Urology Journal

Background: Lower urinary tract dysfunction (LUTD) is the most common problem of the referral children to the pediatric urology clinics. If this condition does not treat early in life, it will be a lifelong problem. During recent decades, electrical stimulation therapy has been expanded and extensively used for the treatment of LUTD in both adults and children. The aim of this review is to suggest clinicians an updated understanding of effects of interferential (IF) electrical stimulation therapy in management of LUTD in children.

Materials and methods: The search was performed in databases of Medline, PubMed, Google Scholar, ,and Scopus for information about  IF electrical stimulation and its application using search words such as “ IF electrical stimulation”, “transcutaneous IF electrical stimulation” ,  “IF therapy ” , “ electrical stimulation”, “voiding dysfunction” , “ LUTD”, “ urinary incontinence” and “ children”. As this review focuses on the answer of this question “Does transcutaneous IF electrical stimulation has effect on management of LUTD in children?” we included the reference list of articles identified by this search strategy and selected those we judged relevant according to our keywords. Clinical trial studies that publishing in English were included. Categorical data were reported as frequencies and percentages.

Results: Eleven studies were included in this review. The success rate of IF therapy in these studies has been reported from 61% to 90% of children with LUTD and urinary incontinence.

Conclusion: IF electrical stimulation is an effective, safe and reproducible option to manage LUTD and urinary incontinence in children.

Purpose: To examine the correlation between prostate specific antigen (PSA) and the risk of Gleason sum upgrading (GSU) from biopsy Gleason sum (bGS) to prostatectomy Gleason sum (pGS).

Materials and Methods: Five electronic databases (Web of Science, Ovid Medline, Ovid Embase, SCOPUS and the Cochrane Library) were searched from inception until March 2020. Studies were included if they focused on the relationship between PSA and GSU analyzed in multivariable analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized. Quality of included studies was appraised utilizing the Newcastle-Ottawa Quality Assessment Scale (NOS) for case-control studies. The publication bias was evaluated by funnel plot and Egger’s test.

Results: Our search yielded 19 studies with high quality including 42193 patients. GSU was found in 28.2% of patients. Higher PSA level was associated with a significant increased risk of GSU (pooled OR = 1.14, 95% CI: 1.10–1.18; P < .05; I² = 92%). For the definition of upgrading from bGS ≤ 6 to pGS ≥ 7, the odds of upgrading with higher PSA level as opposed to lower PSA level was 1.12 (95% CI: 1.11–1.14; P < .05; I² = 13%), while the odds of upgrading with other definitions were 1.11 (95% CI: 1.05–1.18; P < .05; I² = 89%).

Conclusion: Patients with high level of serum PSA are at high risk of undergoing pathologic upgrading at prostatectomy. Combined with other risk factors, PSA prompts risk reclassification and improve confidence of urologists in management decisions for optimal therapy. Nevertheless, further robust studies are necessitated to confirm these results.

Purpose:  To evaluate the stone-free rates, quality of life, complications, use of fluoroscopy, analgesic requirements, a hospital stay following the management of lower calyceal with two different techniques (Mini Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery) in a prospective manner.

Material and Methods: 50 patients with a diagnosis lower pole 1-2 cm stone were included into the study and were randomized into two groups.(Mini PCNL n: 25) ( RIRS n: 25). Safety and efficacy of both methods along with some other certain related factors were comparatively evaluated in both groups.

Results: There was no significant difference between preoperative stone size, stone to skin distance, hemogram and creatinine values, need for analgesic drug, patients' replies to visual analog scale (VAS). The duration of both the hospital stay and the exposure to fluoroscopy, hematocrit decrease due to hemorrhage, complication rates were significantly higher in cases undergoing mini PCNL when compared to RIRS. Additionally, any significant difference was not observed with respect to the stone-free rates. Despite an increase in quality of life following the both type operations was noted; there was no significant difference in the quality of life between the patients in both groups.

Conclusion: Our findings demonstrated that both surgical techniques are the feasible alternatives in the minimal invasive treatment of lower pole stones. Although there was no meaningful difference in stone-free rates between two groups; complications, use of fluoroscopy, bleeding and duration of hospital stay were noted to be significantly higher in cases treated with mini PCNL.

Purpose: The cumulative effect of measurable parameters on proximal ureteral stone clearance followed by the shock wave lithotripsy was assessed via the application of an artificial neural network.

Methods and patients: From January 2015 to January 2020, 1182 patients with upper ureteral stone underwent extracorporeal shock wave lithotripsy (ESWL) with supine position. The corresponding significance of each variable inputted in this network was determined by means of Wilk’s generalized likelihood ratio test. If the connection weight of a given variable can be set to zero while maximizing the accuracy of the network classification, the variable is not considered an important predictor of stone removal.

Results: A total of 1174 cases (excluding 8 cases) were randomly assigned into a training group (813 cases), testing group (270 cases), and keeping group (91 cases). We evaluated artificial neural network analysis to the stone clearance rate of the training group, with a predictive accuracy of 93.2% (482/517 cases). While the predictive accuracy of the stone clearance rate of the training group was 75.3% (223 cases/296 cases). The order of importance of independent variables was stone length > course (d) > patient’s age > Stone Width > PH value.

Conclusion: The neural network possess a huge prediction potential for the invalidation of ESWL.

Background: Experts recommend us to keep a safety guidewire during the process of upper urinary tract endoscopy, though there is a lack of high-level evidence to support  the efficacy and safety of  this opinion. This study conducted to compare the outcome of ureteral stone breakage in the presence or absence of safety guidewire.

Materials and methods: Patients candidate for endoscopic breakage of ureteral stone using a semi-rigid ureteroscope, were randomly assigned in  two groups based on keeping a safety guidewire (group1)  or removing the guidewire (group2) before the process of breaking ureteral stone by lithoclast. Demographic factors, history of previous stone treatment, kidney function, stone location, symptoms duration and severity were recorded for each patient. Primary outcomes include success rate of stone treatment and secondary outcomes include number of attempts to enter to ureter, success rate of ureteral entry, success rate of stone achievement, stone migration rate and success rate of ureteral stent insertion.

The recorded data were entered to the SPSS software and descriptive statistical analysis including power calculation and non-inferiority design for the primary and secondary outcomes, was performed. P-value less than 0.05 was considered significant.

Results: From January 2016 till May 2018, 320 patients were randomized with 160 patients in each arm. Considering the cases who were missed due to follow-up loss, there were 153 patients in group 1 and 147 patients in group 2 at the end of the study. Baseline data were equally distributed in both groups. Based on the initial analysis, the studied variables had no significant difference between two groups; though, according to the subgroup analysis of patients with proximal ureter stones, patients in Group 1 had higher rates of ureteral injury comparing to the patients in Group 2 (p=0.03).

Conclusion: According to our findings, keeping the safety guidewire through the process of endoscopic stone breakage (stone size: less than 1.5Cm) seems to add no significant benefit to the procedure outcome, while it increases the ureteral injuries in the proximal ureter stones, but not in mid or distal ureter stones.

Purpose: Usual laparoscopic surgery of localized prostate cancer uses antegrade dissection. We describe and evaluate the original RELP (Retrograde Extraperitoneal Laparoscopic Prostatectomy).

Materials and Methods: A prospective cohort of 1005 patients with clinical localized cancer prostate were operated from December 1999 to September 2013, in Lyon (France), and followed up to 172 months (median: 60 months). Patients encountered a RELP procedure, a totally extra-peritoneal approach with a retrograde dissection from the apex to the bladder neck, and ascending dissection of the erectile neurovascular bundles, facilitated by the 30° optic telescope. Adjunctive treatments were: immediate radiotherapy (9.2%), salvage radiotherapy (13.4%), androgen deprivation therapy (10.8%), chemotherapy (1.4%), no treatment (75.8%).

Results

The mean age was 63.4, the Gleason score was 4+3 or worse in 24.9%, there were 2.3% unifocal tumors. The pathology stages were pT2A (8.71%), pT2B (2.80%), pT2C (69.0%), pT3A (13.1%), and pT3B (6.41%). There were 60.8% negative margins (R0) in total (90.1% for basal locations, and 75.8% for apical locations). The mean operating time was 115 minutes for the last 100 patients. The BPFSR (biological progression free survival rate, PSA≤0.10 ng/ml) was 71.9% at 5 years, and 61.4% at 10 years. The cancer specific survival rate was 99.4% at 5 years, and 98.3% at 10 years. After 12 months, 88.6% of patients did not require an incontinence pad, and 67.0% retained the pre-operative quality of their erection.

Conclusion: RELP yields good oncologic results and quality of life, as good as robot-assisted surgery.

Purpose: Previous reports showed that targeted therapy efficacy varied due to different metastatic organs in patients with metastatic renal cell carcinoma (mRCC). This study aimed to further evaluate the response and progression-free time (PFT) of individual metastatic organs.

Materials and Methods: Data from mRCC patients, who were treated with sunitinib between January 2008 to December 2018, were retrospectively reviewed. Individual metastatic organs were assessed separately by The Response Evaluation Criteria in Solid Tumors criteria.

Results: We evaluated response heterogeneity and PFT as characteristics of 281 individual organs affected by mRCC in 213 patients. The objective response rates in these organs were 72.7% in pancreas, 63.7% in spleen, 14.3% in adrenal glands, 13.5% in bone and soft tissue, 11.6% in lymph nodes, 11.6% in lungs, and 9.1% in liver. The median PFT was 15.2 months (95% confidence interval [CI] 2.7–27.7 months) for adrenal glands, 13.2 months (95% CI 3.5–22.9 months) for bone and soft tissue, 9.0 months (95% CI 7.6–10.4 months) for lymph nodes, 8.6 months (95% CI 6.3–10.9 months) for lungs, and 5.2 months (95% CI 2.9–7.5 months) for liver. Median PFT was not reached in pancreas and spleen, but was > 22.8 months and > 20.6 months, respectively.

Conclusion: Our results indicated that organs affected by metastasis may have individual responses to sunitinib treatment. The pancreas and spleen may have the best responses, and liver may have the worst response. Further research is needed to verify these findings.

Purpose: The conventional Trans-Peritoneal Radical Cystectomy (TPRC) harbors numerous postoperative complications, the most prevalent of which are Gastrointestinal (GI) problems. To reduce these morbidities we introduced our own version of extra-peritoneal approach and compared it with the conventional method. 

Materials and Methods: In a cross-sectional observational retrospective design, eligible bladder cancer patients whom underwent Extra-Peritoneal Radical Cystectomy (EPRC) or TPRC in our center, were considered for this study and were compared for early post-operative complications .

Results: Ninety nine patients in TPRC and 81 in EPRC were compared. The two techniques differed in their mean operation time (298.2±37.8 min TPRC vs. 262.8±37.2 min EPRC , P: 0.001). Early GI complications were lower in EPRC groups, including oral intake intolerance ( 21 vs. 8, P: 0.04), ileus (19 vs. 8, P: 0.04),  intestinal obstruction (3 vs. 0, P: 0.04) and anastomosis leak (8 vs. 1, P: 0.01). Urine leak (14 vs.7 , P: 0.02) and wound related complications (19 vs. 6 , P: 0.02) also favored EPRC group.

Conclusion: The extra-peritoneal technique is beneficial in reducing the post operative morbidity, especially the more prevalent GI complications. This approach is functionally safe and allows preservation of the peritoneal integrity.

Purpose: This study aims to evaluate the effects of action research on neobladder function training in patients with orthotopic ileal neobladders.

Methods: A total of 68 patients with orthotopic ileal neobladders were randomly divided into two groups: a control group (31 patients) and an experimental group (37 patients). Patients in the control group received neobladder function training, while patients in the experimental group received neobladder function training based on the action research method. The effects of neobladder function training in all patients were evaluated after three months.

Results: (1) The differences between the two groups in micturition time interval, urine volume per time, number of incidences of nocturia, and urinary continence rate (day time and night time) were statistically significant (P < 0.05). (2) Compared to the control group (241.6 ± 42.3 mL, 15.1 ± 4.9 mL/s, 23.1 ± 9.9 cmH₂O, 63.6 ± 22.3 mL), the bladder capacity (292.6 ± 66.9 mL), maximum urinary flow rate (19.2 ± 6.5 mL/s), and bladder detrusor pressure (31.2 ± 11.4 cmH₂O) of the experimental group increased, while the residual urine volume (47.2 ± 21.1 mL) decreased (P < 0.05).

Conclusion: Neobladder function training based on the action research method can improve the neobladder function of patients with orthotopic ileal neobladders.

Purpose: In this study, we aimed to determine whether there is a significant difference in endocan expression levels between prostate adenocarcinoma and prostate hyperplasia tissues by using an immunohistochemical method. 

Materials and Methods: All of 51 patients, who were getting treatment for the last 5 years, participated in the study. 31 of 51 patients underwent transrectal sonography (TRUSG) -assisted prostate biopsy because of prostate adenocarcinoma as diagnosed with elevated PSA levels and histopathological examination. The remaining 20 patients comprised the control group. The control group included patients with benign prostate hyperplasia based on pathological examination. 

Results: It was found that there was strong positive epithelial staining in 74.2% of patients with prostate cancer while in 5% of controls, indicating a statistically significant difference (P < .001). It was also found that the rate of strong positive endothelial staining was 77.4% in the patient group whereas 5% in the control group (P < .001). Also, the rate of strong positive stromal staining was 64.5% in the patient group while 5% in the control group (P < .001). 

Conclusion:  We found that tissue endocan expression level was statistically significantly higher in patients with prostate cancer compared to those with benign prostate hyperplasia by using an immunohistochemical method. 

Purpose: To assess the long-term outcomes of patients treated for distal hypospadias. Assessment of long-term follow-up for a homogeneous population with hypospadias is difficult and there has consequently been a paucity of publications in this regard.

Materials and Methods: A retrospective review was carried out to compile cases of distal hypospadias operated at our center between 1990 and 1999 according to the MAGPI procedure. Four parameters were evaluated based on four validated questionnaires: Health-related quality of life (SF-36), Genital self-perception (PPS), Self-esteem (Rosenberg Self-Esteem Scale), and Erectile function (IIEF).

Results: A total of 77 patients who had undergone MAGPI surgery for hypospadias during the specified period were selected. Sufficient clinical data were available for 51 patients and only 15 of these patients were included, after a median follow-up of 22 years (20-26). Their outcomes were compared with those for a population of 15 matched circumcised men and 15 matched uncircumcised men. No significant difference was found between the patients and the control groups in terms of the score for quality of life (p = .29). There were, however, significant differences in the scores for self-perception of the penile cosmetic appearance (13.3 vs. 15.8; p < .01), self-esteem (30.6 vs. 35.8; p < .01), and erectile function (31.4 vs. 33.7; p = .04) between the patients and the controls. Lower self-esteem correlated with poor genital self-perception (r  = .92).

Conclusion: This study confirms that adult patients operated for distal hypospadias have poor genital self-perception. This poor genital perception correlated with lower self-esteem.

Purpose: SNRIs (serotonin and norepinephrine reuptake inhibitors) like duloxetine are known to have role in the treatment of anxiety disorder and stress urinary incontinence. According to the correlation of anxiety disorder and overactive bladder, this study aimed to evaluate the clinical efficacy and complications of duloxetine (SNRI) as a medication in the treatment of overactive bladder in the female patients. We were interested to know the probable therapeutic effect and side effects of duloxetine in overactive bladder.

Methods and Materials: In this single-blinded interventional randomized clinical trial, 60 female patients with idiopathic overactive bladder (hyperreflexia) referred to the urology clinic, were divided into two groups as pilots. The first group were treated by 10mg/daily solifenacin and the second group received 20mg/daily duloxetine. The patients were evaluated by the ICIQ-OAB Questionnaire before and after one-month follow-up period. The intervention primary outcomes were evaluated by the patient’s presentation of the frequency, nocturia, urgency, urge urinary incontinence and the drugs side effects as secondary outcomes were checked.

Results: Sixty women with confirmed overactive bladder disease were evaluated. Solifenacin and duloxetine had the same effect on the treatment of overactive bladder (p value=0.148). The clinical symptoms were obviously relieved in both groups after treatment. Side effects were insignificantly more common in the solifenacin group (p value>0.05). However, the different frequency of blurred vision in the two groups was statistically significant (p value=0.04). The most common complication in solifenacin and duloxetine group was anxiety.

Conclusion: The results showed that solifenacin and duloxetine improved overactive bladder symptoms. According to this evaluation, duloxetine can be a suitable alternative option for overactive bladder treatment, due to the acceptable therapeutic effect and side effects.

Purpose: Male infertility accounts for about half of all infertility cases. Asthenoteratozoospermia is a severe form of male infertility. Free radicals play an important role in infertility. In a study we found that asthenoteratozoospermic men had a lower mean percentage of sperm HSPA2+ and higher intracellular anion superoxide than normozoospermia. Antioxidants are thought to be able to counteract the negative effects of free radicals. We explored the efficacy of vitamin E in combination with Se on the level of sperm HSPA2+, intracellular anion superoxide and chromatin integrity in these patients.

Materials and methods: 60 patients entered the study. They were randomized to treatment group of oral Se (200 μg) in combination with vitamin E (400 units) for 3 months (n= 30) or placebo (n= 30). Semen samples were obtained and assessed for sperm parameters, intracellular O2-, protamine deficiency, sperm HSPA2+ and apoptotic spermatozoa at baseline and after treatment phase.

Results: There were no significant differences in baseline semen parameters, intracellular O2- protamine deficiency, sperm HSPA2+ and apoptotic spermatozoa between the treatment and placebo groups. There was a statistically significant decrease in sperm apoptosis and the level of anion superoxide (P=.001) and an increase in sperm motility and viability (P=.001) in the treated group, but no significant difference was found in the percentage of sperm HSPA2+ and sperm protamine deficiency compared with baseline. Moreover, no significant change was found in these parameters in placebo group after 3 months.

Conclusion: Our results showed that administration of vitamin E and selenium for three months may improve sperm motility and viability by decreasing intracellular anion superoxide and sperm apoptosis in asthenoteratozoospermic infertile men. We suggest that consuming these supplements before assisted reproductive technology (ART) may improve outcomes in these patients.

Purpose: To compare the clinical effects of three methods of circumcision: modified circumcision, traditional circumcision, and disposable suturing device circumcision.

Materials and Methods: Male patients (n = 241) with redundant prepuce and/or phimosis were included in a clinical trial from January 2019 to March 2020. Patients were divided into 3 groups based on the surgical method: group A, traditional circumcision (n = 79); group B, modified circumcision (n = 80); and group C, disposable suturing device circumcision (n = 82).

Results: The operation times in groups A, B, and C were 25.2 ± 3.3 min, 10.2 ± 2.7 min, and 6.7 ± 1.4 min, respectively. The volumes of intraoperative blood loss in groups A, B, and C were 12.7 ± 2.3 mL, 8.1 ± 3.4 mL, and 2.2 ± 0.8 mL, respectively (P < 0.05). Groups A and B were superior to group C in terms of the 6-h postoperative visual analog scale score and appearance satisfaction (P < 0.05). There were no obvious differences in the 7-day postoperative pain score and total healing time (P > 0.05). The operating expenses in groups A and B were lower than that in group C (P < 0.05).

Conclusion: Modified circumcision, with its advantages of shorter operation time, less blood loss and pain, lower cost, and better postoperative penile appearance, is easily accepted by patients and deserves wide clinical application.

Purpose: To detect possible effects of magnetic resonance imaging (MRI) scans on the function of an InterStim Twin sacral nerve stimulation (SNS) device and on patient’s health. There is no authorization for MRI scans in InterStim Twin SNS at all.

Material and Methods: 10 patients with Interstim Twin sacral nerve stimulator implants underwent a singular MRI scan. Before the MRI was performed, the SNS device function was evaluated and the device was deactivated be the implanting urologist. A continuous monitoring took place during MRI procedure. Micturition-time chart pre- and post MRI procedures were conducted. After the MRI session was completed, the implanted device was examined once more and reactivated, function then was evaluated.

Results: A total of 10 patients required MRI examinations in 8 different body regions. No patient reported pain or discomfort during and after the MRI scan. After reactivation of the InterStim Twin device following the MRI, impedances and stimulation amplitude, micturition frequency, urgency, and incontinence episodes remained stable. No significant differences between pre- and post MRI were found (p>0.05).

Conclusion: This is the first report of patients successfully undergoing a MRI scan despite a previously implanted Interstim Twin sacral nerve stimulator. No negative effect of SNS function or negative side effects for the patients were observed.

Purpose: Benign prostatic hyperplasia (BPH) significantly reduces the quality of life. However, the biological mechanisms of BPH development remain largely unknown. We aimed to investigate the essential genomic and immunogenic features in BPH.

Materials and Methods: Transcriptome profiling and clinical data of BPH and normal prostate samples were acquired from GEO datasets. The discovery sets were composed of GSE119195, GSE7307, GSE101486, while validation set was GSE132714. ESTIMATE and CIBERSORT was used to investigate the immunogenic features. Furthermore, transcriptional and weighted gene co-expression network analysis (WGCNA) was used for further analysis.

Results: BPH samples presented higher immune score. Meanwhile, CIBERSORT deconvolution revealed that BPH exists significantly abundant M2 Macrophages, follicular T helper cells, resting mast cells, and fewer plasma cells, activated CD4+ memory T cells and activated mast cells. WGCNA analysis also revealed significantly enriched immune-related modules in BPH. Transcriptomic analysis identified SOCS3, IL6, C3, IGF1, NOTCH1 and VCAN as key regulators of immunogenic phenotype in BPH. Moreover, we generated an immunological gene signature for BPH, which worked well in validation cohort.

Conclusion: In our study, BPH samples exhibited a distinct immune infiltration pattern, represented by an immunological gene signature. This genomic-based assessment model reveals the potential transcriptomic patterns during BPH development.

Purpose: Traumatic penile amputation is a rare case with various etiologies. Penile reconstruction using replantation technique should be performed to prevent the decline of patients quality of life even in areas with limited facilites.

Material and Methods: We report three cases of total penile amputation in children after circumcision, who were successfully replanted by macro-surgical technique and cavernoglandular shunt procedure.

Results: Postoperative follow-up showed promising results with good micturition, erectile function, cosmetic, and minimal complications.

Conclusion: Matters affecting the successful penile replantation in macro-surgical techniques have been discussed. In addition, we also highlight the potential of cavernoglandular shunt procedure that can be used as an alternative treatment for penile replantation in limited facilities.