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Article of the month: Better QOL with orthotopic neobladders

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Singh of orthotopic neobladder reconstruction by sigmoid colon.

If you only have time to read one article this week, it should be this one

Prospective comparison of quality-of-life outcomes between ileal conduit urinary diversion and orthotopic neobladder reconstruction after radical cystectomy: a statistical model

Vishwajeet Singh, Rahul Yadav, Rahul Janak Sinha and Dheeraj Kumar Gupta
Department of Urology, King George Medical University, Lucknow, Uttar Pradesh, India

Read the full article
OBJECTIVE

• To conduct a prospective comparison of quality-of-life (QoL) outcomes in patients who underwent ileal conduit (IC) urinary diversion with those who underwent orthotopic neobladder (ONB) reconstruction after radical cystectomy for invasive bladder cancers.

PATIENTS AND METHODS

• Between January 2007 and December 2012, 227 patients underwent radical cystectomy and either IC urinary diversion or ONB (sigmoid or ileal) reconstruction.

• Contraindications for ON were impaired renal function (serum creatinine >2 mg/dL), chronic inflammatory bowel disease, previous bowel resection and tumour involvement at the bladder neck/prostatic urethra. Patients who did not have these contraindications chose to undergo either IC or ONB reconstruction, after impartial counselling.

• Baseline characteristics, including demographic profile, body mass index, comorbidities, histopathology of the cystoprostatectomy (with lymph nodes) specimen, pathological tumour stage, postoperative complications, adjuvant therapy and relapse, were recorded and compared.

• The European Organization for Research and Treatment of Cancer QoL questionnaire C30 version 3 was used to analyse QoL before surgery and 6, 12 and 18 months after surgery.

RESULTS

• Of the 227 patients, 28 patients in the IC group and 35 in the ONB group were excluded. The final analysis included 80 patients in the IC and 84 in the ONB group.

• None of the baseline characteristics were significantly different between the groups, except for age, but none of the baseline QoL variables were found to be correlated with age.

• In the preoperative phase, there were no significant differences in any of the QoL domains between the IC or the ONB groups. At 6, 12 and 18 months in the postoperative period, physical functioning (P < 0.001, P < 0.001 and P = 0.001, respectively), role functioning (P = 0.01, P = 0.01 and P = 0.003, respectively), social functioning (P = 0.01, P = 0.01 and P = 0.01, respectively) and global health status/QoL (P < 0.001, P < 0.001 and P = 0.002, respectively) were better in patients in the ONB group than in those in the IC group and the differences were significant.

• The financial burden related to bladder cancer treatment was significantly lower in the ONB group than in the IC group at 6, 12 and 18 months of follow-up (P = 0.05, P = 0.05 and P = 0.005, respectively)

CONCLUSIONS

• ONB is better than IC in terms of physical functioning, role functioning, social functioning, global health status/QoL and financial expenditure.

• ONB reconstruction provides better QoL outcomes than does IC urinary diversion.

Read more articles of the week

 

Editorial: Life is good with orthotopic bladder substitutes!

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In the present issue of the BJUI, Singh et al. [1] present the results of a non-randomized prospective study comprising 80 patients who underwent ileal conduit diversion and 84 who underwent orthotopic bladder substitution. Quality of life was assessed using the European Organisation for the Research and Treatment of Cancer quality-of-life questionnaire, the QLQ-30C, at 6, 12 and 18 months postoperatively. Physical and social functioning and global health status were significantly better in patients with orthotopic bladder substitution than in those who underwent ileal conduit diversion. Moreover, the postoperative financial burden was significantly lower for patients in the orthotopic bladder group than for those in the ileal conduit group, who required stoma appliances, a finding of particular importance not only in India, where the study was performed, but worldwide. The authors’ results are particularly impressive given their use of a questionnaire that included many items (‘Were you short of breath?’, ‘Did you need to rest?’, ‘Have you lacked appetite?’, ‘Have you been constipated?’, ‘Did you feel tense?’, ‘Did you worry’ or ‘Did you feel irritable?’, etc.) that can hardly discriminate between the quality of life of patients who underwent orthotopic bladder substitution and those who underwent ileal conduit diversion. To find significant differences between the two types of urinary diversion, despite such dilution factors, speaks strongly in favour of orthotopic bladder substitution.

The results of this prospective single-centre trial are of particular importance because, as the authors state, other investigators could not show such differences, presumably for a variety of reasons, such as too few patients or single follow-up assessments given at time points that varied from patient to patient. Quality-of-life assessment at similar follow-up time points, as performed by these authors, is important because, with adequate counselling, the postoperative function of orthotopic bladder substitutes improves over time.

Without a doubt, however, a poorly functioning orthotopic bladder substitute may lead to a poorer quality of life than a well-functioning ileal conduit diversion. Poor functional results and life-threatening complications can be largely avoided with ileal orthotopic bladder substitutes, provided the treating urologist has adequate knowledge of the procedure and the patient receives adequate postoperative education [2]. The major ways to ensure good results are:

  • appropriate patient selection (good renal function, regular follow-up possible);
  • the avoidance of damage to the sphincter apparatus and its innervation (individualized nerve-sparing cystectomy, minimum use of bipolar electrocautery near the pelvic plexus and membranous urethra);
  • the use of ileum instead of colon (better compliance) [3-5];
  • the avoidance of a funnel-shaped outlet that can result in kinking, outlet obstruction, residual infected urine and, in the worst case, lifelong need for clean intermittent catheterization (CIC) (Fig. 1).

By contrast to most other urological procedures, orthotopic bladder substitution requires proactive postoperative management [6] to ensure:

  • residual urine-free spontaneous voiding after catheter removal;
  • sterile urine to improve urinary continence and to reduce mucous production [7];
  • the prevention of salt loss syndrome and metabolic acidosis by increased salt intake and sodium bicarbonate substitution in the early postoperative period to ensure a base excess of +2;
  • a systematic increase in functional capacity by progressively expanding voiding intervals to obtain a reservoir capacity of ∼500 mL and, thus, a low end-fill pressure which ensures urinary continence day and night (the latter combined with the use of an alarm clock).

It is equally important to perform lifelong follow-up of patients and regularly at 6- to 12-month intervals so as to diagnose and treat early secondary complications, such as uretero-intestinal strictures or residual, infected urine. If the latter occurs, any form of outlet obstruction, such as ileal mucosa protruding in front of the bladder outlet, strictures or growth of inadvertently left prostatic tissue, must be looked for and treated. In our own experience, secondary outlet obstruction occurred in ∼20% of patients observed for 10 years. This rather high incidence is typical for intestinal bladder substitutes because when voiding, unlike the genuine bladder, there is no coordinated contraction of the reservoir wall which would result in an elevated voiding pressure which, in turn, would overcome an outlet resistance. Bladder substitutes empty mainly by gravitational force alone. If voiding is only possible by abdominal straining, then something must be wrong; therefore, instead of recommending CIC for patients who build up residual and consecutively infected urine, we strongly favour treating the outlet obstruction, usually on an outpatient basis. The avoidance of the need for CIC through surgical technique (no funnel-shaped outlet) and during regular follow-up by treating any potential cause of residual urine can substantially improve the patient’s quality of life. It also avoids the cost of catheters and the risk of infectious complications. Thanks to this active management and removal of any outlet obstruction, 96% of our patients followed for 10 years were still able to void spontaneously [8].

Urs E. Studer
Department of Urology, University Hospital Bern, Bern, Switzerland

Read the full article

References

  1. Singh V, Yadav R, Sinha RJ, Gupta DK. Prospective comparison of quality-of-life outcomes between ileal conduit urinary diversion and orthotopic neobladder reconstruction after radical cystectomy: a statistical model. BJU Int 2014; 113: 726–732
  2. Thurairaja R, Burkhard FC, Studer UE. The orthotopic neobladder. BJU Int 2008; 102: 1307–1313
  3. Berglund B, Kock NG, Myrvold HE. Volume capacity and pressure characteristics of the continent cecal reservoir. Surg Gynecol Obstet 1986; 163: 42–48
  4. Schrier BP, Laguna MP, van der Pal F, Isorna S, Witjes JA. Comparison of orthotopic sigmoid and ileal neobladders: continence and urodynamic parameters. Eur Urol 2005; 47: 679–685
  6. Varol C, Studer UE. Managing patients after an ileal orthotopic bladder substitution. BJU Int 2004; 93: 266–270
  7. Zehnder P, Dhar N, Thurairaja R, Ochsner K, Studer UE. Effect of urinary tract infection on reservoir function in patients with ileal bladder substitute. J Urol 2009; 181: 2545–2549
  8. Thurairaja R, Studer UE. How to avoid clean intermittent catheterization in men with ileal bladder substitution. J Urol 2008; 180: 2504–2509

 

Video: Orthotopic neobladder reconstruction by sigmoid colon

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Prospective comparison of quality-of-life outcomes between ileal conduit urinary diversion and orthotopic neobladder reconstruction after radical cystectomy: a statistical model

Vishwajeet Singh, Rahul Yadav, Rahul Janak Sinha and Dheeraj Kumar Gupta
Department of Urology, King George Medical University, Lucknow, Uttar Pradesh, India

 

Read the full article
OBJECTIVE

• To conduct a prospective comparison of quality-of-life (QoL) outcomes in patients who underwent ileal conduit (IC) urinary diversion with those who underwent orthotopic neobladder (ONB) reconstruction after radical cystectomy for invasive bladder cancers.

PATIENTS AND METHODS

• Between January 2007 and December 2012, 227 patients underwent radical cystectomy and either IC urinary diversion or ONB (sigmoid or ileal) reconstruction.

• Contraindications for ON were impaired renal function (serum creatinine >2 mg/dL), chronic inflammatory bowel disease, previous bowel resection and tumour involvement at the bladder neck/prostatic urethra. Patients who did not have these contraindications chose to undergo either IC or ONB reconstruction, after impartial counselling.

• Baseline characteristics, including demographic profile, body mass index, comorbidities, histopathology of the cystoprostatectomy (with lymph nodes) specimen, pathological tumour stage, postoperative complications, adjuvant therapy and relapse, were recorded and compared.

• The European Organization for Research and Treatment of Cancer QoL questionnaire C30 version 3 was used to analyse QoL before surgery and 6, 12 and 18 months after surgery.

RESULTS

• Of the 227 patients, 28 patients in the IC group and 35 in the ONB group were excluded. The final analysis included 80 patients in the IC and 84 in the ONB group.

• None of the baseline characteristics were significantly different between the groups, except for age, but none of the baseline QoL variables were found to be correlated with age.

• In the preoperative phase, there were no significant differences in any of the QoL domains between the IC or the ONB groups. At 6, 12 and 18 months in the postoperative period, physical functioning (P < 0.001, P < 0.001 and P = 0.001, respectively), role functioning (P = 0.01, P = 0.01 and P = 0.003, respectively), social functioning (P = 0.01, P = 0.01 and P = 0.01, respectively) and global health status/QoL (P < 0.001, P < 0.001 and P = 0.002, respectively) were better in patients in the ONB group than in those in the IC group and the differences were significant.

• The financial burden related to bladder cancer treatment was significantly lower in the ONB group than in the IC group at 6, 12 and 18 months of follow-up (P = 0.05, P = 0.05 and P = 0.005, respectively)

CONCLUSIONS

• ONB is better than IC in terms of physical functioning, role functioning, social functioning, global health status/QoL and financial expenditure.

• ONB reconstruction provides better QoL outcomes than does IC urinary diversion.

Read more articles of the week

 

Article of the week: Preserving sexual function with the prostatic urethral lift

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Henry Woo discussing his paper.

If you only have time to read one article this week, it should be this one

Multicentre prospective crossover study of the ‘prostatic urethral lift’ for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia

Anthony L. Cantwell, William K. Bogache*, Steven F. Richardson†, Ronald F. Tutrone‡, Jack Barkin§, James E. Fagelson, Peter T. Chin†† and Henry H. Woo

‡‡Atlantic Urological Associates, Daytona Beach, FL, *Carolina Urological Research Center, Myrtle Beach, SC, †Western Urological Clinic, Salt Lake City, UT, ‡Chesapeake Urology, Baltimore, MD, USA, §University of Toronto, Toronto, ON, Canada, Urology Associates of Denver, Denver, CO, USA, ††Figtree Private Hospital, Figtree, and ‡‡Sydney Adventist Hospital Clinical School, University of Sydney, Sydney, NSW, Australia

Read the full article
OBJECTIVE

• To assess the clinical effect of the ‘prostatic urethral lift’ (PUL) on lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) through a crossover design study.

PATIENTS AND METHODS

• Men aged ≥50 years with an International Prostate Symptom Score of ≥13, a maximum urinary flow rate (Qmax) of ≤12 mL/s, and a prostate of 30–80 mL were enrolled into a crossover study after completing a prospective, randomised, controlled, ‘blinded’ pivotal study in which they were control subjects receiving a sham procedure.

• Patients were followed for 1 year after crossover PUL at 19 centres in the USA, Canada and Australia. The sham procedure involved rigid cystoscopy with simulated active treatment sounds.

• PUL involved placing permanent UroLift® (NeoTract, Inc., Pleasanton, CA, USA) implants into the lateral lobes of the prostate to enlarge the urethral lumen.

• Urinary symptom relief, health-related quality of life (HRQL) impact, urinary flow parameters, sexual function, and adverse events were assessed and compared between the sham and PUL using paired statistical analysis.

RESULTS

• Symptom, flow, HRQL and sexual function assessments showed response improvements from baseline results, similar to results from other published studies, and most parameters were markedly improved after PUL vs the sham procedure in the same patients.

• Symptom, flow, and HRQL improvements were durable over the 12 months of the study.

• Adverse events associated with the procedure were typically transient and mild to moderate; one patient (2%) required re-intervention with transurethral resection of the prostate in the first year.

• There were no occurrences of de novo, sustained ejaculatory or erectile dysfunction.

CONCLUSION

• The PUL can be performed under local anaesthesia, causes minimal associated perioperative complications, allows patients to quickly return to normal activity, provides rapid and durable improvement in symptoms, and preserves sexual function.

 

Read more articles of the week

Editorial: Going with the flow! Relieving LUTS and preserving ejaculation

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Within the last few months of 2013, the Prostatic Urethral Lift procedure, using the UroLift® implant device (NeoTract, Inc., Pleasonton, CA, USA), appeared on the global urology stage. UroLift has the unusual distinction of being both radically new and yet highly studied. The creative crossover study by Cantwell et al. [1] in the present edition of the BJUI adds to the positive evidence for this new treatment option for men with LUTS. Roehrborn et al. [2] have also recently published a high-quality randomized, blinded study. The accumulating published data indicates a new response profile of rapid relief from LUTS and improved urinary flow, while preserving sexual function, including the often overlooked but much valued benefit of preserving ejaculation. In September 2013, Urolift was approved by the US Food and Drug Administration (FDA) [3] and then subsequently by the National Institute for Health and Care Excellence (NICE) in the UK [4]. Gaining regulatory approval at the first attempt is a strikingly unusual achievement but one we can learn from.

The development of this technique began with initial work in 2005 showing that prostatic glandular tissue could be compressed and tethered to the outer prostatic capsule to open up the prostatic urethra [5]. Neotract and its clinical advisors then embarked on years of device development and iteration, culminating in the current version of the UroLift implant device and the currently preferred technique [6]. The rigorous development and clinical testing programme represents a master class in how a new minimally invasive procedure should be developed.

The process illustrates the benefits of cooperation between active clinicians and expert engineers. One particularly important element in this cooperation was the identification of the critical evidence that would be necessary to overcome regulatory hurdles but also to allow clinicians to understand and evaluate this procedure as they adopt it into practice. Neotract’s determination to produce high-quality data first, rather than publicising the method and developing the data to support it later, represents a refreshing change.

So, get a good and novel idea, develop the engineering, do the high-quality studies, et voila – approval! But is it as easy as that? No, the missing element is finance – lots of it. For a company to tread this recommended path, although required by regulators (and indeed by editors), takes a huge amount of money. An FDA pivotal trial of sufficient quality to convince is likely to cost upwards of $20 m. Few start-up companies or indeed established device companies will take that gamble on truly innovative solutions, particularly when economic conditions are tough. NeoTract and its UroLift technology persevered through the economic crash of 2008 and have continued to achieve key clinical milestones against fierce regulatory and financial headwinds. Given these formidable challenges, it is reasonable to wonder how many other developers with novel ideas would be capable of completing the course. Most, unfortunately, would fail.

for detailed instructions and video.

I encourage you to both review the data of Cantwell et al. [1] in this journal and take a look at the Prostatic Urethral Lift technique, as an innovation that is now available for wider adoption (Fig. 1). It does require judgement to select those most likely to benefit and endoscopic skill to achieve the maximum therapeutic benefit, but it appears to be an effective option for men poorly served by drugs, yet wishing to avoid the negative effects of existing surgical options. Additional studies continue to enrol participants, including a European randomized study, but the evidence currently available greatly exceeds that of most newly introduced minimally invasive developments. Why not take the opportunity to assess it yourself?

Tom McNicholas
Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, and University of Hertfordshire, Hatfield, UK

Read the full article

References

  1. Cantwell AL, Bogache WK, Richardson SF et al. Multicentre prospective crossover study of the prostatic Urethral Lift for the treatment of LUTS secondary to BPH. BJU Int 2014; 113: 615–622
  2. Roehrborn CG, Gange SN, Shore ND et al. The prostatic urethral lift for the treatment of lower urinary tract symptoms associated with prostate enlargement due to benign prostatic hyperplasia: the L.I.F.T. study. J Urol 2013; 190: 2162–2167
  3. FDA. FDA News Release: new medical device treats urinary symptoms related to enlarged prostate. Available at: https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm368325.htm. Accessed 14 January 2014
  4. NICE. https://guidance.nice.org.uk/IP/1032. Accessed 15 January 2014
  5. Woo HH, Chin PT, McNicholas TA et al. Safety and feasibility of the prostatic urethral lift: a novel minimally invasive treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hypertrophy (BPH). BJU Int 2011; 108: 82–88
  6. McNicholas TA, Woo HH, Chin PT et al. Minimally invasive prostatic urethral lift: surgical technique and multinational study. Eur Urol 2013; 64: 292–299

 

Video: Prostatic urethral lift for the treatment of LUTS

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Multicentre prospective crossover study of the ‘prostatic urethral lift’ for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia

Anthony L. Cantwell, William K. Bogache*, Steven F. Richardson†, Ronald F. Tutrone‡, Jack Barkin§, James E. Fagelson, Peter T. Chin†† and Henry H. Woo

‡‡Atlantic Urological Associates, Daytona Beach, FL, *Carolina Urological Research Center, Myrtle Beach, SC, †Western Urological Clinic, Salt Lake City, UT, ‡Chesapeake Urology, Baltimore, MD, USA, §University of Toronto, Toronto, ON, Canada, Urology Associates of Denver, Denver, CO, USA, ††Figtree Private Hospital, Figtree, and ‡‡Sydney Adventist Hospital Clinical School, University of Sydney, Sydney, NSW, Australia

Read the full article
OBJECTIVE

• To assess the clinical effect of the ‘prostatic urethral lift’ (PUL) on lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) through a crossover design study.

PATIENTS AND METHODS

• Men aged ≥50 years with an International Prostate Symptom Score of ≥13, a maximum urinary flow rate (Qmax) of ≤12 mL/s, and a prostate of 30–80 mL were enrolled into a crossover study after completing a prospective, randomised, controlled, ‘blinded’ pivotal study in which they were control subjects receiving a sham procedure.

• Patients were followed for 1 year after crossover PUL at 19 centres in the USA, Canada and Australia. The sham procedure involved rigid cystoscopy with simulated active treatment sounds.

• PUL involved placing permanent UroLift® (NeoTract, Inc., Pleasanton, CA, USA) implants into the lateral lobes of the prostate to enlarge the urethral lumen.

• Urinary symptom relief, health-related quality of life (HRQL) impact, urinary flow parameters, sexual function, and adverse events were assessed and compared between the sham and PUL using paired statistical analysis.

RESULTS

• Symptom, flow, HRQL and sexual function assessments showed response improvements from baseline results, similar to results from other published studies, and most parameters were markedly improved after PUL vs the sham procedure in the same patients.

• Symptom, flow, and HRQL improvements were durable over the 12 months of the study.

• Adverse events associated with the procedure were typically transient and mild to moderate; one patient (2%) required re-intervention with transurethral resection of the prostate in the first year.

• There were no occurrences of de novo, sustained ejaculatory or erectile dysfunction.

CONCLUSION

• The PUL can be performed under local anaesthesia, causes minimal associated perioperative complications, allows patients to quickly return to normal activity, provides rapid and durable improvement in symptoms, and preserves sexual function.

 

Read more articles of the week

Article of the week: Stent QOL comes with strings attached

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Barnes and colleagues summarising their paper on stent extraction strings.

If you only have time to read one article this week, it should be this one

Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial

Kerri T. Barnes, Megan T. Bing and Chad R. Tracy

Department of Urology, University of Iowa, Iowa City, IA, USA

Read the full article
OBJECTIVE

• To determine whether ureteric stent extraction strings affect stent-related quality of life (QoL) or increase complications after ureteroscopy (URS) for stone disease.

PATIENTS AND METHODS

• In all, 68 patients undergoing URS (October 2011 to May 2013) for stone disease were randomised to receive a ureteric stent with or without an extraction string.

• Patients completed the Ureteric Stent Symptom Questionnaire (USSQ) on postoperative days 1 and 6, and 6 weeks after stent removal.

• Pain was assessed at stent removal.

• Adverse events, including early stent removal, stent migration, retained stent, urinary tract infection (UTI), emergency room (ER) visits and postoperative phone calls were monitored.

RESULTS

• There was no difference in stent-related QoL as measured by the USSQ between those with and without a stent extraction string, pain at stent removal between those who pulled their stent independently vs those who underwent cystoscopy for stent removal, or in the rate of UTIs, ER visits or phone calls between groups.

• Five patients (four female, one male) removed their stent early by inadvertently pulling the string; none required replacement.

• Patients without a string had a significantly longer period with the postoperative ureteric stent (10.6 vs 6.3 days, P < 0.001).

• One patient without a stent string retained her ureteric stent for 6 months, which was removed by cystoscopy without incident.

CONCLUSION

• Ureteric stent extraction strings may offer several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.

 

Read more articles of the week

Editorial: Tether your stents!

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Ureteric stents are commonly placed after ureteroscopy to protect the ureter and to facilitate subsequent stone fragment passage. They are known to be a cause of significant morbidity as judged by standardised validated questionnaires [1]. Whether placement of a stent is required at all is debatable, with randomised studies suggesting they are unnecessary after routine ureteroscopy [2]. The European Association of Urology (EAU) guidelines recommend stent insertion only ‘in patients who are at increased risk of complications’ and ‘in all doubtful cases to avoid stressful emergency situations’. Despite this, available evidence would suggest that we continue to commonly place stents [3].

If a stent is placed, the principal means of reducing morbidity is by minimising the stent dwell-time. One of the ways of doing this is to leave a stent with extraction strings/tether. This obviates the delay associated with scheduling cystoscopic extraction, the morbidity of cystoscopy and potentially reduces additional hospital visits if the patient is able to remove the stent at home.

Tethered stents are not widely used due to preconceptions about their tolerability, increased risk of complications (e.g. infection, migration) and accidental removal. Perhaps for this reason there have been few studies into the effectiveness of tethered stents in minimising stent-related morbidity to date, with only a handful in the past 30 years that have specifically addressed this issue.

In this issue of BJUI, Barnes et al. [4] report on the results of a prospective randomised trial analysing stented patients with or without the extraction strings attached, for both quality of life and postoperative complications after ureteroscopy for stone disease. This follows on from a retrospective series previously reported by the same group [5]. It is pleasing to see the authors, who originally concluded that randomised trials are needed in this area, actually get on and do the trial!

Two aspects of the trial methodology are worth highlighting: (i) the surgeons were not told that the patient was part of the study until they had made the decision to stent to minimise selection bias; (ii) patients completed the Ureteric Stent Symptom Questionnaire (USSQ) 6 weeks after stent removal as a control for their USSQ scores at postoperative days 1 and 6.

The headline results showed that there was no difference in quality of life and stent-related symptoms between patients with and without the extraction strings. There was also no difference in postoperative complications, emergency room visits or phone calls between the groups. What is surprising is that they found no difference in pain scores between self-removal and cystoscopic removal. This has not been our experience with tethered stents and may be due to the few men in the study. However, stent dwell-time was significantly less for patients with tethers compared with those without (10.6 vs 6.3 days, P < 0.001).

For urologists planning on using this technique it should be noted that the authors removed the original knot and shortened the string considerably to reduce the risk of accidental removal. For this reason the string was not attached to the patient’s skin.

This trial addresses many of the reservations urologists have about the use of tethered stents. Furthermore, reducing accidental removal and encouraging self-removal should be possible with improved patient education and selection. This was addressed by a study in New Zealand [6], which showed the feasibility of self-removal of stents.

The authors also acknowledged weaknesses in their study, which included failure to reach target enrolment, a 68% completion of trial surveys and a larger proportion of women in the study group due to male anxiety about self-removal of stents. In all, 15% of stents were inadvertently removed early and thus this technique should be used with caution in patients where early removal may be detrimental, e.g. in single kidneys. This does of course prompt the question: ‘If you are going to place a stent, how long does the stent need to stay for?’ and hopefully future trials may address this unanswered question.

Archana Fernando and Matthew Bultitude
Urology Department, Guy’s and St Thomas’ NHS Trust, London, UK

References

  1. Joshi HB, Newns N, Stainthorpe A et al. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol 2003; 169: 1060–1064
  2. Song T, Liao B, Zheng S, Wei Q. Meta-analysis of postoperatively stenting or not in patients underwent ureteroscopic lithotripsy. Urol Res 2012; 40: 67–77
  3. Mangera A, Parys B. BAUS Section of Endourology national ureteroscopy audit: setting the standards for revalidation. J Clin Urol 2012; 6: 45–49
  4. Barnes KT, Bing MT, Tracy CR. Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial. BJU Int 2014; 113: 605–609
  5. Bockholt N, Wild T, Gupta A et al. Ureteric stent placement with extraction strings: no strings attached? BJU Int 2012; 110: 1069–1073
  6. York N, English S. Self-removal of ureteric JJ stents: analysis of patient experience. Presented at AUA 2013, May 7; San Diego, CA, USA. Abstract no. 1979. J Urol 2013; 189 (Suppl. 4): e812

 

Video: Stent extraction strings after ureteroscopy

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Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial

Kerri T. Barnes, Megan T. Bing and Chad R. Tracy

Department of Urology, University of Iowa, Iowa City, IA, USA

Read the full article
OBJECTIVE

• To determine whether ureteric stent extraction strings affect stent-related quality of life (QoL) or increase complications after ureteroscopy (URS) for stone disease.

PATIENTS AND METHODS

• In all, 68 patients undergoing URS (October 2011 to May 2013) for stone disease were randomised to receive a ureteric stent with or without an extraction string.

• Patients completed the Ureteric Stent Symptom Questionnaire (USSQ) on postoperative days 1 and 6, and 6 weeks after stent removal.

• Pain was assessed at stent removal.

• Adverse events, including early stent removal, stent migration, retained stent, urinary tract infection (UTI), emergency room (ER) visits and postoperative phone calls were monitored.

RESULTS

• There was no difference in stent-related QoL as measured by the USSQ between those with and without a stent extraction string, pain at stent removal between those who pulled their stent independently vs those who underwent cystoscopy for stent removal, or in the rate of UTIs, ER visits or phone calls between groups.

• Five patients (four female, one male) removed their stent early by inadvertently pulling the string; none required replacement.

• Patients without a string had a significantly longer period with the postoperative ureteric stent (10.6 vs 6.3 days, P < 0.001).

• One patient without a stent string retained her ureteric stent for 6 months, which was removed by cystoscopy without incident.

CONCLUSION

• Ureteric stent extraction strings may offer several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.

 

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Article of the week: Survival and causes of death after RP

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Røder discussing his paper.

If you only have time to read one article this week, it should be this one

Survival after radical prostatectomy for clinically localised prostate cancer: a population-based study

Martin Andreas Røder1, Klaus Brasso1, Ib Jarle Christensen2, Jørgen Johansen3, Niels Christian Langkilde4, Helle Hvarness1, Steen Carlsson5, Henrik Jakobsen6, Michael Borre7 and Peter Iversen1

1Copenhagen Prostate Cancer Center and Department of Urology, 2The Finsen Laboratory, Copenhagen Biotech Research and Innovation Centre (BRIC), Rigshospitalet Copenhagen University Hospital, Faculty of Health and Medical Sciences, Copenhagen, 3Department of Urology, Regional Hospital West Jutland, Holstebro, 4Department of Urology, Aalborg University Hospital, Faculty of Medicine, Aalborg, 5Department of Urology, Odense University Hospital, Faculty of Health Sciences, Odense, 6Department of Urology, Herlev Hospital, Copenhagen University Hospital, Faculty of Health and Medical Sciences, Herlev and 7Department of Urology, Skejby, Aarhus University Hospital, Department of Clinical Medicine, Aarhus, Denmark

 

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OBJECTIVES

• To describe survival and cause of death in a nationwide cohort of Danish patients with prostate cancer undergoing radical prostatectomy (RP).

• To describe risk factors associated with prostate cancer mortality.

PATIENTS AND METHODS

• Observational study of 6489 men with localised prostate cancer treated with RP at six different hospitals in Denmark between 1995 and 2011.

• Survival was described using Kaplan–Meier estimates. Causes of death were obtained from the national registry and cross-checked with patient files.

• Cumulative incidence of death, any cause and prostate cancer-specific, was described using Nelson–Aalen estimates.

• Risk for prostate cancer death was analysed in a Cox multivariate regression model using the covariates: age, cT-category, PSA level and biopsy Gleason score.

RESULTS

• The median follow-up was 4 years. During follow-up, 328 patients died, 109 (33.2%) from prostate cancer and 219 (66.8%) from other causes. Six patients (0.09%) died ≤30 days of RP.

• In multivariate analysis, cT-category was a predictor of prostate cancer death (P < 0.001). Compared with T1 disease, both cT2c (hazard ratio [HR] 2.2) and cT3 (HR 7.2) significantly increased the risk of prostate cancer death. For every doubling of PSA level the risk of prostate cancer death was increased by 34.8% (P < 0.001). Biopsy Gleason score 4 + 3 and ≥8 were associated with an increased risk of prostate cancer death compared with biopsy Gleason score ≤ 6 of 2.3 and 2.7 (P = 0.003), respectively.

• The cumulative hazard of all-cause and prostate cancer-specific mortality after 10 years was 15.4% (95% confidence interval [CI] 13.2–17.7) and 6.6% (95% CI 4.9–8.2) respectively.

CONCLUSIONS

• We present the first survival analysis of a complete, nationwide cohort of men undergoing RP for localised prostate cancer.

• The main limitation of the study was the relatively short follow-up.

• Interestingly, our national results are comparable to high-volume, single institution, single surgeon series.

 

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