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CircumcisionView Articles
CirrhosisView Articles

Volume 18, Number 3Case Review

A Case of Pelvic Organ Prolapse in the Setting of Cirrhotic Ascites

Kristene WhitmoreNatasha GinzburgNima M Shah

Ascites is commonly found in patients with liver cirrhosis. Although conservative therapy is often the ideal choice of care with these patients who also have symptomatic pelvic organ prolapse, this may fail and surgical methods may be needed. Literature is limited regarding surgical repair of prolapse in the setting of ascites. The authors present the surgical evaluation and management of a 63-year-old woman with recurrent ascites from liver cirrhosis who failed conservative therapy. With adequate multidisciplinary care and medical optimization, this patient underwent surgical therapy with resolution of her symptomatic prolapse and improved quality of life. [Rev Urol. 2016;18(3):178-180 doi: 10.3909/riu0702] © 2016 MedReviews®, LLC

AscitesCirrhosisProlapseColpocleisis

Citrate metabolismView Articles

Volume 11, Number 3Review Articles

Hypocitraturia: Pathophysiology and Medical Management

Management Review

Jack M ZuckermanDean G Assimos

Low urinary citrate excretion is a known risk factor for the development ofkidney stones. Citrate inhibits stone formation by complexing with calciumin the urine, inhibiting spontaneous nucleation, and preventing growth andagglomeration of crystals. Hypocitraturia is a common metabolic abnormalityfound in 20% to 60% of stone formers. It is most commonly idiopathic inorigin but may be caused by distal renal tubular acidosis, hypokalemia, boweldysfunction, and a high-protein, low-alkali diet. Genetic factors, medications,and other comorbid disorders also play a role. Hypocitraturia should be managedthrough a combination of dietary modifications, oral alkali, and possiblylemonade or other citrus juice–based therapy. This review concerns thepathophysiology of hypocitraturia and the management of stone formersafflicted with this abnormality.[Rev Urol. 2009;11(3):134-144 doi:10.3909/riu0424]© 2009 MedReviews®, LLC

HypocitraturiaCitrate metabolismCitrate pathophysiologyHypocitraturia etiologiesMedical management of stone diseaseAlkali citratePotassium citrateCitrus juiceLemonade

Citrate pathophysiologyView Articles

Volume 11, Number 3Review Articles

Hypocitraturia: Pathophysiology and Medical Management

Management Review

Jack M ZuckermanDean G Assimos

Low urinary citrate excretion is a known risk factor for the development ofkidney stones. Citrate inhibits stone formation by complexing with calciumin the urine, inhibiting spontaneous nucleation, and preventing growth andagglomeration of crystals. Hypocitraturia is a common metabolic abnormalityfound in 20% to 60% of stone formers. It is most commonly idiopathic inorigin but may be caused by distal renal tubular acidosis, hypokalemia, boweldysfunction, and a high-protein, low-alkali diet. Genetic factors, medications,and other comorbid disorders also play a role. Hypocitraturia should be managedthrough a combination of dietary modifications, oral alkali, and possiblylemonade or other citrus juice–based therapy. This review concerns thepathophysiology of hypocitraturia and the management of stone formersafflicted with this abnormality.[Rev Urol. 2009;11(3):134-144 doi:10.3909/riu0424]© 2009 MedReviews®, LLC

HypocitraturiaCitrate metabolismCitrate pathophysiologyHypocitraturia etiologiesMedical management of stone diseaseAlkali citratePotassium citrateCitrus juiceLemonade

CitratesView Articles
Citrus juiceView Articles

Volume 11, Number 3Review Articles

Hypocitraturia: Pathophysiology and Medical Management

Management Review

Jack M ZuckermanDean G Assimos

Low urinary citrate excretion is a known risk factor for the development ofkidney stones. Citrate inhibits stone formation by complexing with calciumin the urine, inhibiting spontaneous nucleation, and preventing growth andagglomeration of crystals. Hypocitraturia is a common metabolic abnormalityfound in 20% to 60% of stone formers. It is most commonly idiopathic inorigin but may be caused by distal renal tubular acidosis, hypokalemia, boweldysfunction, and a high-protein, low-alkali diet. Genetic factors, medications,and other comorbid disorders also play a role. Hypocitraturia should be managedthrough a combination of dietary modifications, oral alkali, and possiblylemonade or other citrus juice–based therapy. This review concerns thepathophysiology of hypocitraturia and the management of stone formersafflicted with this abnormality.[Rev Urol. 2009;11(3):134-144 doi:10.3909/riu0424]© 2009 MedReviews®, LLC

HypocitraturiaCitrate metabolismCitrate pathophysiologyHypocitraturia etiologiesMedical management of stone diseaseAlkali citratePotassium citrateCitrus juiceLemonade

CK20 testView Articles
ClavienView Articles

Volume 17, Number 3Case Review

Treatment of Colonic Injury During Percutaneous Nephrolithotomy

Hakan Öztürk

Colonic injury during percutaneous nephrolithotomy (PCNL) persists despite the advances in technical equipment and interventional radiology techniques. According to the Clavien-Dindo classification of surgical complications, colonic injury is regarded as a stage IVa complication. Currently, the rate of colonic injury ranges between 0.3% and 0.5%, with an unremarkable difference in incidence between supine and prone PCNL procedures. Colon injury is the most significant complication of PCNL. Colonic injury can result in more complicated open exploration of the abdomen, involving colostomy construction. The necessity of a second operation for the closure of the colostomy causes financial and emotional burden on the patients, patients’ relatives, and surgeons. Currently, the majority of colonic injuries occurring during PCNL are retroperitoneal. The primary treatment option is a conservative approach. It must be kept in mind that the time of diagnosis is as important as the diagnosis itself in colonic injury. Surgeons performing PCNL are advised to be conservative when considering exploratory laparotomy and colostomy construction during treatment of colonic injury. We present the case of a 49-year-old woman who underwent left prone PCNL that resulted in retroperitoneal colonic injury, along with a review of the current literature. [Rev Urol. 2015;17(3):194-201 doi: 10.3909/riu0641] © 2015 MedReviews®, LLC

Percutaneous nephrolithotomyPreventionUrolithiasisColonic injuryClavienComplicationManagement

Clean intermittent catheterizationView Articles
Cleavers (Galium aparine)View Articles

Volume 15, Number 3Review Articles

Use of Herbal Supplements for Overactive Bladder

Management Update

Bilal ChughtaiFranklin C LoweElizabeth KavalerAlexis E TeRichard LeeSteven A Kaplan

Anticholinergics, specifically antimuscarinic agents, are the most common medications prescribed for overactive bladder (OAB). The most common side effects of these agents are dry mouth and constipation, although other more concerning effects include changes in blood pressure, pulse rate, or heart rhythm when treatment is initiated. Herbal treatments are an increasingly popular alternative for treating OAB. A 2002 survey of US adults aged ≥ 18 years conducted by the Centers for Disease Control and Prevention indicated that 74.6% of those with OAB had used some form of complementary and alternative medicine. The World Health Organization estimates that 80% of the world’s population presently uses herbal medicine for some aspect of primary health care. Women were more likely than men to use complementary and alternative medicine. The authors review the most commonly used herbal medications for OAB. [Rev Urol. 2013;15(3):93-96 doi: 10.3909/riu0587] © 2013 MedReviews®, LLC

Overactive bladderHerbal medicineGosha-jinki-ganHachi-mi-jio-ganBuchu (Barosma betuline)Cleavers (Galium aparine)Cornsilk (Zea mays)Horsetail (Equisetum)Ganoderma lucidumResinferatoxinCapsaicin

ClinicalView Articles

Volume 17, Number 4Review Articles

Sipuleucel-T for the Treatment of Patients With Metastatic Castrate-resistant Prostate Cancer: Considerations for Clinical Practice

Treatment Update

Dimitrios TelonisVladimir MouravievDavid AlbalaChristopher M Pieczonka

Sipuleucel-T treatment is associated with a significant and consistent survival benefit in patients with metastatic castrate-resistant prostate cancer. Most adverse events are infusion related, manageable, and of short duration. Early screening and diagnosis of metastatic disease is important, as the greatest survival benefit may occur in patients with a lower disease burden. The short duration of sipuleucel-T treatment facilitates the use of subsequent therapies. Sipuleucel-T is now being used in the clinic for patients with a lower disease burden. We present our own experience with the use of sipuleucel-T in the setting of a large urology practice. [Rev Urol. 2015;17(4):203-210 doi: 10.3909/riu0671] © 2016 MedReviews®, LLC

ImmunotherapyMetastatic castrate-resistant prostate cancerSipuleucel-TClinical

clinical codingView Articles
clinical decision-makingView Articles

Volume 23, Number 1Prostate Cancer

Specialty Networks Unveils Revised Advanced Prostate Cancer Clinical Guidelines

David MorrisBenjamin H. Lowentritt

In an ongoing effort to support independent urology practices’ work to provide first-class cancer care, Specialty Networks recently unveiled new, expanded clinical guidelines for advanced prostate cancer (PCa) treatment. (See the guidelines, packaged with this issue of Reviews in Urology.)

Prostatic neoplasmsNeoplasmpractice guidelinesclinical decision-making

Clinical evaluationView Articles
Clinical markersView Articles
Clinical stagingView Articles

Volume 8, Number 3Review Articles

The Importance of Pelvic Lymph Node Dissection in Men With Clinically Localized Prostate Cancer

Diagnostic Review

Mohamad E AllafAlan W PartinH Ballentine Carter

Despite advances in noninvasive staging, pelvic lymph node dissection (PLND) remains the most accurate means of detecting lymph node metastases in men with clinically localized prostate cancer. Nomograms exist that can identify patients at low risk for lymphatic metastases according to preoperative information. In general, it seems reasonable to omit PLND in men with a biopsy Gleason sum of 6 or less and a prostate-specific antigen level of 10 ng/mL or less. Ultimately, however, this decision should be made according to physician and patient preference, considering the low contemporary morbidity associated with PLND. When PLND is performed, studies suggest that an extended dissection maximizes the detection rate of nodal involvement. Retrospective data indicate that an extended dissection might play a therapeutic role in a subset of patients with a limited lymph node burden. However, this might be an artifact of stage migration, and prospective studies are needed to evaluate this further. [Rev Urol. 2006;8(3):112-119]

Prostate cancerNomogramsRadioimmunoscintigraphyLymphadenectomyClinical stagingMagnetic resonanceimagingAlgorithms

Clinical trial designView Articles
Clinical trial resultsView Articles
Clinical trialsView Articles

Volume 23, Number 3Bladder Cancer

Immune Checkpoint Inhibitors for the Treatment of Non–Muscle-Invasive Bladder Cancer: An Overview of Ongoing Clinical Trials

Neal D Shore

Treatment of non–muscle-invasive bladder cancer (NMIBC) is evolving, seeking new treatments to overcome the limitations of bacille Calmette-Guérin therapy and alternatives to radical cystectomy. Studies are currently evaluating the safety and efficacy of immune checkpoint inhibitors in combination with bacille Calmette-Guérin vs bacille Calmette-Guérin monotherapy for patients with high-risk NMIBC that is bacille Calmette-Guérin naive or recurrent after bacille Calmette-Guérin induction. We briefly summarize 4 studies that are evaluating intravenous immune checkpoint inhibitors (atezolizumab, durvalumab, and pembrolizumab) and 1 subcutaneous immune checkpoint inhibitor (sasanlimab). These studies may substantially change standard-of-care treatment for patients with high-risk NMIBC.

immune checkpoint inhibitorsMonoclonal antibodiesClinical trialsnon-muscle invasive bladder neoplasms

Clinical utilityView Articles

Volume 16, Number 4Review Articles

A Guide for Clinicians in the Evaluation of Emerging Molecular Diagnostics for Newly Diagnosed Prostate Cancer

Diagnosis Update

Judd W MoulH Jeffrey LawrenceAdam S KibelSteven E CanfieldPhillip G FebboMichael J Kemeter

Prostate-specific antigen (PSA) screening is associated with a decline in prostate cancerrelated mortality. However, screening has also led to overdiagnosis and overtreatment of clinically insignificant tumors. Recently, certain national guidelines (eg, US Preventive Services Task Force) have recommended against PSA screening, which may lead to a reverse-stage migration. Although many prostate tumors are indolent at presentation, others are aggressive and are appropriate targets for treatment interventions. Utilization of molecular markers may improve our ability to measure tumor biology and allow better discrimination of indolent and aggressive tumors at diagnosis. Many emerging commercial molecular diagnostic assays have been designed to provide more accurate risk stratification for newly diagnosed prostate cancer. Unfamiliarity with molecular diagnostics may make it challenging for some clinicians to navigate and interpret the medical literature to ascertain whether particular assays are appropriately developed and validated for clinical use. Herein, the authors provide a framework for practitioners to use when assessing new tissue-based molecular assays. This review outlines aspects of assay development, clinical and analytic validation and clinical utility studies, and regulatory issues, which collectively determine whether tests (1) are actionable for specific clinical indications, (2) measurably influence treatment decisions, and (3) are sufficiently validated to warrant incorporation into clinical practice. [Rev Urol. 2014;16(4):172-180 doi: 10.3909/riu0644] © 2014 MedReviews®, LLC

Prostate cancerBiomarkerClinical utilityGenomic prostate scoreAdverse pathologyClinical validationMolecular diagnostics

Clinical validationView Articles

Volume 16, Number 4Review Articles

A Guide for Clinicians in the Evaluation of Emerging Molecular Diagnostics for Newly Diagnosed Prostate Cancer

Diagnosis Update

Judd W MoulH Jeffrey LawrenceAdam S KibelSteven E CanfieldPhillip G FebboMichael J Kemeter

Prostate-specific antigen (PSA) screening is associated with a decline in prostate cancerrelated mortality. However, screening has also led to overdiagnosis and overtreatment of clinically insignificant tumors. Recently, certain national guidelines (eg, US Preventive Services Task Force) have recommended against PSA screening, which may lead to a reverse-stage migration. Although many prostate tumors are indolent at presentation, others are aggressive and are appropriate targets for treatment interventions. Utilization of molecular markers may improve our ability to measure tumor biology and allow better discrimination of indolent and aggressive tumors at diagnosis. Many emerging commercial molecular diagnostic assays have been designed to provide more accurate risk stratification for newly diagnosed prostate cancer. Unfamiliarity with molecular diagnostics may make it challenging for some clinicians to navigate and interpret the medical literature to ascertain whether particular assays are appropriately developed and validated for clinical use. Herein, the authors provide a framework for practitioners to use when assessing new tissue-based molecular assays. This review outlines aspects of assay development, clinical and analytic validation and clinical utility studies, and regulatory issues, which collectively determine whether tests (1) are actionable for specific clinical indications, (2) measurably influence treatment decisions, and (3) are sufficiently validated to warrant incorporation into clinical practice. [Rev Urol. 2014;16(4):172-180 doi: 10.3909/riu0644] © 2014 MedReviews®, LLC

Prostate cancerBiomarkerClinical utilityGenomic prostate scoreAdverse pathologyClinical validationMolecular diagnostics

CNS adverse eventsView Articles

Volume 9, Number 4Review Articles

Anticholinergics and Central Nervous System Effects: Are We Confused?

Treatment Update

Edward ZoltanDavid R Staskin

The central nervous system (CNS) effects of anticholinergic agents have been documented in various patient populations and to varying degrees in case reports, brain-activity surrogates, and computerized cognitive testing. The older patient population with overactive bladder represents a group at increased risk of cognitive impairment and other CNS side effects associated with antimuscarinic agents. The complexity of the effect of anticholinergic agents on CNS function requires an increased level of careful investigation. Studies need to be performed in the at-risk population with multiple, validated tests at clinically prescribed doses in acute and chronic situations. These studies need to take into account the effect of commonly prescribed dosing regimens, with doses selected to represent with equivalent bladder potency. The alterations in the serum levels and parent/metabolite effects contributed by metabolic issues or drug delivery systems require special attention. [Rev Urol. 2007;9(4):191-196]

Overactive bladderElderlyAntimuscarinic drugsCNS adverse eventsCognitive impairment

Cognitive impairmentView Articles

Volume 9, Number 4Review Articles

Anticholinergics and Central Nervous System Effects: Are We Confused?

Treatment Update

Edward ZoltanDavid R Staskin

The central nervous system (CNS) effects of anticholinergic agents have been documented in various patient populations and to varying degrees in case reports, brain-activity surrogates, and computerized cognitive testing. The older patient population with overactive bladder represents a group at increased risk of cognitive impairment and other CNS side effects associated with antimuscarinic agents. The complexity of the effect of anticholinergic agents on CNS function requires an increased level of careful investigation. Studies need to be performed in the at-risk population with multiple, validated tests at clinically prescribed doses in acute and chronic situations. These studies need to take into account the effect of commonly prescribed dosing regimens, with doses selected to represent with equivalent bladder potency. The alterations in the serum levels and parent/metabolite effects contributed by metabolic issues or drug delivery systems require special attention. [Rev Urol. 2007;9(4):191-196]

Overactive bladderElderlyAntimuscarinic drugsCNS adverse eventsCognitive impairment

Coil embolizationView Articles

Volume 19, Number 3Case Review

Surgical Solution to an Intracorporeal Nickel Allergy

Paul KozlowskiAndrew StammJared Brandenberger

A previously healthy 30-year-old man with a symptomatic varicocele underwent gonadal vein embolization using nickel vascular plugs. He developed a painful hypersensitivity to his nickel plugs and elected to pursue laparoscopic excision and proximal gonadal vein ligation. In the operating room, the gonadal vein was isolated from the ureter, and ligated proximal to the cephalad plug and distal to the caudal coil. His pain is completely resolved 5 months after surgery. Metal allergies are well documented in orthopedics and cardiology implants, but there are a limited number of case reports of metal allergies after varicocele embolization. Interestingly, nickel is the most common type of metal hypersensitivity. [Rev Urol. 2017;19(3):195–197 doi: 10.3909/riu0769] © 2017 MedReviews®, LLC

VaricoceleMetal allergyNickelCoil embolizationGonadal vein

CoitusView Articles
CollaborationView Articles

Volume 18, Number 3Review Articles

Urology Group Compensation and Ancillary Service Models in an Era of Value-based Care

Health Care Economics

Dana JacobyNeal D Shore

Changes involving the health care economic landscape have affected physicians’ workflow, productivity, compensation structures, and culture. Ongoing Federal legislation regarding regulatory documentation and imminent payment-changing methodologies have encouraged physician consolidation into larger practices, creating affiliations with hospitals, multidisciplinary medical specialties, and integrated delivery networks. As subspecialization and evolution of care models have accelerated, independent medical groups have broadened ancillary service lines by investing in enterprises that compete with hospital-based (academic and nonacademic) entities, as well as non–physician-owned multispecialty enterprises, for both outpatient and inpatient services. The looming and dramatic shift from volume- to value-based health care compensation will assuredly affect urology group compensation arrangements and productivity formulae. For groups that can implement change rapidly, efficiently, and harmoniously, there will be opportunities to achieve the Triple Aim goals of the Patient Protection and Affordable Care Act, while maintaining a successful medical-financial practice. In summary, implementing new payment algorithms alongside comprehensive care coordination will assist urology groups in addressing the health economic cost and quality challenges that have been historically encountered with fee-for-service systems. Urology group leadership and stakeholders will need to adjust internal processes, methods of care coordination, cultural dependency, and organizational structures in order to create better systems of care and management. In response, ancillary services and patient throughput will need to evolve in order to adequately align quality measurement and reporting systems across provider footprints and patient populations. [Rev Urol. 2016;18(3):143-150 doi: 10.3909/riu0726] © 2016 MedReviews®, LLC

Independent practiceCollaborationValue-based careSpecializationCompensation

CollagenView Articles
Collateral duplicationView Articles

Volume 18, Number 4Case Review

Collateral Urethral Duplication in an Adult With Adult Polycystic Kidney Disease

Lester Joesph PratsAmanda Feige SaltzmanDunia Taufiq Khaled

Duplications of the lower urinary tract are rare congenital anomalies that are usually accompanied by concomitant nonurologic anomalies; they are typically diagnosed in early childhood. In more rare cases these are isolated, leading to diagnosis later. We describe a 50-year-old man who remained asymptomatic and therefore undiagnosed for five decades. His is one of fewer than 20 cases in the literature describing urethral duplication in the coronal (collateral) plane, the more common variant being sagittal (dorsal-ventral) duplication. He is one of only four cases reported without concomitant midline anomaly. Furthermore, he is the sole case associated with adult polycystic kidney disease. [Rev Urol. 2016;18(4):242-245 doi: 10.3909/riu0705] © 2016 MedReviews®, LLC

Collateral duplicationCoronal duplicationDuplicate urethraUrethral anomalyDuplication of lower urinary tract

Colonic injuryView Articles

Volume 17, Number 3Case Review

Treatment of Colonic Injury During Percutaneous Nephrolithotomy

Hakan Öztürk

Colonic injury during percutaneous nephrolithotomy (PCNL) persists despite the advances in technical equipment and interventional radiology techniques. According to the Clavien-Dindo classification of surgical complications, colonic injury is regarded as a stage IVa complication. Currently, the rate of colonic injury ranges between 0.3% and 0.5%, with an unremarkable difference in incidence between supine and prone PCNL procedures. Colon injury is the most significant complication of PCNL. Colonic injury can result in more complicated open exploration of the abdomen, involving colostomy construction. The necessity of a second operation for the closure of the colostomy causes financial and emotional burden on the patients, patients’ relatives, and surgeons. Currently, the majority of colonic injuries occurring during PCNL are retroperitoneal. The primary treatment option is a conservative approach. It must be kept in mind that the time of diagnosis is as important as the diagnosis itself in colonic injury. Surgeons performing PCNL are advised to be conservative when considering exploratory laparotomy and colostomy construction during treatment of colonic injury. We present the case of a 49-year-old woman who underwent left prone PCNL that resulted in retroperitoneal colonic injury, along with a review of the current literature. [Rev Urol. 2015;17(3):194-201 doi: 10.3909/riu0641] © 2015 MedReviews®, LLC

Percutaneous nephrolithotomyPreventionUrolithiasisColonic injuryClavienComplicationManagement

Color Doppler imagingView Articles