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Recent papers on Urology

Urology GPSI Dr Jonathan Rees reviews recent papers which could impact on general practice

Urology GPSI Dr Jonathan Rees reviews recent papers which could impact on general practice

How do self management techniques compare with medical management of lower urinary tract symptoms (LUTS)?

The paper Van der Meulen J et al. Self-management for men with lower urinary tract symptoms: randomised controlled trial. BMJ 2007; 3334: 25.

Method 140 men with uncomplicated LUTS were randomised to standard care or standard care plus self-management advice (three small group sessions).

Results At three months treatment failure – such as prescription of alpha blocker or significant rise in symptom scores – had occurred in 10% of the self-management group compared with 42% of the standard care group and this difference increased over the 12 months of the study.

Conclusion Self-management techniques such as fluid management and bladder retraining can significantly improve symptoms and may enable some men to avoid medical treatment of their LUTS.

What I'm going to do now I will write a self-management information leaflet for use within the practice, and try these techniques for patients with mild LUTS or as an adjunct to medical treatment in those with more severe symptoms.

What dietary modifications should recurrent renal stone formers make?

The Paper Kennedy K et al. Dietary advice for patients with renal stones: Are we practising evidence-based medicine? British Journal of Urology International 2006; 97 (5): 903-4.

Method A survey was carried out of patients with renal stones (calcium oxalate only) and of the urologists advising them to see what advice they had received or given regarding dietary modification. A literature review was carried out to see how this compared with best evidence.

Results Inconsistent and inaccurate advice was given. The evidence is that increasing fluid intake and eating a balanced diet with decreased animal protein and salt were the most important factors in preventing stone formation. Low calcium diets actually increase the risk of calcium oxalate stones.

Conclusion Many patients are significantly restricting their diets on the basis of inaccurate advice received from urologists.

What I'm going to do now Opportunistically discuss diet with all recurrent stone formers, encouraging that pleasurable foods such as strawberries and chocolate have no effect on the risk of stones.

What is the chance of finding significant pathology in a patient with haematuria?

The Paper Edwards T et al. A prospective analysis of the diagnostic yield resulting from the attendance of 4,020 patients at a protocol-driven haematuria clinic. British Journal of Urology International 2006; 97: 301-305.

Method Study looked at all patients seen in the haematuria clinic in Plymouth over five years. All patients were investigated with a flexible cystoscopy and an ultrasound.

Results The overall incidence of malignancy was 18.9% in macroscopic and 4.8% in microscopic haematuria. In men older than 50 with microscopic haematuria the risk of finding malignancy was only 0.44%, and a comparable rate of 0.75% was seen in women older than 60. The risk of malignancy was seen to increase significantly with increasing age.

Conclusion The risk of malignancy in patients with microscopic haematuria is low overall but increases with age and in smokers.

What I'm going to do now Use these figures to help decide on whether and when to refer patients with microscopic haematuria by stratifying into lower and higher risk groups.

Can we combine anti-cholinergics and alpha-blockers to treat men with LUTS?

The Paper Kaplan S et al. Tolterodine and Tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder – a randomised controlled trial. JAMA 2006: 296; 2319-2328.

Method Randomised double-blind placebo-controlled trial in US of men over 40 with LUTS and symptoms of an overactive bladder. Randomised to placebo, tolterodine, tamsulosin or both with around 220 patients in each arm.

Results Combination therapy gave symptomatic improvement in 80%, compared with approximately 70% with single therapy and 62% in the placebo arm. Acute retention occurred in 0.5% of patients receiving tolterodine but in no patients in the other arms.

Conclusion Combination therapy is marginally better than single therapy so may be worth a try in patients refractory to treatment with an alpha-blocker alone. Placebo is a surprisingly effective treatment, illustrating the psychological component of LUTS.

What I'm going to do now Consider dual therapy especially for those with predominant symptoms of urgency and frequency.

How do urologists decide on treatment modalities in prostate cancer?

The Paper Clinical Judgment Analysis of the parameters used by consultant urologists in the management of prostate cancer. Clarke MG et al .J Urol 2007: e-publication ahead of print.

Method Thirty consultant urologists were asked to assess 70 hypothetical patients with prostate cancer, with different clinical parameters, such as age, PSA, patient choice, Gleason grade, and so on. Statistical analysis enabled the authors to identify the factors that led urologists to decide between surgery, radiotherapy or watchful waiting/hormonal therapy.

Results Consultants varied in the treatments recommended, and used on average only three of the possible nine variables to formulate decisions. PSA and predicted 10-year survival were the most important factors. Other parameters including patient preference and age were used infrequently.

Conclusion Consultants are often inconsistent in their management and may not seek or use all the information that may inform their decisions.

What I'm going to do now Try to ensure that my referral letters contain as much information as possible about co-morbidity and patient preference. Encourage patients to ask their consultant on what basis management decisions have been made.

Dr Jonathan Rees is a GPSI in urology and a GP in Nailsea, Bristol

About 20 per cent of patients will macroscopic haematuria will have a malignancy About 20 per cent of patients will macroscopic haematuria will have a malignancy

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