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Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 9-10

Round up

Chairman Urology and Kidney Transplant, Medanta the Medicity, Gurugram, Haryana, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Anil Mandhani
Chairman Urology and Kidney Transplant, Medanta the Medicity, Gurugram, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/iju.IJU_372_17

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How to cite this article:
Mandhani A. Round up. Indian J Urol 2018;34:9-10

How to cite this URL:
Mandhani A. Round up. Indian J Urol [serial online] 2018 [cited 2022 Sep 26];34:9-10. Available from:

According to 2016 statistics, around 100 of a total of 11,369 journals indexed by Thomson Reuters were on urology. With such a vast amount of information at our disposal, we urologists interpret literature and form guidelines to bring in uniformity in patient care so as to achieve the best outcomes. However, it remains an enigma whether this ever-increasing knowledge has actually brought in any change in real-life practices.

The observation by Pradère et al. about variations in recommendations for various guidelines is worth noticing.[1] With the same literature pool, three different associations have derived three different guidelines based on the grade of recommendation and quality of evidence. For example, a 1.5 cm renal pelvic stone should be best treated by either extracorporeal shock wave lithotripsyor flexible ureterorenoscopy as per the American Urological Association (AUA) guidelines, whereas the European Urological Association (EUA) guidelines state that percutaneous nephrolithotomy should be one of the treatment options. Similarly, stone size below which observation is recommended for asymptomatic renal stones varies as 10 mm, 7 mm, and 6 mm as per the AUA, SIU, and EUA guidelines, respectively. This highlights the inadequacy of evidence and limitation of interpretation. Hence, the level of evidence should not be considered the gospel truth, and expert opinion is equally valuable if it leads to the best stone clearance outcomes.

There is increasing use of retrograde intrarenal surgery over shock wave lithotripsy (SWL) for treating small but symptomatic renal stones. A study in 320 patients studied the long-term (up to 2 years) effects of shock waves used to treat renal stones of <1.5 cm. The extent of renal injury was assessed by changes in renal function and urinary levels of Procollagen III amino-terminal propeptide (PIIINP), a marker of renal fibrosis and as well as by the incidence of worsening blood pressure control.[2] Urinary levels of PIIINP after a single session of SWL increased for up to 1-year posttreatment, followed by a gradual return to the baseline level at 2 years. Although there was no control arm, the number of patients requiring additional antihypertensive therapy was 36.4%. Another 10% of patients developed new-onset hypertension by the end of 2 years of follow-up, which is much higher than the natural incidence in a similar age group and time duration. The study also observed a statistically significant increase in the overall serum creatinine level at the end of the 2-year follow-up. The divide between theory and research can be bridged by the scientific norm of logical reasoning. We need more scientific evidence by conducting well designed studies, to assess the long-term effects of SWL before we shun it as an option for treating small symptomatic renal stones.

Analogously, the science behind renal cell carcinoma (RCC) treatment has come a full circle. The EUA has revised its guidelines for metastatic RCC to include immune checkpoint inhibitors as the first-line therapy in intermediate- and high-risk groups.[3] Interferon immunotherapy could produce complete response in metastatic RCC, albeit in very few patients. Its use was made redundant by the arrival of tyrosine kinase inhibitors, which do not have a direct cytotoxic effect, but can prevent tumor growth in some of the patients. Of late, immunotherapy has regained the upper hand, and immune checkpoint inhibitors have revolutionized the treatment of many cancers. CheckMate-214 is a global, randomized, phase III trial testing the combination of a programmed death receptor-1 and a ligand-1 inhibitor – nivolumab and ipilimumab, respectively. The study randomized 1096 treatment-naïve advanced or metastatic clear-cell RCC patients with measurable disease into either 3 mg/kg nivolumab intravenous (IV) +1 mg/kg ipilimumab IV every 3 weeks for four doses, followed by 3 mg/kg nivolumab IV monotherapy every 2 weeks, or sunitinib 50 mg orally once daily for 4 weeks, followed by 2 weeks (6-week cycles). The trial showed superior survival rates in patients receiving the new immune checkpoint inhibitors as compared to the previous standard of care, i.e. sunitinib. Altogether, these results showed that nivolumab–ipilimumab combination is the new benchmark in the intermediate and poor prognostic subgroups of patients with metastatic RCC.

It is being postulated that akin to the fate of IV pyelogram, the epitaph to laparoscopic surgery will soon be written due to the increasing use of robot assistance in urological surgeries. However, laparoscopic surgery might still be kept afloat by sheer surgical skills. This is evidenced by a large retrospective comparative analysis between robotic and laparoscopic assistance for radical nephrectomy. Of the 23,753 patients included in the study, 18,573 had laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy.[4] Although the complications were equal with both approaches, the direct hospital cost was significantly higher with robotic assistance. Furthermore, the number of patients having operative time of more than 4 h was much higher with robotic assistance as compared to the laparoscopic group (46.3% vs. 25.8%, respectively).

Finally, it is pleasing to note that we should bring in music to our minor OT in outdoor establishments. A recent review of 16 randomized trials including 1950 patients has highlighted the effect of music in reducing pain (measured by visual analog scale) and allaying anxiety (measured by State-Trait Anxiety Inventory) during procedures.[5] Hence, the next time you are doing procedures such as transrectal ultrasound-guided prostate biopsy, SWL, cystoscopy, urodynamic studies, or percutaneous nephrostomy, you may use music as an adjunct to local anesthesia.

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   References Top

Pradère B, Doizi S, Proietti S, Brachlow J, Traxer O. Evaluation of guidelines for surgical management of urolithiasis. J Urol 2017. pii: S0022-5347(17)78023-8.  Back to cited text no. 1
Ng CF, Luke S, Yee CH, Leung SC, Teoh JYC, Yuen J, et al. Extracorporeal shockwave lithotripsy could lead to a prolonged increase in renal fibrotic process of up to 2 years. J Endourol 2017; doi: 10.1089/end. 2017.0684. [Epub ahead of print] [Last accessed on 2017 Dec 20].  Back to cited text no. 2
Powles T, Albiges L, Staehler M, Bensalah K, Dabestani S, Giles RH, et al. Updated European Association of Urology guidelines recommendations for the treatment of first-line metastatic clear cell renal cancer. Eur Urol 2017. pii: S0302-2838(17)31001-1.  Back to cited text no. 3
Jeong IG, Khandwala YS, Kim JH, Han DH, Li S, Wang Y, et al. Association of robotic-assisted vs. laparoscopic radical nephrectomy with perioperative outcomes and health care costs, 2003 to 2015. JAMA 2017;318:1561-8.  Back to cited text no. 4
Kyriakides R, Jones P, Geraghty R, Skolarikos A, Liatsikos E, Traxer O, et al. Effect of music on outpatient urological procedures: A systematic review and meta-analysis from European section of Uro-technology (ESUT). J Urol 2017. pii: S0022-5347(17)78038-X.  Back to cited text no. 5


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