RESUMEN
PURPOSE: To determine whether omitting antimicrobial prophylaxis (AMP) in TURB is safe in patients undergoing TURB without an indwelling pre-operative catheter/nephrostomy/DJ and a negative pre-operative urinary culture. MATERIALS AND METHODS: A multi-centered randomized controlled trial (RCT) from 17-09-2017 to 31-12-2019 in 5 hospitals. Patients with a pre-operative indwelling catheter/DJ-stent or nephrostomy and a positive pre-operative urinary culture (> 104 uropathogens/mL) were excluded. Post-operative fever was defined as body temperature ≥ 38.3 °C. A non-inferiority design with a 6% noninferiority margin and null hypothesis (H0) that the infection risk is at least 6% higher in the experimental (E) than in the control (C) group; H0: C (AMP-group) - E (no AMP-group) ≥ Δ (6% noninferiority margin). A multivariable, logistic regression was performed for AMP and post-TURB fever with covariates: tumor size and (clot-) retention. The R Project® for statistical computing was used for statistical analysis and a p value of 0.05 was considered as statistically significant. RESULTS: 459 Patients were included and 202/459 (44.1%) received AMP vs 257/459 (55.9%) without AMP. Fever occurred in 6/202 [2.9%; 95% CI (1.2-6.6%)] patients with AMP vs 8/257 [3.1%; 95% CI (1.5%-6.1%)] without AMP (p = 0.44). Multivariable, logistic regression showed no significant harm in omitting AMP when controlled for (clot-)retention and tumor size (p = 0.85) and an adjusted risk difference in developing post-TURB fever of 0.0016; 95% CI [- 0.029; 0.032]. CONCLUSION: Our data suggest the safety of omitting AMP in patients undergoing TURB without an indwelling, pre-operative catheter/nephrostomy/DJ and a negative pre-operative urinary culture.
Asunto(s)
Antibacterianos/uso terapéutico , Profilaxis Antibiótica/métodos , Carcinoma de Células Transicionales/cirugía , Cistoscopía/métodos , Infección de la Herida Quirúrgica/prevención & control , Neoplasias de la Vejiga Urinaria/cirugía , Infecciones Urinarias/prevención & control , Anciano , Anciano de 80 o más Años , Amicacina/uso terapéutico , Cefazolina/uso terapéutico , Ciprofloxacina/uso terapéutico , Femenino , Fiebre/epidemiología , Humanos , Levofloxacino/uso terapéutico , Modelos Logísticos , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Infección de la Herida Quirúrgica/epidemiología , Infecciones Urinarias/epidemiologíaRESUMEN
PURPOSE: We sought to determine whether omitting antimicrobial prophylaxis is safe in patients undergoing transurethral resection of the prostate without preoperative pyuria and a preoperative catheter. MATERIALS AND METHODS: We conducted a multicenter randomized controlled trial from September 17, 2017 until December 31, 2019 in 5 hospitals. Patients with pyuria (>100 white blood cells/ml) and a preoperative indwelling catheter were excluded. Postoperative fever was defined as a body temperature ≥38.3C. A noninferiority design was used with a 6% noninferiority margin and null hypothesis (H0) that the infection risk is at least 6% higher in the experimental (E) than in the control (C) group; H0: C (antimicrobial prophylaxis group) - E (no antimicrobial prophylaxis group) ≥ Δ (6% noninferiority margin). A multivariable, logistic regression was performed regarding posttransurethral resection of the prostate fever and antimicrobial prophylaxis with co-variates: (clot-)retention and operating time. The R Project® for statistical computing was used and a p value of 0.05 was considered as statistically significant. RESULTS: Of the patients 474 were included for multivariable analysis and 211/474 (44.5%) received antimicrobial prophylaxis vs 263/474 (55.5%) patients without antimicrobial prophylaxis. Antibiotics were fluoroquinolones in 140/211 (66.4%), cephazolin in 58/211 (27.5%) and amikacin in 13/211 (6.2%) patients. Fever occurred in 9/211 (4.4%) patients with antimicrobial prophylaxis vs 13/263 (4.9%) without antimicrobial prophylaxis (p=0.8, risk difference 0.006 [95% CI -0.003-0.06, relative risk 1.16]). We were able to exclude a meaningful increase in harm associated with omitting antimicrobial prophylaxis (p=0.4; adjusted risk difference 0.016 [95% CI -0.02-0.05]). CONCLUSIONS: Our data demonstrate the safety of omitting antimicrobial prophylaxis in patients undergoing transurethral resection of the prostate without preoperative pyuria and a preoperative indwelling catheter.
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Amicacina/uso terapéutico , Antibacterianos/uso terapéutico , Profilaxis Antibiótica , Cefazolina/uso terapéutico , Fluoroquinolonas/uso terapéutico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Resección Transuretral de la Próstata , Infecciones Urinarias/epidemiología , Infecciones Urinarias/prevención & control , Anciano , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Método Simple CiegoRESUMEN
BACKGROUND: Acquired rectourethral fistula (RUF) is an uncommon complication mostly resulting from surgery or radiation. Standardization of the surgical management is lacking. The aim of this study was to report our experience with surgery for RUF. METHODS: This was a retrospective study of a prospectively maintained clinical database. The surgical strategy was tailored to complexity of RUF, presence of sepsis, history of radiation and residual urinary/fecal functionality. Outcomes measured were RUF closure and permanent fecal/urinary diversion. Impact of radiotherapy was also assessed. RESULTS: Between November 2002 and January 2019, 52 patients were identified (100% males). Median follow-up was 10.5 (0.5-16.8) years. Three patients had RUF closure after conservative management. The remaining 49 patients had a total of 76 procedures. The cumulative closure rate after the first, second and third attempt was 55.1%, 85.7% and 95.9%, respectively. Fistula closure together with preservation of the fecal and urinary function was achieved in 49%, 65.3% and 67.3% after the first, second and third repair, respectively. The overall success rate for transanal, transperineal, restorative transabdominal and non-restorative transabdominal procedures was 35.7%, 64.3%, 57.1% and 94.1%, respectively. A significantly higher rate of urinary/intestinal stomas was observed in the irradiated vs non-irradiated patients (84.2% vs 42.4%; p = 0.004). CONCLUSIONS: Surgery ensured healing in 96% of the patients. Radiotherapy led to higher rate of permanent urinary/fecal diversion. Nearly all irradiated patients who had transabdominal repair end up with a definitive stoma. When transperineal repair with gracilis flap interposition was used, the rate of fistula closure approached 90%. A treatment algorithm is proposed.
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Fístula Rectal , Enfermedades Uretrales , Fístula Urinaria , Femenino , Humanos , Masculino , Fístula Rectal/etiología , Fístula Rectal/cirugía , Estudios Retrospectivos , Colgajos Quirúrgicos , Enfermedades Uretrales/etiología , Enfermedades Uretrales/cirugía , Fístula Urinaria/etiología , Fístula Urinaria/cirugíaRESUMEN
PURPOSE: Antibiotic prophylaxis is standard procedure in transurethral resection of the prostate (TURP). We evaluated the necessity of antibiotic (AB) prophylaxis in TURP due to increasing microbial antibiotic resistance. METHODS: This is a prospective cohort study of 506 patients. Only patients with a pre-operative catheter/pyuria received AB-prophylaxis. Urine analysis (pre-operative, at discharge, and 3 week post-operative) was performed next to an analysis of the blood culture/irrigation fluid and of the resected prostatic tissue. Statistical analysis was performed using Fisher's exact test. RESULTS: 67/506 (13.2%) patients received prophylactic antibiotics. 56/67 (83.5%) patients had a pre-operative catheter and 11/67 (16.4%) had pre-operative pyuria in which a fluoroquinolone-resistance (FQ-R) rate of 69.2% in Escherichia coli (EC) was observed. Clinical infectious symptoms were present in 13/439 (2.9%) patients without antibiotic prophylaxis; 12/439 (2.7%) patients had uncomplicated fever (<38.5°) during or after hospitalization and only 1/439 patient (0.2%) was high degree fever (> 38.5°) observed. Uncomplicated fever developed in 7/67 (10.4%) patients who did receive AB-prophylaxis. FQ-R was observed in 60% of the positive urine cultures at discharge and in 53.8% 3 week post-operatively. CONCLUSIONS: Our data show a low infectious complication rate (2.9%) in patients without a pre-operative catheter or pyuria,undergoing TURP without AB-prophylaxis. These findings might question the current use of AB prophylaxis in TURP in patients without a pre-operative catheter or pyuria, in times of antibiotic stewardship due to the high rate of microbial-resistance in our population.
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Antibacterianos/uso terapéutico , Profilaxis Antibiótica/estadística & datos numéricos , Programas de Optimización del Uso de los Antimicrobianos , Infecciones Bacterianas/prevención & control , Complicaciones Posoperatorias/prevención & control , Neoplasias de la Próstata/cirugía , Resección Transuretral de la Próstata , Humanos , Masculino , Estudios ProspectivosRESUMEN
BACKGROUND: Bowel function can be markedly changed after a spinal cord injury (SCI). These changes, and the care associated with managing the changes, can greatly impact a person's quality of life over a lifetime. PURPOSE: The purpose of the SIU-ICUD workgroup was to identify, assess, and summarize evidence and expert opinion-based themes and recommendations regarding bowel function and management in SCI populations. METHODS: As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury, a workgroup was formed and comprehensive literature search of English language manuscripts regarding bowel physiology and management plans for the SCI patient. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs). RESULTS: Neurogenic bowel symptoms are highly prevalent in the SCI population. Patients with injuries above the conus medullaris have increased bowel motility and poor anorectal sphincter relaxation. Patients with injuries below the conus are more likely to have an areflexic colon and low sphincter tone. Conservative management strategies include diet modification and anorectal stimulation. There are few evidence-based pharmacologic interventions, which improve fecal transit time. Intestinal ostomy can be an effective treatment for reducing hours spent per week on bowel management and colostomy may be easier to manage than ileostomy due to solid vs liquid stool. CONCLUSIONS: By understanding physiology and treatment options, patients and care teams can work together to achieve goals and maximize quality of life after injury.
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Intestino Neurogénico/terapia , Traumatismos de la Médula Espinal/complicaciones , Adulto , Tratamiento Conservador , Humanos , Intestino Neurogénico/etiología , Calidad de Vida , Reflejo Anormal , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: After a spinal cord injury, patients have different perceptions of sexuality, sexual function, and potential for fertility. These changes can greatly impact quality of life over a lifetime. PURPOSE: The purpose of this workgroup was to identify common evidence based or expert opinion themes and recommendations regarding treatment of sexuality, sexual function and fertility in the spinal cord injury population. METHODS: As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury (SCI), a workgroup and comprehensive literature search of English language manuscripts regarding fertility and sexuality in the spinal cord injury patient were formed. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs). RESULTS: Genital arousal, ejaculation, and orgasm are significantly impacted after spinal cord injury in both male and female SCI patients. This may have a more significant impact on potential for fertility in male spinal cord injury patients, particularly regarding ability of generate erection, semen quantity and quality. Female patients should be consulted that pregnancy is still possible after injury and a woman should expect resumption of normal reproductive function. As a result, sexual health teaching should be continued in women despite injury. Pregnancy in a SCI may cause complications such as autonomic dysreflexia, so this group should be carefully followed during pregnancy. CONCLUSIONS: By understanding physiologic changes after injury, patients and care teams can work together to achieve goals and maximize sexual quality of life after the injury.
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Fertilidad , Sexualidad/psicología , Traumatismos de la Médula Espinal/complicaciones , Nivel de Alerta , Eyaculación , Femenino , Humanos , Masculino , Orgasmo , Embarazo , Complicaciones del Embarazo/etiología , Calidad de Vida , Factores Sexuales , Disfunciones Sexuales Fisiológicas , Traumatismos de la Médula Espinal/psicologíaRESUMEN
OBJECTIVE: To investigate the long-term outcomes of unilateral mid-urethral sling transection to treat voiding dysfunction after synthetic mid-urethral sling placement for stress urinary incontinence. STUDY DESIGN: Twenty-three patients who underwent an unilateral sling transection were analyzed retrospectively. Patient records were analyzed for subjective outcome, and pre- and postoperative flow patterns were used as objective outcome parameters. RESULTS: At the first postoperative follow-up, 77.3% of the patients remained dry. After a mean follow-up of 42 months, 73.9% of patients were continent. The flow pattern after lateral sling transection was significantly better than pre-operatively, with higher maximum flow rate (24.2ml/s, p=0.001), higher mean flow rate (10.4ml/s, p=0.001), higher voided volume (308.5ml, p=0.002) and lower residual volume (28.7ml, p=0.003). At final postoperative follow-up, eight patients (34.8%) reported urgency and six patients (26.1%) were incontinent; four of these patients (17.4%) mainly had urge incontinence. CONCLUSIONS: Unilateral mid-urethral sling transection is a safe, effective technique to treat voiding symptoms with good preservation of continence. The technique repairs the obstructive flow effectively. Urgency and urge incontinence after mid-urethral sling placement are difficult to treat with transection alone.
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Dispareunia/etiología , Complicaciones Posoperatorias/etiología , Cabestrillo Suburetral/efectos adversos , Incontinencia Urinaria de Esfuerzo/cirugía , Incontinencia Urinaria de Urgencia/etiología , Retención Urinaria/etiología , Infecciones Urinarias/etiología , Bélgica/epidemiología , Estudios de Cohortes , Dispareunia/epidemiología , Dispareunia/fisiopatología , Dispareunia/prevención & control , Registros Electrónicos de Salud , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Satisfacción del Paciente , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/prevención & control , Recurrencia , Estudios Retrospectivos , Riesgo , Prevención Secundaria , Incontinencia Urinaria de Esfuerzo/epidemiología , Incontinencia Urinaria de Esfuerzo/fisiopatología , Incontinencia Urinaria de Esfuerzo/prevención & control , Incontinencia Urinaria de Urgencia/epidemiología , Incontinencia Urinaria de Urgencia/fisiopatología , Incontinencia Urinaria de Urgencia/prevención & control , Retención Urinaria/epidemiología , Retención Urinaria/fisiopatología , Retención Urinaria/prevención & control , Infecciones Urinarias/epidemiología , Infecciones Urinarias/fisiopatología , Infecciones Urinarias/prevención & control , UrodinámicaRESUMEN
INTRODUCTION: Mid-urethral slings are currently considered to be the gold standard for the surgical treatment of stress urinary incontinence, replacing bladder neck suspension techniques which previously occupied this position. In recent years, however, there have been concerns with regard to the use of synthetic material in vaginal surgery. METHODS: We performed a review of the literature to discuss the role of bladder neck suspension techniques in the current clinical setting. CONCLUSIONS: Bladder neck suspension techniques consist of vaginal techniques, needle suspension techniques and retropubic techniques. The latter two techniques have been proven to offer durable outcomes for stress urinary incontinence. As compared to autologous slings, the long-term success rates may be considered inferior, but so is the rate of complication, resulting in higher patient satisfaction. Bladder neck suspension techniques may have a role in treating recurrent and/or persisting stress urinary incontinence after (failed) sling surgery and remain of particular interest in patients with stress urinary incontinence when performing concomitant surgery, for example for prolapse.
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Cabestrillo Suburetral , Incontinencia Urinaria de Esfuerzo/cirugía , Procedimientos Quirúrgicos Urológicos/métodos , HumanosRESUMEN
Retrieval of spermatozoa is unfortunately still only successful in a subset of patients suffering from non-obstructive azoospermia (NOA) by conventional testicular sperm extraction (TESE). Microdissection TESE may have some theoretical benefits over conventional TESE, but uncertainty exists about its superiority. The objective of this systematic review was therefore to compare the efficacy and safety of microTESE with conventional TESE in men with NOA. The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Literature was searched for studies comparing outcome of conventional TESE with microdissection TESE. Primary outcome was sperm retrieval rate (SRR). Secondary outcomes were clinical predictors of sperm retrieval as well as complication rate. Of 62 articles, a total of seven studies were included in the final analysis. Overall SRR was significantly higher in the microTESE group in comparison with conventional TESE in five of these studies. Overall sperm retrieval ranged from 16.7 to 45% in the conventional TESE vs. 42.9 to 63% in the microTESE group. A sub-analysis of the SRR according to testicular histology was available in four of the selected articles. MicroTESE in men with Sertoli cell only syndrome and hypospermatogenesis carried a small but significant more favourable outcome according to, respectively, two and one of the studies. Correlation of serum follicle stimulating hormone and testicular volume with positive outcome was variable. Fewer complications were observed on ultrasound examination after microTESE procedure. Clinical randomized studies comparing microTESE with conventional TESE in NOA are still lacking to date. Pseudo-randomized prospective data, however, show more favourable sperm retrieval in NOA for microTESE, especially in histological patterns of patchy spermatogenesis such as Sertoli cell only syndrome. However, in patients with uniform histological patterns such as maturation arrest outcome of microTESE seems less favourable.
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Azoospermia/cirugía , Microdisección/métodos , Oligospermia/cirugía , Síndrome de Sólo Células de Sertoli/cirugía , Recuperación de la Esperma/efectos adversos , Hormona Folículo Estimulante/sangre , Humanos , Masculino , Espermatozoides , Testículo/diagnóstico por imagen , Testículo/fisiología , Testículo/cirugía , Resultado del Tratamiento , UltrasonografíaRESUMEN
Anticholinergics and intermittent catheterization are the cornerstones of bladder management in early multiple sclerosis (MS). In advanced MS however, bladder management is based more on tradition than on evidence. Nurses seem to deal with catheter problems and chronic incontinence. Despite the abundant use of indwelling catheters, there is a lack for guidelines on catheter-induced problems. The psychosexual and social impact of bladder problems in advanced MS is often neglected. The international multidisciplinary special interest group on sexual, urological and bowel dysfunction in MS (SUBDIMS) as a special interest group of the Rehabilitation in Multiple Sclerosis (RIMS) was confronted with a high variability in practice and a lack of guidelines. A literature review was prepared during three multidisciplinary expert meetings. This review will be the basis of further initiatives to improve the urological treatment of patients with advanced MS.
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Esclerosis Múltiple/complicaciones , Cateterismo Urinario , Incontinencia Urinaria/etiología , Incontinencia Urinaria/terapia , Medicina Basada en la Evidencia , Humanos , Esclerosis Múltiple/enfermería , Guías de Práctica Clínica como Asunto , Incontinencia Urinaria/enfermeríaRESUMEN
INTRODUCTION: High-grade prostatic intraepithelial neoplasia (HGPIN) is generally accepted to be a precursor lesion of prostate cancer. The likely outcome of isolated low-grade PIN (LGPIN) lesions in prostate biopsies remains unclear. A follow-up study of 106 patients with LGPIN- and HGPIN lesions was performed. MATERIALS AND METHODS: In a 2-y period, 207 men were diagnosed with isolated PIN on standard systematic sextant biopsy of the prostate. In total, 104 patients had LGPIN and 103 had HGPIN. No patients had ever received androgen deprivation therapy, chemotherapy or radiation therapy. In all, 106 patients who underwent repeat second or third sextant biopsies were analysed in the study; 30% of these patients received a selenium-vitamin E supplement for at least 6 months. RESULTS: In total, 43 had LGPIN and 63 HGPIN on the first biopsy. The mean age was 63.5 y (range 46-77) in the LGPIN group and 64.9 y in the HGPIN group. The mean total PSA was 6.96 ng/ml (range 0.59-34.13) in the LGPIN group and 8.44 ng/ml (range 0.59-35.3) in the HGPIN group. In the LGPIN group, 30% of the patients had cancer in at least one of the repeat biopsy cores. In the HGPIN group, 27% had cancer in at least one of the repeat biopsy cores. The mean total PSA of patients who had cancer in repeat biopsies with LGPIN was 7.84 ng/ml (range 2.92-34.13). The mean total PSA of the patients who had cancer in repeat biopsy in the HGPIN was 6.73 ng/ml (range 0.56-25). There was no significant difference in PSA and pathological stage between those patients who did and those who did not receive selenium-vitamin E supplements. CONCLUSIONS: These data are intriguing since the risk of finding prostate carcinoma on repeat sextant biopsy in the LGPIN group is 30%. This is higher than commonly reported. The importance of recognising and re-biopsying HGPIN was confirmed. If chemoprevention could be shown to be effective, it might be beneficial not only in HGPIN but also in LGPIN. The possible activity of chemopreventive agents and their combination with iso-flavonoids needs further investigation.
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Neoplasia Intraepitelial Prostática/sangre , Neoplasia Intraepitelial Prostática/patología , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/patología , Anciano , Biopsia con Aguja , Estudios de Seguimiento , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Pronóstico , Antígeno Prostático Específico/sangre , Neoplasia Intraepitelial Prostática/complicaciones , Neoplasia Intraepitelial Prostática/prevención & control , Neoplasias de la Próstata/complicaciones , Neoplasias de la Próstata/prevención & control , Factores de Riesgo , Selenio/farmacología , Vitamina E/farmacologíaRESUMEN
The objective of the study was to evaluate unilateral nerve sparing prostate surgery. Patient files of men who underwent unilateral nerve sparing radical prostatectomy were analyzed retrospectively after a minimum follow-up period of 18 months. Of 46 patients who received unilateral nerve sparing surgery, 14 (30.4%) regained full potency after surgery. In 92.9% of these patients, recovery occurred within a period of 18 months. Age is the single most important factor in the recuperation of potency after unilateral nerve sparing surgery. Most of the patients (84.8%) reported the ability to achieve orgasm. Of eight patients with positive section margins, two had positive section margins at the spared side only. Unilateral nerve sparing surgery remains a feasible treatment option for prostate cancer.