Current opinion in urology
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Neuromodulation is a successful treatment for patients with refractory lower urinary tract dysfunction. In the recent years, more applications of various types and ways have been developed and put into clinical practice. It is important, therefore, for urologists to know the existing theories on the working mechanisms that explain the effect. Although much research has been devoted to this subject for the past 35 years, the working mechanism is still unknown. This review presents an overview of the different theories and research into the physiological background of neuromodulation during the past 3 decades with emphasis on recent developments. ⋯ Neuromodulation in the treatment of stress incontinence probably induces physiological changes in the sphincter muscles and pelvic floor. In the treatment of overactive bladder syndrome, nonobstructive voiding dysfunction and chronic pelvic pain, the mechanism of action seems to be more complicated. Most likely, it is a combination of the different suggested modes of action, involving the neuroaxis at different levels.
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Training in laparoscopy has become an important issue in the current surgical scenario. In this overview we aim to update the current knowledge in the field of laparoscopic urological training and to highlight the potential dangers of using simulation for accreditation and selection purposes at this stage. ⋯ In spite of the abundant literature there is still little evidence about the learning mechanism involved in acquiring laparoscopic skills. Physical and virtual reality simulators have been proven to be efficient in improving dexterity and some evidence exists of a positive transfer from virtual reality to the operating room in cholecystectomy. Very few models, however, have been described for reconstructive urology, and effective transfer to the operating room has not yet been proven, although validation work is in progress in the field of urology.
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Progressive neurological disease can cause lower urinary tract symptoms similar to those seen in bladder outflow obstruction. Increasingly common with age, these two groups of conditions often coexist. The complex pathophysiology of men with this combination of problems is often poorly understood and suboptimally managed, mostly with long-term indwelling catheters. This review looks at recent diagnostic advances and emerging therapeutic alternatives. ⋯ Urodynamic studies are important and increasingly regarded as mandatory in all men considered for outflow surgery. Neurogenic bladder and sphincter dysfunction can be managed conservatively or with new minimally invasive techniques. Surgery should be reserved for severely symptomatic treatment failures. A working knowledge of common neurological disease associated with lower urinary tract dysfunction is important for urologists to diagnose these conditions or initiate an appropriate referral. This article gives an overview of recent work that has implications for the diagnosis and management of neurological disorders of micturition.
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Renal cell carcinoma is estimated to account for more than 35,000 new diagnoses and more than 12,000 cancer-related deaths in the United States in 2005, making it the most lethal of genitourinary malignancies. Approximately 25% of patients with renal cell carcinoma present with metastases, and about a third of those treated surgically for localized renal cell carcinoma will develop a recurrence. Current therapeutic options for disseminated disease benefit only a small percentage of patients. ⋯ Renal cell carcinoma nomograms allow more accurate counseling of patients regarding their probable clinical course, facilitate treatment planning, and identify high-risk patients for experimental treatments.
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Dietary manipulation still remains one of the most important strategies for therapy. A growing body of evidence, however, suggests that severe calcium restriction is inappropriate in patients with recurrent nephrolithiasis. Dietary recommendations based on recent evidence and the role of bacteria in the pathogenesis of calcium nephrolithiasis are discussed. ⋯ Metabolic abnormalities responsible for stone recurrence are currently identified in 97% of evaluated patients and remission rates of medical prophylaxis in calcium stone formers are approaching 80%. Urinary calcium excretion in most renal stone formers is more dependent on the dietary acid load than on the dietary calcium intake itself. Reducing the acid-ash content of the diet has an impact on decreasing stone recurrence, while preventing bone loss. New evidence associates the decolonization of oxalate degrading intestinal flora with a higher risk of calcium oxalate stone formation, possibly opening the door for biological manipulation as a novel approach for the prevention of urinary stone formation.