyelonephritis: a single-center experience at Siriraj Hospital

The impact of musical intervention on pain and anxiety levels during percutaneous nephrostomy tube replacement: a randomized controlled trial

Cover

Cardiovascular risk and urolithiasis: underestimated or unknown relationship?

Transforming urology: exploring the innovations and utilizations of robotic systems

Editorial Board

Editorial

Contents

Instructions for Authors

An intravesical ureterocele with a large impact stone: a case report