Urological Clinical Practice Research Articles

Evidence-based medicine in urology

“Evidence-based medicine” refers to a set of principles and methods to ensure that, to the greatest extent possible, individual decisions and population-based policies are consistent with the evidence of their eVectiveness and beneWt [1]. The term that was coined less than 20 years ago by Gordon Guyatt at McMaster University has grown from a Xedging concept to the fundamental basis of clinical practice that reaches into all aspects of medical practice [2]. The importance of evidence-based medicine and evidence-based clinical practice is highlighted by the fact that statements encouraging adherence to these principles are included in the landmark health care reform legislation enacted in the United States in 2010 and is guiding health care policy in countries such as the United Kingdom. With increasing recognition that greater adherence to evidencebased practice can improve quality of care and reduce costs, it is critically important that all practitioners in urology understand the underpinnings of the concepts of evidencebased medicine as well as its applicability and limitations. This issue of the World Journal of Urology pays tribute to the remarkable and growing impact that evidence-based medicine has had on the practice of urology. It includes eleven articles written by recognized experts in the Weld that provide in-depth analyses of the inXuence of evidencebased medicine on key areas of clinical practice, education, publishing, health policy, and clinical research. Lavallee et al. explore the current and future role of randomized controlled trials—recognized as leading the “hierarchy of evidence” as the best original study design to provide high quality evidence for questions of therapeutic eVectiveness—in guiding the clinical practice of urology. It is followed by studies by Porten et al. and Yu et al. that provide similar analyses of the roles of observational study designs/registries and health services research, respectively, in addressing the most important evidence gaps in urology. The following two articles by Wang et al. and Shelton et al. put these Wndings into perspective by discussing the growing importance of comparative eVectiveness research as well as their implications for health policy decision-making. Recognizing the critical role of clinical practice guidelines to guide evidence-based clinical practice, MacLennan et al. discuss the value of clinical pathways as a guide to their development; an approach that is being promoted by the European Association of Urology and The British Association of Urological Surgeons guideline developer groups. Wolf et al. analyze the considerable eVorts of the American Urological Association (AUA) as an example of how rigorous methodology can feasibly be applied to the development of evidence-based recommendations. A review by CanWeld et al. then discusses the GRADE approach for rating the quality of evidence and strengths of recommendations. It provides a transparent and methodologically rigorous framework for developing clinical practice guidelines that has been adopted by over Wfty professional organizations all over the globe (http://www.gradeworkinggroup.org). GRADE holds the promise of becoming the unifying methodological framework for guideline developers, which would allow enhanced collaboration and improved resource utilization for professional urological organizations. P. Dahm (&) Department of Urology, College of Medicine, Health Science Center, University of Florida, Box 100247, Room N-203, Gainesville, FL 32610-0247, USA e-mail: p.dahm@urology.ufl.edu

How to critically appraise a clinical practice guideline

Purpose:Clinical practice guidelines play a critical role in guiding the evidence-based clinical practice of urology. We describe a systematic approach to critical appraisal of urology guidelines.Materials and Methods:Based on a focused clinical question derived from a clinical scenario, we identified a relevant clinical practice guideline that we critically appraised using the Users’ Guide to the Medical Literature framework as to whether the results are valid, what are the results, and can they be applied to the care of an individual patient.Results:A clinical practice guideline by the National Institute for Clinical Excellence on the use of sunitinib as the first line treatment for patients with metastatic renal cell carcinoma was identified. The guideline development process was found to be appropriately rigorous and included an explicit rating of the quality of evidence. The recommendations were clearly stated and appeared applicable to the specific patient in the clinical scenario.Conclusions:Clinical practice guidelines should be developed using rigorous evidence-based methodology. Urologists should have the skills and knowledge to critically appraise a guideline before applying it to the care of their patients.

Critical Appraisal of Prostate-specific Antigen in Prostate Cancer Screening: 20 Years Later

Prostate-specific antigen (PSA) is secreted by all types of prostate epithelial cells and has been used for 2 decades as a biologic marker for prostate cancer (PCa). Since the implementation of PSA screening in the United States, the detection of PCa has increased, accompanied by a decrease in the incidence of high-grade cancer and PCa-specific mortality rates. It has been suggested that these decreases have resulted from the enhanced detection of PCa while still curable. These data have been the impetus for early detection programs, which have recommended the initiation of screening as early as 40 years of age. Despite widespread use, PSA screening remains controversial, principally because of the lack of evidence from randomized controlled trials demonstrating a mortality benefit that could outweigh the concerns of the costs of overdiagnosis and overtreatment. Two ongoing, randomized controlled trials are examining whether screening reduces the risk of PCa-related mortality, and the results of these studies are expected soon. Although it has its limitations, PSA still remains the best-studied marker for the detection of PCa.

Cystic Lesions of the Prostate Gland: An Ultrasound Classification With Pathological Correlation

Cysts of prostate tissue are common. Most cases are diagnosed accidently during ultrasound but they sometimes have clinical relevance when related to lower urinary tract symptoms, infertility or the expression of neoplastic disorders. Clinical relevance is linked to the differential diagnosis of the different types of cysts. We provide an updated classification of prostate cyst disorders and indicate how these disorders appear on transrectal ultrasound based on our experience and a literature review. We retrospectively analyzed the ultrasound database and surgical specimen archives. We performed a MEDLINE(R) search of the peer reviewed literature on the diagnosis and classification of prostate cysts. Cysts of the prostate gland can be classified into 6 categories, including 1) isolated medial cysts, 2) cysts of the ejaculatory duct, 3) simple or multiple cysts of the parenchyma, 4) complicated infectious or hemorrhagic cysts, 5) cystic tumors and 6) cysts secondary to parasitic disease. Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors, such as inflammatory disease, benign prostatic hyperplasia, ejaculatory duct obstruction and cancer. The differential diagnosis and diagnostic criteria are shown for each category. A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated. This is the initial step toward a more detailed classification and the basis for further pathological studies. This comprehensive classification could be a useful tool in urological and andrological clinical practice, and for research purposes.

How to Use a Clinical Practice Guideline

Leading organizations increasingly recognize clinical practice guidelines as an important approach in promoting an evidence-based clinical practice of urology. In light of their considerable clinical, economic and medicolegal impact, guideline users should be confident that the guidelines were rigorously developed and address relevant patient questions. In this article we outline a practical approach for critically appraising a clinical practice guideline. We outline a 3-step approach to the assessment of a clinical practice guideline that answers the questions of whether the recommendations are valid, what the recommendations are and whether they will help in the treatment of an individual patient. To determine the adequacy of a clinical practice guideline, urologists should carefully review the rigor of the development process and its content. Important questions that relate to the validity of a guideline are whether, for specific questions, all important management options and outcomes were considered, and whether there was an explicit and sensible process to identify, select and combine all relevant evidence. Clinical practice guidelines should formally grade the quality of the available evidence for a given clinical question and outline a formal process of how the recommendations were derived. Value judgments made in the guideline development process about the relative importance of the potential benefits and harms of a given health care intervention should be made transparent to the reader. The recommendations made should be practical and should address important clinical issues. Furthermore, their strength should be graded to reflect the underlying uncertainty about the evidence and the values applied in the guideline development process. The systematic approach presented in this article will allow urologists to critically appraise clinical practice guidelines. Determining the validity of the recommendations, understanding the recommendations and assessing their applicability to patients are 3 fundamental steps toward an evidence-based approach to using clinical practice guidelines.

Molecular markers in prostate cancer. Part I: predicting lethality

Assessing the lethality of 'early,' potentially organ-confined prostate cancer (PCa) is one of the central controversies in modern-day urological clinical practice. Such cases are often considered for radical 'curative' treatment, although active surveillance may be equally appropriate for many men. Moreover, the balance between judicious intervention and overtreatment can be difficult to judge. The patient's age, comorbidities, family history and philosophy of self-health care can be weighed against clinical features such as the palpability of disease, the number and percentage of biopsy cores involved with the disease, histological grade, presenting prostate-specific antigen (PSA) and possible previous PSA kinetics. For many years, scientists and physicians have sought additional molecular factors that may be predictive for disease stage, progression and lethality. Usually, claims for a 'new' unique marker fall short of true clinical value. More often than not, such molecular markers are useful only in multivariate models. This review summarizes relevant molecular markers and models reported up to and including 2008.

Barriers to the Practice of Evidence-Based Urology

We investigated urologist perceptions of barriers to implementing evidence-based medicine in clinical practice. In April 2005 an Internet survey was conducted to assess American Urological Association member attitudes toward evidence-based medicine. This analysis presents the responses to an open-ended question about perceived barriers to implementing evidence-based clinical practice in urology. Two raters developed a coding scheme with 5 main categories of evidence concerns, system level factors, physician factors, patient factors and other barriers. Each rater independently assigned a category to each response. Discrepancies were resolved by consensus. A total of 365 participants (72%) responded to the open-ended question, each providing up to 4 codable responses. Of the group 53% cited concerns about the evidence including the lack thereof, low quality, limited applicability and biased presentation. In addition, 37% reported system level factors such as issues of reimbursement, fear of litigation, problems with implementation, interference/bias by third parties, and expectations and attitudes of other providers as important issues. Physician factors and patient factors were further cited by 28% and 9%, respectively. In terms of the legitimacy of evidence-based medicine 9% expressed skepticism whereas 5% of respondents indicated that they saw no barriers to implementing evidence-based medicine in urology. Efforts to promote evidence-based medicine in urology should focus not only on the generation of high quality clinical research but also on its unbiased reporting and timely dissemination. Concerted efforts should be made to reduce system level factors that hinder the implementation of evidence-based care.

The Usefulness of the Detection of GSTP1 Methylation in Urine as a Biomarker in the Diagnosis of Prostate Cancer

Prostate cancer has a unique set of problems associated with its early detection and diagnosis that might be aided by the addition of molecular markers, such as DNA hypermethylation. DNA methylation is an important epigenetic mechanism of gene regulation that has a critical role in normal developmental processes. Aberrant DNA methylation is a hallmark of carcinogenesis and GSTP1 hypermethylation is the most common molecular alteration in human prostate cancer. To our knowledge the clinical usefulness of the detection of gene methylation is yet to be established. We evaluated GSTP1 hypermethylation in urine collected after prostatic massage and in core needle biopsies from 100 men referred for diagnostic biopsy. Methylation of GSTP1 in urine specimens had 75% sensitivity and 98% specificity for prostate cancer. GSTP1 methylation in the biopsy had 88% specificity and 91% sensitivity. Interestingly we observed a higher frequency of GSTP1 methylation in the urine of men with stage III vs II disease (100% vs 20%, p = 0.05). This study suggests that the detection of GSTP1 methylation in prediagnostic urine may improve the specificity of PSA and help distinguish men with prostate cancer from those with benign prostatic hyperplasia. This finding should be further explored in a larger, prospective screening trial.

Autoaumento vesical por laparoscopia. Modelo experimental en conejos (oryctolagus cuniculus)

IntroductionSmall contracted bladder remains a challenge in clinical urological practice and treatment options are not always effective. Urothelium sparing surgical techniques represent a reasonable therapeutical option. We aimed to evaluate the feasibility of a rabbit model (Oryctolagus cuniculus) in the teaching and training setting for laparoscopic vesical autoaugmentation MethodsTransperitoneal laparoscopic bladder autoaugmentation was performed in five New Zealand male rabbits (Oryctolagus cuniculus). A three port technique was used for all cases. Circumferential detrusorectomy was performed with vascular pedicles sparing, subsequently submucosal detailed blunt dissection allowed the creation of a bladder diverticulum which was verified intraoperatively. Eye-ball cystometry was performed preoperatively and postoperatively to verify bladder capacity variations. Postoperatively cystometry was done immediately after the procedure and 7 and 15 days postoperatively. Statistical analysis was performed with T-student model. A p-value < 0.05 was considered of significance for the analysis. Surgical procedure and perioperative animal care was minutely precised according to the Guidelines of the Institute of Laboratory Animal Resources, Commission on Life Sciences, National Research Council ResultsFive New Zealand male rabbits (Oryctolagus cuniculus) were surgically treated as described. Median operative time was 68.8 minutes (range 44 -120). Median preoperatory bladder capacity for the series was 25.8 cc (7-52). Median postoperative bladder capacity was diminished in 33% immediately after the operation. Then, bladder capacity augmented 72% and 52% for 7th and 15th postoperative days, respectively. Percentage variation in bladder capacity is statistically significant. Two operative complications (mucosal tear) were reported. A postoperatory abscess was observed in one animal ConclusionsThe rabbit (Oryctolagus cuniculus) model for the laparoscopic bladder autoaugmentation is feasible for teaching, training and research. Bigger series and longer follow-up should be addressed

Interleukin-6/10 Ratio as a Prognostic Marker of Recurrence in Patients With Intermediate Risk Urothelial Bladder Carcinoma

Several potential markers have been investigated to improve the noninvasive diagnosis of recurrent superficial bladder carcinoma. We evaluated the role of the interleukin-6/10 ratio as a prognostic marker of recurrence in patients with intermediate risk superficial bladder carcinoma. A total of 65 consecutive urological patients seen in the office, including 41 with intermediate risk superficial bladder carcinoma and 24 controls, were selected for this prospective study. Five urine samples for urinary cytology and interleukin analyses were collected from each subject at baseline, and 3, 6, 9 and 12 months after surgery, respectively. Interleukin-6 and 10 were determined in urine by the Quantikine solid phase interleukin-6 and 10 enzyme-linked immunosorbent assay, respectively. Sensitivity, specificity, and positive and negative predictive values of the method were calculated. At baseline sample collection the interleukin-6/10 ratio was not statistically different between patients and controls (p = 0.58). Interleukin-6/10 was statistically different between patients with vs without recurrence 3 (0.009 vs 0.408), 6 (0.011 vs 0.268), 9 (0.012 vs 0.288) and 12 months (0.009 vs 0.302) after pre-transurethral bladder tumor resection (each p <0.001). Multivariate analysis indicated that interleukin-6/10 was an independent prognostic factor of recurrence (HR 3.62, 95% CI 2.80-4.92, p <0.001). Test sensitivity and specificity were 0.83% (95% CI 0.57-0.95) and 0.76% (95% CI 0.45-0.93), respectively. The current study highlights the feasible role of the interleukin-6/10 ratio for predicting intermediate risk superficial bladder carcinoma recurrence. However, clinical trials with a greater number of patients are needed to consider its use in clinical urological practice.

Loss of P16 Expression and Chromosome 9p21 LOH in Predicting Outcome of Patients Affected by Superficial Bladder Cancer

To evaluate the prognostic role of p16 expression and loss of heterozygosity (LOH) on chromosome 9p21 in patients affected by low-grade (G1-G2) urothelial bladder cancer. Fifty-six consecutive patients with diagnosis of urothelial bladder cancer were enrolled in this prospective study. LOH analysis was performed on a blood/tumor pair sample of each patient, by using polymerase chain reaction analysis. The D9S171 (9p21) locus on chromosome 9 was investigated. All tumors were stained immunohistochemically for p16. Data from p16 and LOH analyses were compared with follow-up data to evaluate the prognostic role of these molecular markers. Loss of p16 expression was found in 33 patients (58.9%) and was significantly associated with the reduced recurrence-free probability (P < 0.0001). No correlations were reported with stage (P = 0.162) or grade (P = 0.051). Forty-three patients (76.7%) showed LOH on chromosome 9p21 (D9S171). A significant association was observed between loss of p16 expression and LOH on chromosome 9p21 (P = 0.005). The Kaplan-Meier curves showed a significant correlation between recurrence-free status and p16 expression (P = 0.0001). By multivariate analysis, p16 expression (P = 0.002) and number of lesions (P = 0.002) were identified as independent tumor recurrence factors. Our study highlights the prognostic role of p16 in predicting the recurrence-free probability in patients affected by low-grade urothelial bladder and highlights the fact that this method could be used in everyday urologic clinical practice to better characterize the natural history of urothelial bladder carcinomas.

Local Anesthesia During Transrectal Ultrasonography-guided Prostate Biopsy: does it have any Effect on Sexual Function?

TRUS (Trans Rectal Ultra Sonographic)-guided biopsy of the prostate is the procedure of choice for prostate cancer diagnosis in urological clinical practice. TRUS-guided biopsies are associated with pain and anxiety and may interfere with sexual function and potency. The aim of this study was to evaluate whether local anesthesia during TRUS-guided prostate biopsies has any effect on the sexual behavior of patients and to compare the periprostatic infiltration with lidocaine to simple sonographic gel application in a randomized prospective trial. A total of 62 consecutive patients were included in the study randomized in two groups; Group A (n = 30, control group) and Group B (n = 32, lidocaine infiltration group). Interviews regarding their sexual status were conducted at the time they were informed of the need for biopsy, at the time of biopsy and at two scheduled interviews following the biopsy. Similar results of sexual dysfunction were observed between the two groups. About 6% of patients experienced some degree of dysfunction in anticipation of biopsy (P > 0.02 between the two groups) that was resolved by the end of the follow-up period. In total, only one Group B patient continued to show sexual dysfunction at the time of the last interview compared to two patients in Group A. Local infiltration with lidocaine does not seem to play a role in sexual dysfunction following prostate biopsies. Psychological factors influence patients and the urologist should be ready to inform and reassure both the patient and his family.

Primer: using decision analysis to improve clinical decision making in urology

Many clinical decisions in urology involve uncertainty about the course of disease or the effectiveness of treatment. Many decisions also involve trade-offs; for example, an improvement in patient survival at the cost of an increased risk of treatment-related adverse effects. Decision analysis is a formal, quantitative method for systematically comparing the benefits and harms of alternative clinical strategies under circumstances of uncertainty. The basic steps in performing a decision analysis are to define the clinical scenario or problem, identify the clinical strategies to be considered in the decision, enumerate all of the important sequelae of each strategy and their associated probabilities, define the outcome of interest, and assign a value to each possible outcome. Health outcomes can be defined in a number of ways, including quality-adjusted survival. A key aspect of decision analysis is allowing the values of particular health outcomes to vary from patient to patient, depending on individual preferences. Decision analysis has already been used to assess a variety of prevention, screening and treatment decisions in urology, and there is much potential for its future application. Greater incorporation of decision-analytic techniques into urology research and clinical practice might improve decision making, and thereby improve patient outcomes.

Gelatin Packing of Intracortical Tract After Percutaneous Nephrostomy Lithotripsy for Decreasing Bleeding and Urine Leakage

Percutaneous nephrostomy is almost a daily routine procedure in clinical urologic practice. Tract bleeding and urine leakage along the percutaneous tract is a common event and bothersome to both patients and the surgeon. Herein we introduce a simple technique of gelatin packing for stopping subsequent bleeding and urine leakage immediately after a percutaneous nephrostomy lithotripsy (PCNL) procedure. PCNL, using a tubeless technique, was performed in 15 patients with renal calculi. In all cases, stones were removed using grasping forceps after the stones were disintegrated with a lithoclast. In all patients, a retrograde internal ureteral stent was put in place before the PCNL procedure, as was a Foley catheter for bladder drainage. A gelatin patch sealant was placed in the nephrostomy cortical tract under nephroscopic vision, immediately after the PCNL procedure. Another 15 patients, treated using a standard PCNL with tube drainage post-PCNL, were enrolled as a control group. The stone burden, mean operative time, and stone-free rate (67% versus 73%, p = 0.33) were not statistically different between the 2 groups. In the 15 patients who received tubeless PCNL treatment, there were no severe complications related to the gelatin packing in the nephrostomy tract, and no significant bleeding or urine leakage occurred after the packing. The necessity for blood transfusion was much lower in the tubeless group as compared with the tube-drainage group (6.6% versus 26.7%; 0.2 +/- 0.1 units versus 0.9 +/- 0.5 units, p = 0.013). Tubeless patients began ambulation and were discharged from the hospital earlier (3.4 days versus 5.1 days, p = 0.035) than those in the tube-drainage group. Analgesic requirement was significantly less with the gelatin sealant technique when compared with the tube drainage group (85 +/- 20 mg versus 185 +/- 25 mg, p = 0.008). Gelatin sealant packing is an alternative, available, and feasible method for preventing bleeding and urine leakage postoperatively in selected patients receiving tubeless PCNL.

Clinical practice in urology. Chemotherapy and urological malignancy. Edited by A. S. D. Spiers. 250 × 165 mm. Pp. 163 + xvii. Illustrated. 1982. London: Springer-Verlag. £23.00

Journal Article Clinical practice in urology. Chemotherapy and urological malignancy. Edited by A. S. D. Spiers. 250 × 165 mm. Pp. 163 + xvii. Illustrated. 1982. London: Springer-Verlag. £23.00 Get access Clinical Practice in Urology. Chemotherapy and Urological Malignancy. Edited by A S D Spiers. 250 × 165 mm. Pp. 163 + xvii. Illustrated. 1982. London: Springer-Verlag. £23.00. P Riddle P Riddle Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 70, Issue 9, September 1983, Page 572, https://doi.org/10.1002/bjs.1800700947 Published: 07 December 2005

Deletions in L-type calcium channel α1 subunit testicular transcripts correlate with testicular cadmium and apoptosis in infertile men with varicoceles

To identify and understand predictors of successful varicocelectomy. Examination of testicular L-type voltage-dependent calcium channel (L-VDCC) mRNAs and proteins in testis biopsies and comparison of presence and absence of various mRNAs with testicular cadmium levels, with apoptosis, and with sperm count change after varicocelectomy. University clinical urology practice and research laboratories. Infertile men with varicocele (left varicocele only, n = 18; bilateral varicoceles, n = 26) and controls (men with obstructive azoospermia undergoing testicular sperm extraction before intracytoplasmic sperm injection; n = 7). Left testis biopsies by percutaneous needle aspiration biopsy. Varicocele repair by subinguinal approach. Calcium channel mRNA sequence by reverse transcription-polymerase chain reaction and amplicon analysis; calcium channel protein distribution by immunocytochemistry; cadmium levels by atomic absorption and apoptosis by deoxynucleotidyl transferase labeling; and sperm counts in the ejaculate before and after varicocelectomy. Calcium channel mRNAs are polymorphic in human testis biopsies from different men. Proteins from sequence-deleted exons 7 and/or 8 localize to germ cell membranes. Expression of undeleted L-type calcium channel mRNAs correlates with normal testes cadmium and increased sperm count after varicocelectomy. Apoptosis is lower in such cases. Expression of normal testicular L-VDCC sequence in exons 7-8 predicts postvaricocelectomy sperm count increase. Deletions may alter calcium channel function and affect testicular cadmium and apoptosis.

Artificial neural networks in urolithiasis

The management of urolithiasis is a clinical challenge worldwide which may result in difficulty in diagnosis, treatment and prevention of recurrence. Artificial neural networks (ANNs) are well described adjuncts to many aspects of clinical urological practice. We review literature published in on-line Medline-citable English language journals to assess whether ANNs are useful in clinician-led decision-making processes in urolithiasis. Studies have examined the role of ANNs in prediction of stone presence and composition, spontaneous passage, clearance and regrowth after treatment. These reports suggest that ANNs can identify important predictive variables and accurately predict treatment outcome. Although well described in general urological practice, there is comparatively little research into the role of ANNs in urolithiasis. Initial results appear promising; however, further prospective studies are necessary to determine if this mode of analysis is superior to standard statistical predictive methods.

Prostate cancer detection with digital rectal examination, prostate‐specific antigen, transrectal ultrasonography and biopsy in clinical urological practice

To evaluate the utility of digital rectal examination (DRE), prostate specific antigen (PSA) and transrectal ultrasonography and biopsy (TRUSB) in detecting prostate cancer in one teaching-hospital urological practice. In all, 2800 consecutive patients had TRUSB as outpatients by one urologist, the indications for which were a raised or rising PSA level or an abnormal DRE. In addition, the indications for repeat TRUSB included previous abnormal histology, e.g. suspicious areas or atypia or high-grade prostatic intraepithelial neoplasia. All data were collected prospectively. Of 2800 TRUSB, 223 were known cases of prostate cancer (previously diagnosed from transurethral prostatectomy chips or after radical prostatectomy) and were excluded from the analysis. There were 2194 initial and 383 repeat TRUSB; of the former patients, 1129 were found to have prostate cancer, giving a cancer-detection rate of 52%. The positive predictive values (PPVs) for patients with a normal DRE and PSA of < 4, 4-10 and > 10 ng/mL were 9%, 31% and 48%, respectively; the corresponding PPVs for patients with an abnormal DRE and the same PSA levels were 27%, 67% and 85%, respectively. Of the 383 repeat TRUSB, the cancer-detection rate was 31% for the first repeat and 28% for the second. The present values are higher than those reported previously, because these patients were within a clinical urological practice, and the indications for and methods of TRUSB have changed in recent years, such that more lateral areas were biopsied. These values are useful in helping clinicians to counsel patients about the probability of detecting cancer.

Hand-assisted laparoscopic renal surgery: report of 45 cases

To evaluate the effect and clinical application of hand-assisted laparoscopic renal surgery. Forty-five patients with urologic diseases underwent hand-assisted laparoscopic renal surgery: radical nephrectomy was performed on 23 cases, simple nephrectomy on 9 cases, nephroureterectomy on 8 cases, excision of cysts of kidney on 3 cases, partial nephrectomy on 1 case, and upper pole heminephrectomy in duplex kidney on 1 case. The operation was performed by transperitoneal approach in 38 cases and by underwent and by retroperitoneal approach in 7 cases. Hand-assisted laparoscopic renal surgery were performed successfully on all patients. The mean operation time was 154.7 minutes (40 approximately 300 min), and the mean estimated blood loss was 100.4 ml (15 approximately 300 ml). With the advantages of minimal invasion, less blood loss, faster recovery, hand-assisted laparoscopic renal surgery is worth popularizing in urologic clinical practice.

Pharmacological therapy of benign prostatic hyperplasia/lower urinary tract symptoms: an overview for the practising clinician.

Less than 10 years ago surgery and watchful-waiting were the only widely accepted management options for lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) and benign prostatic obstruction (BPO). There has been an enormous decline in the popularity of surgery and it is now apparent that medication is the most frequently used treatment for BPH/LUTS; this has arguably therefore been the most major change in urological clinical practice in the last decade. Currently alpha(1)-adrenoceptor antagonists are the commonest medical therapy, and are thought to act by relaxing prostatic smooth muscle, the neural or so-called 'dynamic' component of BPO. 5alpha-reductase inhibitors (finasteride, dutasteride) are another option for BPH/LUTS, which reduce prostatic mass and therefore the mechanical or 'static' component of BPO. In the last 10 years there have been four direct comparative studies between alpha(1)-adrenoceptor antagonists and finasteride, including their combination, the results of which, and their implications for therapy, are discussed. Another group of agents are the phytotherapeutic extracts, which act via various mechanisms, many as yet poorly defined. This review critically assesses existing publications relating to the medical management of BPH/LUTS.