Nackeeran S, Kohn T, Gonzalez D et al: The effect of route of testosterone on changes in hematocrit: a systematic review and Bayesian network meta-analysis of randomized trials. J Urol 2022; 207: 44–51.

Special thanks to Drs. Jason Huang and Mahmoud Mima at the University of Illinois at Chicago.

Different testosterone formulations increase hematocrit levels to different degrees, but how do they vary? This question is increasingly important as the prevalence of testosterone deficiency is rising with our aging patient population, and the utilization of testosterone replacement therapy is dramatically increasing to treat this condition. But the treatments are not without risk, including cardiac events and venous thromboembolism due to secondary erythrocytosis.

To overcome the lack of studies with head-to-head comparisons of testosterone formulations, these authors applied advanced statistical methods to compare hematocrit changes. The treatment arms of 29 rigorously selected randomized placebo-controlled trials were compared. They observed that all testosterone replacement formulations were associated with increases in hematocrit levels. Intramuscular testosterone enanthate/cypionate was associated with the highest hematocrit increases. Interestingly, none of the other formulations were significantly different from each other. When pooled, no therapy increased the hematocrit beyond 4.3%. The clinical significance of this degree of rising hematocrit is poorly understood. There is no conclusive evidence that such hematocrit changes following testosterone replacement are associated with pathological erythrocytosis.

The authors concluded that while all therapies may lead to rises in hematocrit levels, the increases are relatively low. Urologists can mitigate the risk of adverse events with close clinical monitoring and careful patient selection. Furthermore, regarding hematocrit changes, with the exception of intramuscular testosterone enanthate/cypionate, the testosterone formulations were not significantly different from each other, and urologists may use their choice.

Liaw CW, Khusid JA, Gallante B et al: The T-Tilt position: a novel modified patient position to improve stone-free rates in retrograde intrarenal surgery. J Urol 2021; 206: 1232–1239.

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

Lower pole kidney stones can cause significant difficulty and frustration even for most experienced urologists. What further compounds the frustration of accessing these difficult stones is the potential need for reintervention in an attempt to achieve stone-free clearance. Wouldn’t it be nice to have a low cost intervention that would increase stone-free rates in these challenging patients? Thanks to this excellent randomized study by Liaw and coauthors, we have that intervention. The widely accepted standard lithotomy stone-free rate is compared to a new, innovative positioning named “T-Tilt.” Positioning the patient in 15-degree Trendelenburg and 15-degree airplane away from the kidney stone resulted in a greater than 15% increase in stone-free rates compared to the standard lithotomy position. This low cost intervention can make a big difference in the day-to-day practice of urologists and help keep those patients with difficult lower pole stones from possibly needing reintervention.

Castellani D, Pirola GM, Law YXT et al: Infection rate after transperineal prostate biopsy with and without prophylactic antibiotics: results from a systematic review and meta-analysis of comparative studies. J Urol 2022; 207: 25–34.

Special thanks to Drs. Juan Diego Cedeño and Ervin Kocjancic at the University of Illinois at Chicago.

Antibiotics and bacteria have always been a case of cat and mouse, with the mouse becoming more and more clever in evading the cat and consequently far more dangerous. We’re solidly in the age of superbugs that are resistant to the majority of available antibiotics, and the more we can do to stanch the evolution of bacteria to highly resistant forms, the better. But what of prostate biopsy? Can we as urologists do better there?

The most common route in prostate biopsy remains the transrectal one, and it’s associated with a rate of post-procedural sepsis of between 0.3% to 0.8%, and a hospitalization rate of 1.1% for infections after biopsy. The other option gaining popularity is transperineal, and the European Association of Urology now recommends it as the preferred approach. Yet its guidelines still recommended the use of a single prophylactic dose of a cephalosporin to cover skin organisms. Is this truly necessary?

The authors of this study conducted a systematic review comparing infection rates after transperineal biopsy with and without antibiotic prophylaxis, including 4 prospective nonrandomized trials and 4 retrospectives studies encompassing a total of 2,368 patients with antibiotic prophylaxis and 1,294 without. Post-biopsy genitourinary infection rates were 0.11% in the group with prophylaxis and 0.31% in the group without. Post-biopsy sepsis rates were 0.13% in the group with prophylaxis and 0.09% in the group without. Readmission rates for infections over 8 studies reporting this parameter were 0.13% in the group with prophylaxis and 0.23% in the group without. The authors observed no clinically significant differences in those with and without prophylaxis, and concluded that “it is probably time to abandon the transrectal route to biopsy the prostate.” It’s hard to argue with that.