Special thanks to Drs Ahmad Hefnawy and Omer Acar at the University of Illinois at Chicago.

There are no guidelines for perioperative antibiotic use in urethral reconstruction. Due to a growing concern about antibiotic over-prescription and bacterial resistance, judicious use of antibacterials is strongly recommended by the American Urological Association. This is the first prospective study investigating the infectious outcomes in patients undergoing urethroplasty and antibiotic prophylaxis.

The investigators compared continuous antibiotic prophylaxis in the postoperative period until the catheter is removed with the standardized perioperative protocol recommended in the American Urological Association guidelines. The study had 2 consecutive cohorts. One cohort received postoperative antibiotics until the catheter was removed in addition to 2 doses of quinolone or trimethoprim-sulfamethoxazole around the day of catheter removal, while the other cohort received only 1 day of postoperative antibiotics in addition to 2 doses of quinolone or trimethoprim-sulfamethoxazole around the day of catheter removal. There was no statistically significant difference in urinary tract or wound infection rates between the study groups. Interestingly, there was a trend towards lower infection rates in the standardized prophylaxis group. There were no factors predictive of urinary tract or wound infection within 30 days postoperatively on multivariate logistic regression analysis.

The study was limited by a nonrandomized design and no standardization in the duration of the indwelling catheters. Nevertheless, these results indicate no benefit to the prolonged use of antibiotics following urethroplasty. These data provide guidance to reconstructive urologists towards better antibiotic stewardship.

Malcher MF, Droupy S, Berr C, et al. Dementia associated with anticholinergic drugs used for overactive bladder: a nested case-control study using the French national medical-administrative database. J Urol. 2022;208(4):863-871.

Special thanks to Drs Jason Huang and Omer Acar at the University of Illinois at Chicago.

Overactive bladder is a prevalent clinical condition. Although anticholinergic medications are effective and affordable treatment options, cognitive side effects are frequent and serious, particularly in elderly patients. These investigators conducted an observational study to evaluate the association between anticholinergic oral pharmacotherapy for overactive bladder and the development of dementia.

Using several French nationwide medical databases to study individuals aged 60 years and older, the authors observed that anticholinergic medications are associated with a higher risk of development of dementia. There was in fact a cumulative dose-response relationship. Oxybutynin and solifenacin were the main culprits with odds ratios of 1.28 and 1.29, respectively. Interestingly, trospium did not demonstrate a similar association, which could be attributed to its weakly lipophilic nature impeding transport across the blood-brain barrier. The authors could not draw conclusions for flavoxate and fesoterodine because of their relatively lower frequency of use.

The authors concluded that anticholinergic medications should be used with caution among elderly patients, particularly for oxybutynin and solifenacin. This study adds to the mounting body of evidence that cognitive side effects of anticholinergic medications may not merely be temporary but may eventually lead to dementia, especially with prolonged use. When possible, we should avoid anticholinergic medications in our elderly patients with overactive bladder and use alternative therapies.

Su ZT, Patel HD, Huang MM, et al. Active surveillance versus immediate intervention for small renal masses: a cost-effectiveness and clinical decision analysis. J Urol. 2022;208(4):794-803.

Special thanks to Drs Marcin Zuberek and Simone Crivellaro at the University of Illinois at Chicago.

Urological practice embraces the latest surgical techniques in patient management. However, how can you answer the critical question of when not to intervene? The rule of primum non nocere has historically been the cornerstone of medical practice and is front and center in the management of many urological cancers, including small renal masses. The paradigm of treatment has recently changed from direct intervention to active surveillance. But how does one quantify the cost of that decision on a patient’s health?

These investigators used analytical Markov modeling to compare the opportunity cost of active surveillance with an option for direct intervention to partial nephrectomy, radical nephrectomy, and thermal ablation for small renal masses less than 2 cm. The 10-year all-cause mortality was similar to all of these groups with 22.6%, 21.9%, 22.4%, and 23.7%, respectively. Most importantly, active surveillance was the most cost-effective option in all of the intervention arms of the model if the mass was of low malignant potential

This analysis allows for a proper cost vs benefit discussion for the incidentally found small renal mass and brings accurate cost analysis to the forefront of patient care. It allows the urologist to guide the patient through what is a challenging decision, which undoubtedly benefits not only the patient but health care resources that are far from unlimited. In the case of small renal masses, active surveillance is having the cake and eating it too in positive health care outcomes and primum non nocere.