How well do polygenic risk scores identify men at high risk for prostate cancer? Systematic review and meta-analysis

OBJECTIVES

Genome-wide association studies have revealed over 200 genetic susceptibility loci for prostate cancer (PCa). By combining them, polygenic risk scores (PRS) can be generated to predict risk of PCa. We summarize the published evidence and conduct meta-analyses of PRS as a predictor of PCa risk in Caucasian men.

PATIENTS AND METHODS

Data were extracted from 59 studies, with 16 studies including 17 separate analyses used in the main meta-analysis with a total of 20,786 cases and 69,106 controls identified through a systematic search of ten databases. Random effects meta-analysis was used to obtain pooled estimates of area under the receiver-operating characteristic curve (AUC). Meta-regression was used to assess the impact of number of single-nucleotide polymorphisms (SNPs) incorporated in PRS on AUC. Heterogeneity is expressed as I² scores. Publication bias was evaluated using funnel plots and Egger tests.

RESULTS

The ability of PRS to identify men with PCa was modest (pooled AUC 0.63, 95% CI 0.62-0.64) with moderate consistency (I² 64%). Combining PRS with clinical variables increased the pooled AUC to 0.74 (0.68-0.81). Meta-regression showed only negligible increase in AUC for adding incremental SNPs. Despite moderate heterogeneity, publication bias was not evident.

CONCLUSION

Typically, PRS accuracy is comparable to PSA or family history with a pooled AUC value 0.63 indicating mediocre performance for PRS alone.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

Conservative treatment for urinary incontinence in Men After Prostate Surgery (MAPS): two parallel randomised controlled trials

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of active conservative treatment, compared with standard management, in regaining urinary continence at 12 months in men with urinary incontinence at 6 weeks after a radical prostatectomy or a transurethral resection of the prostate (TURP).

BACKGROUND

Urinary incontinence after radical prostate surgery is common immediately after surgery, although the chance of incontinence is less after TURP than following radical prostatectomy.

DESIGN

Two multicentre, UK, parallel randomised controlled trials (RCTs) comparing active conservative treatment [pelvic floor muscle training (PFMT) delivered by a specialist continence physiotherapist or a specialist continence nurse] with standard management in men after radial prostatectomy and TURP.

SETTING

Men having prostate surgery were identified in 34 centres across the UK. If they had urinary incontinence, they were invited to enroll in the RCT.

PARTICIPANTS

Men with urinary incontinence at 6 weeks after prostate surgery were eligible to be randomised if they consented and were able to comply with the intervention.

INTERVENTIONS

Eligible men were randomised to attend four sessions with a therapist over a 3-month period. The therapists provided standardised PFMT and bladder training for male urinary incontinence and erectile dysfunction. The control group continued with standard management.

MAIN OUTCOME MEASURES

The primary outcome of clinical effectiveness was urinary incontinence at 12 months after randomisation, and the primary measure of cost-effectiveness was incremental cost per quality-adjusted life-year (QALY). Outcome data were collected by postal questionnaires at 3, 6, 9 and 12 months.

RESULTS

Within the radical group (n = 411), 92% of the men in the intervention group attended at least one therapy visit and were more likely than those in the control group to be carrying out any PFMT at 12 months {adjusted risk ratio (RR) 1.30 [95% confidence interval (CI) 1.09 to 1.53]}. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (75.5%) and control (77.4%) groups was -1.9% (95% CI -10% to 6%). NHS costs were higher in the intervention group [£ 181.02 (95% CI £ 107 to £ 255)] but there was no evidence of a difference in societal costs, and QALYs were virtually identical for both groups. Within the TURP group (n = 442), over 85% of men in the intervention group attended at least one therapy visit and were more likely to be carrying out any PFMT at 12 months after randomisation [adjusted RR 3.20 (95% CI 2.37 to 4.32)]. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (64.9%) and control (61.5%) groups for the unadjusted intention-to-treat analysis was 3.4% (95% CI -6% to 13%). NHS costs [£ 209 (95% CI £ 147 to £ 271)] and societal costs [£ 420 (95% CI £ 54 to £ 785)] were statistically significantly higher in the intervention group but QALYs were virtually identical.

CONCLUSIONS

The provision of one-to-one conservative physical therapy for men with urinary incontinence after prostate surgery is unlikely to be effective or cost-effective compared with standard care that includes the provision of information about conducting PFMT. Future work should include research into the value of different surgical options in controlling urinary incontinence.

Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence (SUI) through systematic review and economic modelling.

DATA SOURCES

The Cochrane Incontinence Group Specialised Register, electronic databases and the websites of relevant professional organisations and manufacturers, and the following databases: CINAHL, EMBASE, BIOSIS, Science Citation Index and Social Science Citation Index, Current Controlled Trials, ClinicalTrials.gov and the UKCRN Portfolio Database.

STUDY SELECTION

The study comprised three distinct elements. (1) A survey of 188 women with SUI to identify outcomes of importance to them (activities of daily living; sex, hygiene and lifestyle issues; emotional health; and the availability of services). (2) A systematic review and meta-analysis of non-surgical treatments for SUI to find out which are most effective by comparing results of trials (direct pairwise comparisons) and by modelling results (mixed-treatment comparisons - MTCs). A total of 88 randomised controlled trials (RCTs) and quasi-RCTs reporting data from 9721 women were identified, considering five generic interventions [pelvic floor muscle training (PFMT), electrical stimulation (ES), vaginal cones (VCs), bladder training (BT) and serotonin-noradrenaline reuptake inhibitor (SNRI) medications], in many variations and combinations. Data were available for 37 interventions and 68 treatment comparisons by direct pairwise assessment. Mixed-treatment comparison models compared 14 interventions, using data from 55 trials (6608 women). (3) Economic modelling, using a Markov model, to find out which combinations of treatments (treatment pathways) are most cost-effective for SUI.

DATA EXTRACTION

Titles and abstracts identified were assessed by one reviewer and full-text copies of all potentially relevant reports independently assessed by two reviewers. Any disagreements were resolved by consensus or arbitration by a third person.

RESULTS

Direct pairwise comparison and MTC analysis showed that the treatments were more effective than no treatment. Delivering PFMT in a more intense fashion, either through extra sessions or with biofeedback (BF), appeared to be the most effective treatment [PFMT extra sessions vs no treatment (NT) odds ratio (OR) 10.7, 95% credible interval (CrI) 5.03 to 26.2; PFMT + BF vs NT OR 12.3, 95% CrI 5.35 to 32.7]. Only when success was measured in terms of improvement was there evidence that basic PFMT was better than no treatment (PFMT basic vs NT OR 4.47, 95% CrI 2.03 to 11.9). Analysis of cost-effectiveness showed that for cure rates, the strategy using lifestyle changes and PFMT with extra sessions followed by tension-free vaginal tape (TVT) (lifestyle advice-PFMT extra sessions-TVT) had a probability of greater than 70% of being considered cost-effective for all threshold values for willingness to pay for a QALY up to 50,000 pounds. For improvement rates, lifestyle advice-PFMT extra sessions-TVT had a probability of greater than 50% of being considered cost-effective when society's willingness to pay for an additional QALY was more than 10,000 pounds. The results were most sensitive to changes in the long-term performance of PFMT and also in the relative effectiveness of basic PFMT and PFMT with extra sessions.

LIMITATIONS

Although a large number of studies were identified, few data were available for most comparisons and long-term data were sparse. Challenges for evidence synthesis were the lack of consensus on the most appropriate method for assessing incontinence and intervention protocols that were complex and varied considerably across studies.

CONCLUSIONS

More intensive forms of PFMT appear worthwhile, but further research is required to define an optimal form of more intensive therapy that is feasible and efficient for the NHS to provide, along with further definitive evidence from large, well-designed studies.

Systematic review of the clinical effectiveness and cost-effectiveness of photodynamic diagnosis and urine biomarkers (FISH, ImmunoCyt, NMP22) and cytology for the detection and follow-up of bladder cancer

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of photodynamic diagnosis (PDD) compared with white light cystoscopy (WLC), and urine biomarkers [fluorescence in situ hybridisation (FISH), ImmunoCyt, NMP22] and cytology for the detection and follow-up of bladder cancer.

DATA SOURCES

Major electronic databases including MEDLINE, MEDLINE In-Process, EMBASE, BIOSIS, Science Citation Index, Health Management Information Consortium and the Cochrane Controlled Trials Register were searched until April 2008.

REVIEW METHODS

A systematic review of the literature was carried out according to standard methods. An economic model was constructed to assess the cost-effectiveness of alternative diagnostic and follow-up strategies for the diagnosis and management of patients with bladder cancer.

RESULTS

In total, 27 studies reported PDD test performance. In pooled estimates [95% confidence interval (CI)] for patient-level analysis, PDD had higher sensitivity than WLC [92% (80% to 100%) versus 71% (49% to 93%)] but lower specificity [57% (36% to 79%) versus 72% (47% to 96%)]. Similar results were found for biopsy-level analysis. The median sensitivities (range) of PDD and WLC for detecting lower risk, less aggressive tumours were similar for patient-level detection [92% (20% to 95%) versus 95% (8% to 100%)], but sensitivity was higher for PDD than for WLC for biopsy-level detection [96% (88% to 100%) versus 88% (74% to 100%)]. For more aggressive, higher-risk tumours the median sensitivity of PDD for both patient-level [89% (6% to 100%)] and biopsy-level [99% (54% to 100%)] detection was higher than those of WLC [56% (0% to 100%) and 67% (0% to 100%) respectively]. Four RCTs comparing PDD with WLC reported effectiveness outcomes. PDD use at transurethral resection of bladder tumour resulted in fewer residual tumours at check cystoscopy [relative risk, RR, 0.37 (95% CI 0.20 to 0.69)] and longer recurrence-free survival [RR 1.37 (95% CI 1.18 to 1.59)] compared with WLC. In 71 studies reporting the performance of biomarkers and cytology in detecting bladder cancer, sensitivity (95% CI) was highest for ImmunoCyt [84% (77% to 91%)] and lowest for cytology [44% (38% to 51%)], whereas specificity was highest for cytology [96% (94% to 98%)] and lowest for ImmunoCyt [75% (68% to 83%)]. In the cost-effectiveness analysis the most effective strategy in terms of true positive cases (44) and life-years (11.66) [flexible cystoscopy (CSC) and ImmunoCyt followed by PDD in initial diagnosis and CSC followed by WLC in follow-up] had an incremental cost per life-year of over 270,000 pounds. The least effective strategy [cytology followed by WLC in initial diagnosis (average cost over 20 years 1403 pounds, average life expectancy 11.59)] was most likely to be considered cost-effective when society's willingness to pay was less than 20,000 pounds per life-year. No strategy was cost-effective more than 50% of the time, but four of the eight strategies in the probabilistic sensitivity analysis (three involving a biomarker or PDD) were each associated with a 20% chance of being considered cost-effective. In sensitivity analyses the results were most sensitive to the pretest probability of disease (5% in the base case).

CONCLUSIONS

The advantages of PDD's higher sensitivity in detecting bladder cancer have to be weighed against the disadvantages of a higher false-positive rate. Taking into account the assumptions made in the model, strategies involving biomarkers and/or PDD provide additional benefits at a cost that society might be willing to pay. Strategies replacing WLC with PDD provide more life-years but it is unclear whether they are worth the extra cost.

Outcomes of stenting after uncomplicated ureteroscopy: systematic review and meta-analysis

OBJECTIVE

To investigate the potential beneficial and adverse effects of routine ureteric stent placement after ureteroscopy.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Cochrane controlled trials register (2006 issue 2), Embase, and Medline (1966 to 31 March 2006), without language restrictions. Review methods We included all randomised controlled trials that reported various outcomes with or without stenting after ureteroscopy. Two reviewers independently extracted data and assessed quality. Meta-analyses used both fixed and random effects models with dichotomous data reported as relative risk and continuous data as a weighted mean difference with 95% confidence intervals.

RESULTS

Nine randomised controlled trials (reporting 831 participants) were identified. The incidence of lower urinary tract symptoms was significantly higher in participants who had a stent inserted (relative risk 2.25, 95% confidence interval 1.14 to 4.43, for dysuria; 2.00, 1.11 to 3.62, for frequency or urgency) after ureteroscopy. There was no significant difference in postoperative requirement for analgesia, urinary tract infections, stone free rate, and ureteric strictures in the two groups. Because of marked heterogeneity, formal pooling of data was not possible for some outcomes such as flank pain. A pooled analysis showed a reduced likelihood of unplanned medical visits or admission to hospital in the group with stents (0.53, 0.17 to 1.60), although this difference was not significant. None of the trials reported on health related quality of life. Cost reported in three randomised controlled trials favoured the group without stents. The overall quality of trials was poor and reporting of outcomes inconsistent.

CONCLUSIONS

Patients with stents after ureteroscopy have significantly higher morbidity in the form of irritative lower urinary symptoms with no influence on stone free rate, rate of urinary tract infection, requirement for analgesia, or long term ureteric stricture formation. Because of the marked heterogeneity and poor quality of reporting of the included trials, the place of stenting in the management of patients after uncomplicated ureteroscopy remains unclear.

Short term urinary catheter policies following urogenital surgery in adults

BACKGROUND

Urinary catheterisation (by the urethral or suprapubic routes) is common following urogenital surgery. There is no consensus on how to minimize complications and practice varies.

OBJECTIVES

To establish the optimal way to manage urinary catheters following urogenital surgery in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised trials register (searched 30 May 2005) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials were identified. Studies were excluded if they were not randomised or quasi-randomised trials of adults being catheterised following urogenital surgery.

DATA COLLECTION AND ANALYSIS

Data collection was performed independently by two of the review authors and cross-checked. Where data might have been collected but not reported, clarification was sought from the trialists.

MAIN RESULTS

Thirty nine randomised trials were identified for inclusion in the review. They were generally small and of poor or moderate quality reporting data on only few outcomes. Confidence intervals were all wide. USING A URINARY CATHETER VERSUS NOT USING ONE: The data from five trials were heterogeneous but tended to indicate a higher risk of (re)catheterisation if a catheter was not used postoperatively. The data gave only an imprecise estimate of any difference in urinary tract infection. URETHRAL CATHETERISATION VERSUS SUPRAPUBIC CATHETERISATION: In six trials, a greater number of people needed to be recatheterised if a urethral catheter rather than a suprapubic one was used following surgery (RR 3.66, 95% CI 1.41 to 9.49). SHORTER POSTOPERATIVE DURATION OF CATHETER USE VERSUS LONGER DURATION: In 11 trials, the seven trials with data suggested fewer urinary tract infections when a catheter was removed earlier (for example 1 versus 3 days, RR 0.50, 95% CI 0.29 to 0.87) with no pattern in respect of catheterisation. CLAMP AND RELEASE POLICIES BEFORE CATHETER REMOVAL VERSUS IMMEDIATE CATHETER REMOVAL: In a single small trial, the clamp-and-release group showed a significantly greater incidence of urinary tract infections (RR 4.00, 95% 1.55 to 10.29) and a delay in return to normal voiding (RR 2.50, 95% CI 1.16 to 5.39).

AUTHORS' CONCLUSIONS

Despite reviewing 39 eligible trials, few firm conclusions could be reached because of the multiple comparisons considered, the small size of individual trials, and their low quality. Whether or not to use a particular policy is usually a trade-off between the risks of morbidity (especially infection) and risks of recatheterisation.

Does retrograde balloon dilation compromise outcome of secondary open pyeloplasty: 17 Years’ experience at a single center

OBJECTIVES

To determine whether the outcome of secondary open pyeloplasty is compromised by previous retrograde balloon dilation.

METHODS

Patients undergoing secondary open pyeloplasty after retrograde balloon dilation (n = 25) were compared with a similar group undergoing primary open pyeloplasty (n = 25) at the same institution. Patients were assessed by renography before and after surgery, and postoperative success was determined by the complete absence of pain.

RESULTS

In the primary pyeloplasty group, the success rate was 96%, with a mean follow-up of 33 months (range 17 to 53). In the secondary pyeloplasty group, the success rate was 88%, with a mean follow-up of 20 months (range 9 to 32). No statistically significant difference was found in the success rates between the two groups (P = 0.6).

CONCLUSIONS

Treatment failures after retrograde balloon dilation can be salvaged by secondary pyeloplasty with no detriment to the chance of long-term success compared with primary pyeloplasty.

IS ORTHOTOPIC BLADDER REPLACEMENT THE NEW GOLD STANDARD? EVIDENCE FROM A SYSTEMATIC REVIEW

PURPOSE

In this systematic review we determined whether the outcome of orthotopic bladder replacement is superior to that of continent and incontinent urinary diversion.

MATERIALS AND METHODS

We searched MEDLINE, PubMed, EMBASE, CINAHL and the Cochrane Library from January 1990 to January 2003. A total of 3,370 abstracts were reviewed, including all types of studies from prospective, randomized, controlled studies to small, retrospective series. All relevant articles with at least 10 patients and a mean followup of at least 1 year were retrieved. There were no language restrictions. NonEnglish articles were translated. Comparisons were made between the major surgery types, including ileal conduit, continent diversion, bladder reconstruction and bladder replacement. All studies were scored using a predetermined quality assessment checklist to assess internal validity (bias and confounding) and external validity.

RESULTS

A total of 405 studies met inclusion criteria. There were 32 prospective and 373 retrospective studies describing a total of 32,795 patients. The majority of studies were incompletely or poorly described and outcomes were often not defined. When they were defined, definitions varied. In clinical outcomes ileal conduit diversions had the lowest operative complications rate but highest reported postoperative morbidity. They also had a higher reported incidence of symptomatic urinary tract infections. The rates of postoperative morbidity, mortality and need for reoperation varied widely among studies even for the same procedure. Of physiological outcomes metabolic acidosis was the most commonly reported metabolic complication in patients with various urinary diversions. The quality of the reported literature was poor. There were no studies of the health economic implications of performing 1 type of surgery vs another type.

CONCLUSIONS

While enthusiasts regard orthotopic bladder replacement as the new gold standard when lower urinary tract function must be replaced, the level and quality of current evidence are poor. The immediate concern must be to rectify this paucity of evidence with well designed and well reported prospective studies, ideally in a randomized setting, comparing the various major forms of urinary diversion and bladder replacement surgery.

THE BLADDER DOES NOT APPEAR TO HAVE A DYNAMIC SECRETED CONTINUOUS MUCOUS GEL LAYER

PURPOSE

We determined whether the nature of any protective barrier in the bladder is composed of a secreted mucous gel layer.

MATERIALS AND METHODS

We collected 24-hour urine samples for analysis from 8 healthy 22 to 49-year-old volunteers and 5, 19 to 59-year-old patients treated with bladder reconstruction, in addition to scrapings from 100 freshly slaughtered pig bladders. Samples were subjected to homogenization, dialysis, freeze-drying, papain digestion, gel chromatography, equilibrium density gradient centrifugation, periodic acid-Schiff assay and amino acid analysis. Normal human bladder, pig bladder, normal ileum and transposed intestinal segments were studied for the presence of a mucous layer using a new method of histological analysis.

RESULTS

Mucin content in normal urine is 2.7 mg/24 hours, meaning that less than 0.6% of nondialyzable material in normal urine is mucin. The mucin content of urine from reconstructed bladders amounted to 86 mg/24 hours (5.2% of nondialyzable material). We observed that glycosaminoglycans accounted for 41% of the peak total elution volume of PAS positive material in normal urine. Mucin estimation in urine can be grossly overestimated if contaminating glycoconjugates are not removed. Biochemical analysis of material scraped off the pig bladder surface demonstrated that the maximum thickness of a continuous layer that could be achieved was 13.6 mum. While we could visualize an obvious mucous layer on control ileal samples and biopsies of transposed ileal segments from patients with bladder reconstruction, we were unable to note a distinct, measurable mucous layer lining the bladder surface in humans or pigs.

CONCLUSIONS

Mucin levels in normal human and pig urine would be enough for slow turnover of a thin barrier but the large increase in mucin in the urine of patients with transposed intestinal segments demonstrates that any layer in normal bladder is much different than that lining the transposed intestinal segment. The most likely constituents of this barrier are membrane bound rather than secreted mucins along with the proteoglycan components of the glycocalix.

Characterization of Escherichia coli strains causing urinary tract infections in patients with transposed intestinal segments

PURPOSE

Transposition of intestinal segments into the urinary tract predisposes to urinary tract infections. We characterized bacterial infections in these patients and examined the virulence genotype and persistence of Escherichia coli isolates.

MATERIALS AND METHODS

We followed 26 patients who underwent bladder reconstructive surgery using transposed intestinal segments. E. coli strains isolated from the urine of these patients were genotyped for established virulence determinants and the frequency of carriage was compared with E. coli strains isolated from community acquired urinary infections and the fecal flora of anonymous volunteers. A longitudinal study of E. coli strains in 9 patients was also done using pulsed field gel electrophoresis.

RESULTS

E. coli was the most frequently isolated organism, responsible for 59% (62 of 105) of monobacterial infections. Other bacteria isolated included Klebsiella species, Proteus species and Enterococcus faecalis. Community acquired E. coli strains were more likely to carry multiple determinants for particular adhesins (P and S fimbriae) and toxins (alpha-hemolysin and cytotoxic necrotizing factor) than fecal strains. Carriage frequency for bladder reconstruction strains was intermediary and not significantly different. The key finding was that E. coli strains persisted for prolonged periods, including 2 years in certain patients, often despite various antimicrobial treatments.

CONCLUSIONS

This study highlights that further steps must be taken to prevent and treat urinary tract infections in this susceptible group. Particular attention should be given to the treatment of persistent infections.

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

BACKGROUND

Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments.

OBJECTIVES

To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group's specialised register (3 May 2001), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2001), MEDLINE (1966 to May 2001), PREMEDLINE (4 June 2001), Dissertation Abstracts (18.6.2001) and the reference lists of relevant articles. Date of most recent search: June 2001.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for appropriateness for inclusion and for methodological quality by the reviewers. Three reviewers were involved in the data extraction. The data collected was then analysed for statistical significance.

MAIN RESULTS

Two trials met the inclusion criteria with a total of 164 participants. These trials addressed only four of the 14 comparisons pre-specified in the protocol. There were no statistically significant differences found in the incidence of upper urinary tract infection, ureterointestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. There was no evidence of a difference in incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions. The confidence intervals were all wide, however, and did not rule out important differences. There was some limited evidence that use of the more complex nipple valve at the ureteroileal anastomosis was more likely to lead to upper tract deterioration than implantation into a non-detubularised, isoperistaltic ileal afferent limb.

REVIEWER'S CONCLUSIONS

The evidence from the included trials was very limited. Only two studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The small amount of usable evidence for this review suggests that collaborative multicentre studies should be organised, using random allocation where possible.

Adrenergic drugs for urinary incontinence in adults

BACKGROUND

Adrenergic drugs have been used for the treatment of urinary incontinence. However, they have generally been considered to be ineffective or to have side effects which may limit their clinical use.

OBJECTIVES

To determine the effectiveness of adrenergic agonists in the treatment of urinary incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (January 2002) and the reference lists of relevant articles. Date of the most recent searches: January 2002.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which include an adrenergic agonist drug in at least one arm for adults with urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Collaboration Handbook.

MAIN RESULTS

Fifteen randomised trials were identified, which included 832 women, of whom 506 received an adrenergic drug (phenylpropanolamine in 11 trials, Midodrine in two and Clenbuterol in another two). Of these, six were crossover trials. No trials included men. The limited evidence suggested that an adrenergic agonist drug is better than placebo in reducing number of pad changes and incontinence episodes, as well as improvement in subjective symptoms. The drugs also appeared to be better than pelvic floor muscle training in two small trials, possibly reflecting relative acceptability of the treatments to women but perhaps due to differential withdrawal of women from the trial groups. There was not enough evidence to evaluate the use of higher compared to lower doses of adrenergic agonists nor the relative merits of an adrenergic agonist drug compared with oestrogen, whether used alone or in combination.

REVIEWER'S CONCLUSIONS

There was weak evidence to suggest that use of an adrenergic agonist is better than placebo treatment. There was not enough evidence to assess the effects of adrenergic agonists when compared to or combined with other treatments. Patients using adrenergic agonists may suffer from minor side effects, only occasionally leading them to stop treatment. Rare but serious side effects such as cardiac arrhythmias and hypertension have been reported, however.

Periurethral injection therapy for urinary incontinence in women

BACKGROUND

Stress urinary incontinence is a common, troublesome symptom amongst adult women. Periurethral injection of bulking agents is a surgical procedure used for the treatment of urinary incontinence.

OBJECTIVES

To assess the effects of periurethral injection therapy in the treatment of urinary incontinence in women.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (February 2003), MEDLINE (January 1996 to January 2003), PREMEDLINE (7 February 2003) and the reference lists of relevant articles. Date of the most recent searches: February 2003.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for urinary incontinence, in which at least one management arm involved periurethral injection therapy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality of each study using explicit criteria. Data extraction was undertaken independently using a standard form and clarification concerning possible unreported data sought directly from the investigators.

MAIN RESULTS

We identified seven trials that met the inclusion criteria. The limited data available prevented meta-analysis. Injection of autologous fat was compared to placebo in a study of 68 women which was terminated early because of safety concerns. No differences in subjective or objective outcome were found in the two groups. No studies were found comparing injection therapy with conservative treatment. The single study that compared injection with a variety of surgical management in 133 women found no significant difference in subjective outcome but did note significantly better objective outcome in the surgical group. The four studies that compared different agents found that silicone particles and carbon spheres gave improvement at 12 months equivalent to collagen. A comparison of paraurethral and transurethral methods of delivery of the bulking agent found similar outcome but a higher rate of early complications in the paraurethral group.

REVIEWER'S CONCLUSIONS

Data from the available randomised trials suggest, but do not prove, that periurethral injection of established manufactured bulking agents results in subjective and objective short term improvement of symptomatic female stress urinary incontinence in adults. Future recommendation as a first line treatment would require evidence of patient benefit and cost-effectiveness from randomised trials involving placebo and conservative treatment arms. Future studies should also record long-term outcome and monitor for delayed particle migration. Injection therapy is probably inferior to surgery but a long term comparative study against a single standard procedure (Burch colposuspension) is required to prove this. It is recommended that phase III studies of newer agents will not be worthwhile until the aforementioned trials have been performed and a rationale for the use of injection therapy decided. For women with extensive co-morbidity precluding anaesthesia, injection therapy may represent a useful option for relief of symptoms for a 12 month period although 2 or 3 injections are likely to be required to achieve a satisfactory result.

Reducing mucus production after urinary reconstruction: a prospective randomized trial

PURPOSE

After transposition into the urinary tract, intestinal segments continue to produce mucus. We determine the effectiveness of muco-regulatory drugs, including N-acetylcysteine, aspirin and ranitidine, in reducing mucus secretion and urine viscosity in patients with transposed segments.

MATERIALS AND METHODS

Our trial was a prospective randomized, double-blind placebo controlled crossover study involving 12 patients who underwent ileal conduit and 31 who underwent bladder reconstruction. Each treatment lasted 3 weeks with a 2-week washout. Pretreatment and posttreatment 24-hour urine samples were analyzed for mucin and viscosity after papain digestion, sodium dodecyl sulfate-polyacrylamide gel electrophoresis and periodic acid-Schiff assay. A disease specific questionnaire and SF-36 quality of life survey were completed.

RESULTS

According to the questionnaire, mucus production did not decrease with time in 67% of patients. Mucin comprised 3% of the total nondialyzable material in urine (65 mg./24-hour for ileal conduit and 60 mg./24-hour for bladder reconstruction). Analysis of questionnaires and laboratory results failed to demonstrate any benefit of taking muco-regulatory agents compared with placebo.

CONCLUSIONS

The use of N-acetylcysteine, aspirin and ranitidine did not result in a reduction in mucin production, urine viscosity or improvement in quality of life.

Mucin gene expression in human urothelium and in intestinal segments transposed into the urinary tract

PURPOSE

The repertoire of mucin (MUC) gene expression in the normal human urothelium is poorly defined and the alterations in MUC gene expression following transposition of intestinal segments into the urinary tract has not previously been studied. The aims of this study were to define MUC gene expression in the normal human urothelium; and in transposed intestinal segments.

MATERIALS AND METHODS

Non-isotopic in-situ hybridization was carried out using eight digoxigenin labeled oligonucleotide mucin gene probes (MUC 1 - 7). Immunohistochemistry using NCL-MUC1 and NCL-MUC2 monoclonal antibodies was performed on sections of paraffin-embedded tissues. Twenty-seven patients were investigated (normal human urothelium, n = 6; transposed ileal segments, n = 14 and normal ileal controls, n = 7).

RESULTS

MUC1 and MUC4 were the predominant mucin genes expressed in the normal urothelium with MUC3 being expressed in a third of cases studied; MUC2, 5AC, 5B, 6 and 7 were not expressed. Despite the morphological changes seen in transposed ileal segments, MUC2 and MUC3 continued to be expressed in these segments albeit in a disorganised fashion. Both MUC1 and MUC4 were up-regulated in transposed ileal segments, genes expressed by the normal human urothelium. All eight mucin genes were expressed in an area of pyloric-type metaplasia found in one transposed ileal segment. In patients with clam enterocystoplasty there was evidence of increasing up-regulation of MUC2, 3, 4 and 5AC expression in the urothelium toward the anastomotic site.

CONCLUSION

Transposition of ileal segments into the urinary tract results in up-regulation of MUC1 and MUC4, the predominant MUC genes expressed in the human bladder. The clinical implication of the up-regulation of some MUC genes toward the anastomotic site in patients with an enteroplasty and the aberrant expression of MUC5AC - MUC7 by transposed segments is at present unclear.

The suspected scaphoid fracture. How useful is a unit policy?

The records of 196 patients presenting with a clinical suspicion of scaphoid injury were reviewed to evaluate how junior accident and emergency doctors in a teaching hospital managed these patients. The management that was provided was assessed, and it was ascertained whether the presence of a unit policy meant that accident and emergency junior trainees managed patients accordingly. We found that 82% of patients were immobilized for 2 to 13 weeks, with 60 patients (37%) being immobilized for 6 weeks or more. Of the 196 patients presenting with clinical suspicion of scaphoid fracture, a definite scaphoid fracture was found in only 12%. Less than half of the patients (46%) were reviewed by senior accident and emergency doctors or by senior orthopaedic surgeons. Despite the presence of a unit policy, patients were being immobilized for prolonged periods in the absence of a radiographically evident scaphoid fracture. Advice from more experienced members of the staff was not being sought in dubious cases.

Bowel dysfunction after bladder reconstruction

PURPOSE

Bowel function may be disturbed after intestinal segments are used in urinary reconstruction. The etiology of this condition and its incidence in different patient groups is unclear. We studied the incidence of bowel disturbance in patients who underwent bladder replacement, continent diversion, enterocystoplasty for idiopathic detrusor instability and ileal conduit diversion.

MATERIALS AND METHODS

We evaluated 71 patients after ileal conduit diversion and 82 after bladder reconstruction, including clam enterocystoplasty for detrusor instability in 28, neurogenic bladder dysfunction in 26 and nonneuropathic conditions in 28. We noted the severity of symptoms, such as frequency of defecation, nocturnal diarrhea, flatus leakage, fecal urgency, fecal incontinence and explosive diarrhea, as well as quality of life.

RESULTS

Of the patients who underwent bladder reconstruction 24% had symptoms of bowel dysfunction preoperatively and 42% of those who were asymptomatic preoperatively described new bowel symptoms postoperatively. These symptoms were most common and severe in 54% of patients after clam enterocystoplasty for detrusor instability compared to 26% with neuropathy, 14% with a nonneuropathic condition and 15% with an ileal conduit. Compared to those in other groups patients who underwent enterocystoplasty for detrusor instability had a significantly higher incidence of nocturnal bowel movements (18 versus less than 4%, p <0.01), flatus leakage (29 versus less than 8%, p <0.01), fecal urgency (39 versus less than 12%, p <0.001) and fecal incontinence (32 versus less than 16%, p <0.001). The length of ileum used for clam enterocystoplasty was only slightly greater than that used for ileal conduit operations (25 versus 18 cm.). Of the patients who underwent enterocystoplasty for detrusor instability 29% regretted undergoing the procedure due to subsequent bowel symptoms.

CONCLUSIONS

After enterocystoplasty for detrusor instability patients are at risk of significant bowel symptoms. The development of new bowel symptoms was associated with poor patient satisfaction.