Current Urology Reports最新文献

Purpose of review: Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion.

Recent findings: The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.

Purpose of review: The robotic approach is increasingly popular in reconstructive urology. Reconstructive surgeons have commonly used flaps and grafts for obliterating dead space including tissue interposition or as an alternative to mesh in addressing lower urinary tract dysfunction. Advantages of the robotic approach are less incisional pain, excellent visualization in the deep pelvis, and improved surgeon ergonomics. In this literature review, we describe flaps and grafts used in lower urinary tract robotic reconstructive urology, serving as an almanac for these techniques.

Recent findings: Omental, peritoneal, vertical rectus abdominis musculocutaneous (VRAM), sigmoid epiploica, gracilis flaps, and Alloderm^™ have been reported for tissue interposition during fistula repair. Fascia lata has been described as a mesh alternative for robotic sacrocolpopexy. Besides providing interposition, flaps support native tissue healing and blood supply. Grafts are easy to use with low patient morbidity, but rely on the blood supply at the recipient site. Robotic reconstruction is an emerging field, and more studies are needed to define the best uses for each flap and graft as well as strategies to maximize outcomes and minimize morbidity.

Purpose of review: Renal cell carcinoma presents a unique proclivity for vascular involvement giving rise to a peculiar form of locally advanced disease so-called tumor thrombus. To date, the only curative strategy for these cases remains surgery, which should aim to remove every vestige of macroscopic disease. Most of the preexisting literature advocates opening the vena cava to allow tumor thrombus removal and subsequent venous suture closure. However, inferior vena cava circumferential resection (cavectomy) without caval replacement is possible in the majority of cases since progressive occlusion facilitates the development of a collateral venous network aimed at maintaining cardiac preload.

Recent findings: Radical nephrectomy with tumor thrombectomy remains a surgical challenge not exempt of operative complications even in experienced hands. In opposition to what traditional cavotomy and thrombus withdrawal can offer, circumferential cavectomy without caval replacement would provide comparable or even better oncologic control, decrease the likelihood of operative bleeding, and prevent the development of perioperative pulmonary embolism. This review focuses on the rationale of circumferential IVC resection without caval replacement and the important technical aspects of this approach in cases of renal cell carcinoma with vascular involvement. We also include an initial report on the surgical outcomes of a contemporary series of patients managed under this approach at our center.

Purpose of review: This review aims to identify and summarize the current literature on the most recent therapeutic agents and combination strategies for the medical management of lower urinary tract symptoms resulting from benign prostatic hyperplasia.

Recent findings: The latest advancements in BPH therapy have been in combination strategies. Alpha blockers continue to be the mainstay of treatment, but research is exploring the synergistic benefits of combining them with 5-alpha reductase inhibitors (5-ARIs), phosphodiesterase-5 (PDE5) inhibitors, and beta-3 agonists. The alpha-blocker + 5-ARI combination remains ideal for enlarged, significantly reducing clinical progression risk compared to monotherapy. Alpha-blocker + PDE5 inhibitor combinations appear safe and potentially beneficial for men with concomitant erectile dysfunction; sildenafil might hold an edge over tadalafil based on limited data. Beta-3 agonists show synergistic effects with alpha blockers for residual storage symptoms, offering similar efficacy to anticholinergics but with a better side effect profile.

Purpose of review: Uroflowmetry is widely used for initial non-invasive evaluation of lower urinary tract disorders. Current clinical use is mostly restricted to a scrutiny of the maximum flow rate and uroflow pattern recorded by a conventional flowmeter in a health care facility. There are several advancements in our understanding and in available technologies that promise to transform clinical utilization of this simple test.

Recent findings: Several aspects of the uroflow test in addition to maximum flow rate and uroflow pattern show potential diagnostic utility. This includes flow acceleration, uroflow indices, uroflow-electromyography including lag time, stop uroflow test, and uroflow-based nomograms. There are initial attempts to use artificial intelligence in analysis. There is also new data with regard to factors influencing variability of uroflow testing that might influence the diagnostic value in as yet uncertain ways including diurnal variability, postural variability, locational variability, and operator variability. There are new technologies for uroflow testing in a home environment allowing for easy repetition. However, there are several challenges owing to a paucity of clinical data and standardization. There are also critical lacunae in terminology that need to be addressed. There are exciting new advancements in the field of uroflowmetry. However, there is need to standardize and validate the newer uroflow tracing analyses and technologies.

Purpose of review: Benign prostatic hyperplasia affects the quality of life of a significant number of men, especially as they age. There are continuous innovations in the surgical management of benign prostatic hyperplasia, but many of these innovations are studied in the core population of men 50-70 years of age. This review focuses on the outliers of men aged 18-50 and 70 and older.

Recent findings: Older populations have more comorbidities, higher rates of antithrombotic medications, and advanced symptoms. Properly selected older men can safely have significant objective and subjective improvement in their symptoms. The literature was scarce when evaluating younger men; however, ejaculatory preserving techniques are promising providing improvement in symptoms and preserving ejaculation. This review demonstrates that in properly selected elderly patients, improvements in quality of life while also providing safe surgical interventions can be achieved. Ejaculatory preservation techniques demonstrate promising results, but further studies are required to elucidate true outcomes.

Purpose of Review

Lower urinary tract symptoms (LUTS) after surgical management for BPH pose a significant clinical challenge for urologists. Despite high success rates in relieving LUTS, there is a subset of patients who experience persistent symptoms after intervention. In this review article, we describe the management of patients with new or persistent LUTS after endoscopic bladder outlet surgery.

Recent Findings

Previously, the goal for BPH management was to remove as much adenomatous tissue as possible. While potentially effective, this may lead to unwanted side effects. There has been a recent paradigm shift for new minimally invasive surgical therapies (MIST) that strategically treat adenomatous tissue, adding potential complexity in managing patients with new or residual symptoms in the postoperative setting.

Summary

There is a paucity of literature to guide optimal workup and care of patients with persistent LUTS after surgical management. We characterize patients into distinct groups, defined by types of symptoms, irritative versus obstructive, and timing of the symptomatology, short term versus long term. By embracing this patient-centered approach with shared decision management, clinicians can optimize outcomes efficiently improving their patients’ quality of life.

Purpose of review: This review article will examine the current literature on hypospadias-related complications in adult patients.

Recent findings: In this article, we will review the most recent studies evaluating hypospadias-related stricture disease, erectile function, fertility, and psychosexual outcomes in adult men with history of hypospadias repair in childhood. Managing hypospadias-related complications in adult patients is challenging to reconstructive urologists due to the compounded complexity of innate tissue deficiency and history of prior surgical repairs. In this review, we explore overall functional outcomes of adults with history of hypospadias repair as well as repair strategies of hypospadias-related urethral stricture disease. We will review erectile function, fertility and psychosexual outcomes as well as potential complications, which often do not surface until late adolescence and adulthood. Although it is challenging to characterize and quantify hypospadias-related complications, further longitudinal study is needed to better care for this complex patient population.

Purpose of review: Lasers have had a significant impact on the treatment of benign prostatic hypertrophy. This article attempts to distill the advancements in laser technology for the treatment of benign prostatic hypertrophy (BPH) into key and understandable points to help make this topic more accessible to urologists.

Recent findings: The holmium:yttrium-aluminum-garnet (YAG) laser, one of the most significant lasers in the field of urology, has recently been improved with pulse modulating technology (Moses™ technology). New thulium:YAG technology allows both pulsed and continuous wave modes. The thulium fiber laser is one of the newer lasers to come to market and has been shown to have effective and safe outcomes. GreenLight™ lasers are predominantly used in photovaporization procedures and have also been studied extensively, although less in recent years. The modern urologist is fortunate to have many high-quality lasers and a wide variety of surgical techniques to choose from when treating BPH. Understanding the basic laser principles and applications will help urologists to select the best treatment options for their patients with BPH.

Purpose of review: This review aims to provide an in-depth exploration of the recent advancements in robot-assisted laparoscopic pyeloplasty (RALP) and its evolving landscape in the context of infant pyeloplasty, complex genitourinary (GU) anatomy, recurrent ureteropelvic junction (UPJ) obstruction, cost considerations, and the learning curve.

Recent findings: Recent literature highlights the safety and efficacy of RALP in treating the infant population, patients with complex GU anomalies, and recurrent UPJO which were all traditionally managed using the open approach. Cost considerations are evolving, with the potential for RALP to have a lesser financial burden. In addition, the learning curve for RALP is diminishing due to robust training programs and advances in research. RALP has become the gold standard in the treatment of UPJO in pediatric urology at many children's hospitals. Surgeon comfort and research in this space allow safe and successful reconstruction in the most challenging of cases.