ISSN: 1735-1308

Instant 2022

REVIEW


Purpose: Several randomized-controlled trials (RCTs) were performed to compare the efficacy of sexual intercourse or masturbation and no sexual activity in treating distal ureteral stones, indicating conflicting results. The meta-analysis was conducted to assess the role of sexual intercourse or masturbation in the treatment of distal ureteral calculi.


Materials and Methods: PubMed, Cochrane Library, EMBASE, Scopus, Clinicaltrail.gov, and Web of Science were searched by October 2021. Men who were instructed of no sexual intercourse or masturbation, and only received standard symptomatic treatment are comparators. Relative risk (RR), weighted mean difference (WMD), and their 95% confidence intervals (CIs) were calculated using random or fixed effects models.


Results: Five RCTs including 500 subjects were analyzed in the study. Compared with controls, subjects in experimental group had significantly higher expulsion rate at 2nd and 4th week (95%CI: 1.334 to 2.638, RR: 1.876, I2 = 73.6%, P < .001; 95%CI: 1.148 to 1.752, RR: 1.418, I2 = 55.9%, P < .001), significantly decreased requirement for analgesic injections (95%CI: -1.071 to -.126, WMD: -.598, I2 = 90.3%, P = .013), and significantly shorter expulsion time (95%CI: -6.941 to -.436, WMD: -3.689, I2 = 83.7%, P = .026).


Conclusion: Performing sexual intercourse or masturbation 3 or 4 times a week can be an alternative treatment option of distal ureteral calculi (0-10 mm in size). However, more clinical evidence with better designs solving raised concerns is warranted.


 

Purpose: Aspirin (ASA) is often stopped prior to percutaneous nephrolithotomy (PCNL) due to the surgical bleeding risk. However, this practice is based on expert opinion only, and mounting evidence suggests holding aspirin perioperatively can be more harmful than once thought. In our review we aimed to discuss the safety of low dose aspirin continued or discontinued in the whole perioperative period of PCNL.


Patients and Method: We performed a computerized PubMed, EMBASE and Cochrane Library search of relevant studies. Study identification satisfied the PRISMA guidelines. Newcastle-Ottawa scale (NOS) was used to evaluate the quality of including studies. Favored outcomes such as operative time, complications and change in hemoglobin were extracted. Statistical analysis was performed with Rev-Man software 5.3 and forest plots were used to illustrate our findings.


Results: After screening, four studies were included in the present systematic review. There was no difference in the number of total complications (OR:1.25; 95 % CI 0.82-1.90; p=0.30), major complications (OR: 1.24; 95 % CI 0.53-2.93; p=0.62) and blood transfusion rate (OR:0.99; 95 % CI 0.46-2.12; p=0.98) between the continuing low dose aspirin group and discontinuing group. Moreover, the overall stone-free rate was also not statistically significant (OR:3.17; 95 % CI 0.89-11.25; p=0.07). It was similar about the change in hemoglobin, hematocrit and creatinine levels between two groups.


Conclusion: Based on our findings, transient cessation of aspirin perioperatively seems not to be necessary for patients who need PCNL complicated with the necessity of aspirin therapy. However, further well-designed prospective studies with large sample size are needed to confirm and validate our findings.

Effect of vitamin E on Semen Quality Parameters: A Meta-Analysis of a Randomized Controlled Trial

Rui Wang, Shangren Wang, Yuxuan Song, Hang Zhou, Yang Pan, Li Liu, Shuai Niu, Xiaoqiang Liu

Urology Journal, , , Page 7160
https://doi.org/10.22037/uj.v19i.7160

Purpose: To explore the effectiveness of vitamin E in male infertility, a systematic review and meta-analysis was conducted.


Materials and Methods: The retrieval time was from January 1947 to May 2021,without language restriction. Stata 12.0 was used for the meta-analysis.


Results: A total of 8 randomized controlled trials involving 459 patients were included. The results showed that after vitamin E treatment, semen volume was reduced (95% CI: - 0.55 to - 0.06, SMD = - 0.30, p = 0.015), total sperm count was increased (95% CI: 0.02-0.45, SMD = 0.23, p = 0.035), and the differences were statistically significant. There were no statistically significant differences in increasing sperm concentration (95% CI: -0.21-0.29, SMD = 0.04, p = 0.769), total sperm motility (95% CI: -0.01-0.42, SMD = 0.20, p = 0.061) or sperm forward motility rate (95% CI: -0.06-0.65, SMD = 0.29, p = 0.106). Subgroup analysis showed that vitamin E treatment for six months could improve sperm forward motility (95% CI: 0.46-1.14, SMD = 0.80, p <0.001).


Conclusion: Vitamin E could increase the total sperm count and reduce the volume of semen in male infertility patients, and long-term treatment could improve the forward motility rate of sperm. The decrease of semen volume may be the result of different abstinence time before and after the test.

ORIGINAL PAPER (ENDOUROLOGY AND STONE DISEASE)


Purpose: To evaluate the efficacy of flexible ureteroscopic lithotripsy (FURSL) based on the concept of enhanced recovery after surgery (ERAS).


Materials and Methods: This study retrospectively analyzed 435 patients diagnosed with upper urinary calculi between 2017-2020 and categorized them into ERAS (ERAS management) and control groups (traditional management). The operative time, postoperative ambulation time, postoperative hospital stay, the total cost of hospitalization, postoperative complications, and stone removal rate between the two groups were subsequently compared.


Results: The FURSL procedure was successfully performed in 427 patients but failed in 4 patients of the ERAS group (n = 216) and 4 of the control group (n = 219). No postoperative complications occurred in either group except for fever and hematuria. There was no significant difference in postoperative fever and stone removal between the two groups (all P > .05). However, patients in the ERAS group had a shorter operative time, shorter postoperative ambulation time, less postoperative severe hematuria, shorter postoperative hospital stay, and lower total cost of hospitalization than those in the control group (all P < .05).


Conclusion: FURSL, based on the concept of ERAS, is safe and reliable for the treatment of upper urinary calculi, with rapid postoperative recovery and a low cost of hospitalization. It is worthy of clinical promotion.

A Scoring System for Optimal Selection of Endoscopic Treatment for 1-2cm Lower Pole Renal Calculi

Yuleng Huang, Kaiwen Li, Wenzeng Yang, Zhuohang Li, Cheng Liu, Cong Lai, Yongzhong He, Kewei Xu

Urology Journal, , , Page 7195
https://doi.org/10.22037/uj.v19i.7195

Purpose: To explore the establishment of a scoring system that can provide a reference for clinical decision making regarding the endoscopic treatment of 1-2 cm lower pole stones (LPS).


Materials and Methods: The data of patients with renal calculi who were treated with percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) in three hospitals from January 2013 to December 2017 were analyzed retrospectively. Multivariable logistic analysis was performed to determine the statistically significant indicators and regression coefficients, which were used to construct the scoring system. The stone-free rate (SFR) and postoperative complication rates of PCNL and RIRS within the two fractional segments of the scoring system were compared to select the optimal procedures.


Results: A total of 137 patients in the PCNL group and 152 patients in the RIRS group were included in this study. Five factors were found to be most predictive of endoscopic treatment choice: stone number, stone diameter, infundibulopelvic angle (IPA), infundibular length (IL), and infundibular width (IW), yielding a total score ranging from 0-5. In the 0-2 segments, the RIRS group had better outcomes than the PCNL group in terms of the postoperative complication rates (6.8% versus 18.0%, P = .026). In segments 3-5, the SFR of the PCNL group was significantly higher than that of the RIRS group (88.5% versus 70.6%, P = .017).


Conclusion: Our scoring system was based on the patient’s preoperative imaging examination to measure the stone number, stone diameter, IPA, IL and IW. RIRS was recommended at 0-2 segments, and PCNL was recommended at 3-5 segments. This new scoring system is expected to provide guidance for urologists to make endoscopic treatment decisions for 1-2 cm LPS.

Ureteroscopic Lithotripsy in Reverse Trendelenburg Position and Intraoperative Furosemide

cheng-jing zhang, Song Xue, Ren-Fu Chen, Zhen Song, Jun-Qi Wang, Ru-Min WEN, Huan Cheng, Ke-Yu Gao

Urology Journal, , , Page 7163
https://doi.org/10.22037/uj.v19i03.7163

Purpose: Upward stone migration is a significant problem during ureteroscopic lithotripsy (URSL) for upper ureteral stone, especially in absence of a ureteral occlusion device. In this study, we evaluated the novel strategy of reverse Trendelenburg position (RTP) and intraoperative diuresis for URSL without ureteral occlusion devices to avoid upward migration.


Materials and Methods: From March 2018 to May 2020, a total of 119 URSLs were performed for upper ureteral stone (6-15 mm) with 67 procedures in RTP and 52 procedures in conventional lithotomy position (CLP). 20 mg of intravenous furosemide was administered prior to stone fragmentation with holmium laser only in RTP group. Patient demographics, stone side, stone size and operative characteristics were recorded and compared between the two groups.


Results: Patient data, stone side and size were similar in the two groups. All procedures were complete without conversion to open surgery and major complications. There was no significant difference in the mean operative time (47.9 ± 7.7 min vs 45.3 ± 7.0 min, P = .062) and mean hospital stay (3.9 ± 0.9 d vs 4.0 ± 1.0 d, P = .336) between the RTP and CLP group. Stone upward migration was significantly less in RTP group (3.0%, 2/67) than in CLP group (19.2%, 10/52) (P = .005). Stone-free rate at one month after initial treatment was 92.5% in RTP group and 73.1% in CLP group (P = .004).


Conclusion: The strategy of placing the patient in RTP and intraoperative administration of intravenous furosemide is simple, feasible and cost-effective in preventing stone upward migration during URSL with holmium laser in absence of a ureteral occlusion device for upper ureteral stone.

A Safe and Effective Two-Step Tract Dilation Technique in Totally Ultrasound-Guided Percutaneous Nephrolithotomy

Shao-Wei Dong, Su-Wei Hu, Shih-Ping Liu, Chia-Chang Wu, Chu-Tung Lin, Kuan-Chou Chen, Chen-Hsun Ho

Urology Journal, , , Page 7205
https://doi.org/10.22037/uj.v19i.7205

Purpose: To evaluate the safety and the efficacy of a radiation-free 2-step tract dilation technique in totally ultrasound-guided percutaneous nephrolithotomy (PCNL).


Materials and Methods: From Oct 2018 to Mar 2020, we prospectively and consecutively enrolled 18 patients with 19 kidney units with urolithiasis. The nephrostomy tract was established by the following four steps: 1) ultrasound-guided renal puncture, 2) first-stage serial dilation to 16 Fr with Amplatz dilators, 3) check and adjustment of the partially dilated tract with a ureteroscope, 4) second-stage dilation with a 24-Fr balloon dilator.


Results: The median age was 62.0 [IQR 11.0] years, and 11 (61.1%) were male. The median stone size was 3.3 [3.6] cm2, and stone laterality was almost equal over both sides. Successful tract establishment on the first attempt without fluoroscopy was achieved in 18 (94.7%) operations. The median tract establishment time was 10.4 [4.9] mins, and the median operation time was 67.0 [52.2] mins. The median hemoglobin drop was 1.0 [1.1] g/dL, and none required blood transfusion. Three (15.8%) developed fever. Pleural injury occurred in two (10.5%) operations (both had supracostal puncture), and one required drainage with pigtail. Stone-free status was achieved in 15 (77.8%) operations at 3 months postoperatively.


Conclusions: Herein we present a radiation-free 2-step tract dilation technique, which is characterized by ureteroscopic check of the partially dilated tract in between the first dilation with serial fascial dilators and the second dilation with balloon. Our data suggest that it is a safe and effective method.

Risk factors for Infectious Complications of Ureteroscopy after Obstructive Acute Pyelonephritis

Katsuhiro Ito, Toshifumi Takahashi, Shinya Somiya, Toru Kanno, Yoshihito Higashi, Hitoshi Yamada

Urology Journal, , , Page 7241
https://doi.org/10.22037/uj.v19i.7241

Objectives: To identify risk factors for infectious complication of ureteroscopy after obstructive acute pyelonephritis (OAPN).


Patients and Methods: This single-center, retrospective cohort study (#20200002, retrospectively registered in February 1st, 2020) included patients who underwent emergency drainage for OAPN and subsequently underwent ureteroscopic stone removal between January 2006 and December 2020. Multivariable analysis was conducted using demographic and stone-related factors to determine those that could predict postoperative febrile urinary tract infection (UTI).


Results: Overall, 432 patients underwent ureteroscopy after OAPN. The stone-free rate was 84.3%, whereas the overall and major complication rates were 17.6% and 3.2%, respectively. A total of 70 (16.2%) patient developed febrile UTI, among whom 34 (7.9%) and 11 (2.5%) developed sepsis and severe sepsis, respectively. Multivariable analysis identified diabetes mellitus [odds ratio (OR) 1.98, 95% confidence interval (CI) 1.05–3.74], duration from drainage to surgery >1 month (OR 2.28, 95% CI 1.20–4.74), and simultaneous retrograde intrarenal surgery (OR 2.96, 95% CI 1.35–6.48) as significant risk factors for UTI. After dividing patients into low- (0), intermediate- (1), and high- (2–3) risk groups according to the number of factors they had, the risk of postoperative UTI was 6.3%, 14.5%, and 27.7%, respectively (p for trend <0.001).


Conclusions: Patients who underwent ureteroscopy after OAPN were at risk for postoperative UTI, despite its efficacy. Simultaneous retrograde intrarenal surgery should be carefully planned, especially for patients with diabetes mellitus or extended surgery wait times.

ORIGINAL PAPER (PEDIATRIC UROLOGY)


Temporary Renal Enlargement in Children with a First Episode of Febrile Urinary Tract Infection is a Significant Risk of Recurrent Infection

Shingo Ishimori, Junya Fujimura, Shohei Oyama, Tadashi Shinomoto, Satoshi Onishi, Kengo Hattori, Yo Okizuka, Atsushi Nishiyama, Hirotaka Minami

Urology Journal, , , Page 6892
https://doi.org/10.22037/uj.v19i.6892

Purpose: Although morphological renal abnormalities in children with febrile urinary tract infection (fUTI) have been showed a predictive factor for recurrent infection, there are no available data on recurrence regarding sonographic renal enlargement at first fUTI episode, especially focusing on whether renal enlargement is temporary or not.


Materials and Methods: This cohort study reviewed the medical records of children who underwent renal ultrasound during their first fUTI during 2005–2013 and who were aged <15 years at diagnosis. We defined a kidney as temporary enlarged when the kidney length was ≥2 standard deviation above normal renal length for that age on sonography or a difference of ≥1 cm in sonographic length between the right and left kidneys, following normal renal length after antibiotic treatment.


Results: A total of 132 children were enrolled, of whom 11 had sonographic temporary temporal renal enlargement during their first fUTI. After completing antibiotic therapy for a first fUTI episode, 20 (15%) children had fUTI recurrence. The clinical characteristics at first episode of fUTI were not significantly different between renal enlargement and nonrenal enlargement groups. Children with temporary renal enlargement at a first fUTI episode had significantly lower fUTI recurrence-free survival proportion than those with nonrenal enlargement according to the Kaplan–Meier method (p = 0.003)


Conclusion: Identification of temporary temporal renal enlargement as a predictor of recurrent fUTI may help identify children with a first episode of fUTI who will be warned of close monitoring.

Purpose: The purpose of this study is to evaluate the results of two different flap procedures for prevention of urethrocutaneous fistula in hypospadias patients undergoing tubularized incised plate urethroplasty .


Patients and Methods: We retrospectively reviewed 89 patients who underwent hypospadias repair. The standard technique of tubularized incised plate urethroplasty was used. There were 45 patients in Group 1 and 44 patients in Group 2, in which ventral and dorsal dartos flaps were used to cover the neourethra respectively. Surgical complications were assessed as the main outcomes. The results were analyzed with Chi-square and Mann-whitney u tests.


Results: There was no significiant difference between the groups in terms of age and meatus location. We observed postoperative surgical complications in 15 (33.3 %) patients in Group 1 and in 4 (9.1 %) patients in Group 2. The complications noted in the Group 1 were urethrocutaneous fistula in 10 patients ( 22.2 %) and meatal stenosis in 5 patients ( 11.1 %). In Group 2, fistula was observed in 2 patients (4.6 %) and stenosis in again 2 patients (4.6 %). Urethrocutaneous fistulas occurred statistically more frequently when ventral based dartos flaps were used (P < .05).


Conclusion: Several flap procedures and their modifications have been suggested to avoid fistula formation. Within these procedures, dartos flaps are reported to be very useful for primary distal or proximal hypospadias repair and reoperations. In this study, we concluded that ; vascularized dorsal preputial dartos flap procedure is safe and more effective than ventral based flap in prevention of fistula formation.

ORIGINAL PAPER(UROLOGICAL ONCOLOGY)


The Oncological Outcomes of Neoadjuvant Gemcitabine plus Carboplatin versus Gemcitabine plus Cisplatin in Locally Advanced Bladder Cancer: A Retrospective Analysis

Bahram Mofid, Abolfazl Razzaghdoust, Mahdi Ghajari, Abbas Basiri, Mohammad-Reza Fattahi, Mohammad Houshyari, Anya Jafari, Farzad Taghizadeh-Hesary

Urology Journal, , , Page 6841
https://doi.org/10.22037/uj.v19i.6841

Purpose: Cisplatin-based neoadjuvant chemotherapy (NAC) is the standard of care in non-metastatic muscle-invasive bladder cancer (MIBC). There are limited data regarding the alternative choices for cisplatin-ineligible patients. This study has investigated the oncological outcomes of gemcitabine plus cisplatin (Gem/Cis) and gemcitabine plus carboplatin (Gem/Carbo) in this setting. 


Materials and Methods: One hundred forty consecutive patients with MIBC (cT2–T4a) receiving neoadjuvant Gem/Cis or Gem/Carbo before chemoradiation (CRT) or radical cystectomy (RC) were retrospectively evaluated between April 2009 and April 2019. Patients with ECOG performance status 2, creatinine clearance < 60 mL/min, hydronephrosis, ejection fraction < 50%, or single kidney received Gem/Carbo. The complete clinical response (cCR) and overall survival (OS) of NAC regimens were compared. Prognostic significance was assessed with Cox proportional hazards model.


Results: In total, 79 patients (56.4%) received Gem/Cis. The cCR was not significantly different between Gem/Cis and Gem/Carbo regimens (38.7% vs. 36.2%, P = .771). After NAC, 79 patients (56.4%) received CRT, and other cases underwent RC. After a median follow-up of 43 months, patients in the Gem/Cis group had significantly better OS than Gem/Carbo (median OS: 41.0 vs. 26.0 months, P = .008). Multivariable Cox proportional hazards models identified cT4a stage (95% confidence interval [95% CI]: 1.001–4.85, hazard ratio [HR] = 2.08, P = .03) and cCR (95% CI: 0.26–0.99, HR = 0.51, P = .04) as the only independent prognostic factors of OS, and ruled out the type of NAC regimen.


Conclusions:  The choice of NAC (between Gem/Cis and Gem/Carbo) is not the predictor of survival and both regimens had similar cCR.

Purpose: This study aimed to examine whether preoperative Prostate Imaging Reporting and Data System v2 (PI-RADS v2) can predict pathological extracapsular extension (EPE) after radical prostatectomy. We also studied the preoperative factors which can predict EPE.


Materials and Methods: In our institute, 294 patients underwent robot assisted radical prostatectomy (RARP) between December 2012 and August 2016. In this era, we performed MRI after biopsy to determine clinical stage before surgery. PI-RADS v2 scores were retrospectively reviewed using biparametric MRI and EPE in pathological mapping of resected specimens for each lobe.


Results: In the excised specimen, EPE was observed in 73 lobes (12%). The percentage of EPE by PI-RADS v2 score was score ‘1’: 6% (17/297 lobes), ‘2’: 3% (1/33 lobes), ‘3’: 12% (8/67 lobes), ‘4’: 19% (27/139 lobes), and ‘5’: 38% (20/52 lobes). The higher the PI-RADS score, the higher the percentage of EPE (P <0.01). When classified as PI-RADS score ≥4 and <4, the positive predictive value (PPV) was 24.6% (47/191 lobes, 95%CI: 0.187 – 0.313) and negative predictive value (NPV) was 93.5% (371/397 lobes, 95%CI: 0.906 – 0.957). By multivariate analysis, positive biopsy core percentage ≥60%, and PI-RADS score ≥4 were independent factors for predicting EPE. The positive rate of EPE in lobes with zero, one and two factors (PI-RADS ≥4 and positive biopsy core percentage ≥60%) was 4%, 19%, and 38%, respectively.


Conclusion: PPV and NPV of PI-RADS ≥4 for predicting pathologic EPE were 24.6% and 93.5%, respectively. PI-RADS ≥4 and positive biopsy core percentage ≥60% were independent risk factors for predicting EPE. The positive rate of EPE in lobes with zero, one and two factors (PI-RADS ≥4 and positive biopsy core percentage ≥60%) was 4%, 19%, and 38%, respectively.

Purpose: To investigate the potential relationship between differential gene expression, biological function enrichment and disease prognosis affecting the sensitivity of prostate cancer radiotherapy by bioinformatics analysis.


Materials and Methods: Retrieve and obtain data on differential gene expression of prostate cancer radiosensitivity in the GEO database (GSM3954350, GSM3954351, GSM3954352), GER2 tool to screen and analyze the differential genes, Enrichr database for enrichment analysis of GO and KEGG, use Cytoscape software builds protein-protein interaction (PPI) networks and analyzes key genes.


Results: A total of 7043 differentially expressed genes were screenedout, including 3842 high expression genes and 3199 low expressed genes. The top 20 differentially expressed genes were selected for further analysis. Their biological functions are mainly enriched in the following aspects:“Cell communication” and “Signal transduction”; cytological components are mainlylocated outside the cell; molecular functions are enriched in structural molecular activity, receptor binding, serine-like peptidase activity, etc. The KEGG enrichmentanalysisshowedthat the differentially expressed genes were mainly enriched in the mismatch repair pathway, non-homologous terminal binding pathway and so on.Survival analysis showed that VGF gene was associated with the prognosis of prostate cancer patients receiving radiotherapy, and high expression of VGF significantly reduced progression-free survival(PFS) in these patients(HR=4.84, 95% CI: 1.34-17.5, P= .016).


 


Conclusion:This study identified key genes associated with radiation sensitivity in prostate cancer and verified the relationship between the VGF gene and patient prognosis

Construction of A Novel Ferroptosis-related Prognostic Risk Signature for Survival Prediction in Clear Cell Renal Cell Carcinoma Patients

Fucai Tang, Jiahao Zhang, Langjing Zhu, Yongchang Lai, Zhibiao Li, Zeguang Lu, Zhicheng Tang, Yuexue Mai, Rende Huang, zhaohui He

Urology Journal, , , Page 6999
https://doi.org/10.22037/uj.v19i.6999

Purpose: Targeted ferroptosis is a reliable therapy to inhibit tumor growth and enhance immunotherapy. This study generated a novel prognostic risk signature based on ferroptosis-related genes (FRGs), and explored the ability in clinic for clear cell renal cell carcinoma (ccRCC).


Materials and Methods: The expression profile of mRNA and FRGs for ccRCC patients were exacted from The Cancer Genome Atlas (TCGA) database. A ferroptosis-related prognostic risk signature was constructed based on univariable and multivariable Cox-regression analysis. Kaplan-Meier (KM) survival curves and receiver operating characteristic (ROC) curves were performed to access prognostic value of riskscore. A nomogram integrating riskscore and clinical features was established to predict overall survival (OS). Based on differentially expressed genes between high- and low-OS groups with 5-year OS, function enrichment analyses and single-sample gene set enrichment analysis (ssGSEA) were investigated to immune status.


Results: A 9-FRGs prognostic risk signature was constructed based on 37 differentially expressed FRGs. ROC and KM curves showed that riskscore has excellent reliability and predictive ability; Cox regression disclosed the riskscore as an independent prognosis for ccRCC patients. Then, the C-index and calibration curve demonstrated the good performance of nomogram in training and validation cohort, and its predictive ability better than other features. Immune-related biological processes were enriched by function enrichment analysis, and the immune-related cells and functions were differential by ssGSEA between high- and low-OS groups.


Conclusion: Our study identified and verified a novel 9-FRGs prognostic signature and nomogram to predict OS, providing a novel sight to explore targeted therapy of ferroptosis for ccRCC.

Intravesical Gemcitabine versus Intravesical Bacillus Calmette-Guerin for the Treatment of Intermediate-Risk Non-Muscle Invasive Bladder Cancer: A Randomized Controlled Trial

Anahita Ansari Djafari, Babak Javanmard, Mohammadreza Razzaghi, Seyyed Ali Hojjati, Zahra Razzaghi, Saba Faraji, Amirhossein Rahavian, Maryam Garoosi

Urology Journal, , , Page 7194
https://doi.org/10.22037/uj.v19i.7194

Purpose: The most common adjuvant therapy known for non-invasive muscle bladder cancer (NMIBC) is intravesical Bacillus Calmette-Guerin (BCG). Intravesical chemotherapy drugs like gemcitabine can also be used post-TURBT, which is considered as a good alternative for BCG, or can be used as a second-line treatment. Due to the common side effects of BCG, the use of chemotherapy drugs as intravesical treatments is currently increasing.


Materials and Methods: 117 intermediate-risk NMIBC cases were included in this study. All the patients underwent TURBT surgery and received 1 gr intravesical gemcitabine immediately after performing the surgery. The patients were then divided into two groups, either receiving intravesical gemcitabine or intravesical BCG weekly for 6 weeks. The patients were followed up with cystoscopy.


Results: Most patients were men who had smoking risk factors. The youngest patient was 36 years old and the oldest one was 88 years old. The rate of side effects in the group receiving gemcitabine (13.6%) was much lower than the group receiving BCG (44.8%). (P-value = 0.016). The recurrence rate during a one year period was lower in the group consisting of patients receiving gemcitabine compared to the group receiving BCG (19 patients vs. 23 patients) (p-value = 0.401)


Conclusion: The efficacy of intravesical gemcitabine and intravesical BCG was almost equal in the treatment of intermediate-risk NMIBCs. The adverse effects of gemcitabine were found to be significantly lower than BCG. Due to causing fewer complications, gemcitabine can be known as a good alternative, especially among elderly patients with comorbidities.

Oncological Outcomes of Patients with Non-Clear Cell Renal Cell Cancers: Subtypes of Unclassified and Translocation Renal Cell Cancers

Fatih Gokalp, Serdar Celik, Tevfik Sinan Sozen, Abdurrahim Haluk Ozen, Guven Aslan, Volkan Izol, Sumer Baltaci, Talha Muezzinoglu, Bulent Akdogan, Evren Suer, Ilker Tinay

Urology Journal, , , Page 7091
https://doi.org/10.22037/uj.v19i.7091

Purpose: We aimed compare oncological outcomes in the two rare subtypes, unclassified renal cell cancer (unRCC) and translocation RCC (tRCC), vs clear cell RCC (ccRCC).


Materials and Methods: Between 2004 and 2019, from Turkish Urooncology Society Database, we identified 2324 patients for histological subtypes including 80 unRCC (3.4%), 19 tRCC (0.8%) and 2225 ccRCC (95.8%).


Results: The overall (15.8%) and cancer-specific mortalities (11.1%) were found to be higher in tRCC group and the recurrence free mortality (13.8%) was found to be higher in unRCC group. Larger pathological tumor size (p=0.012) and advanced pathological T stage (p=0.042) were independent predictive factors on overall mortality in patients with unRCC tumors.


Conclusion : The oncological outcomes of the unRCC and tRCC are worse than ccRCC and pathological tumor size and pathological stage are predictive factors for mortality in the unRCC.

A New Technique for Continent Urinary Diversion: Initial Experience and Description of the Technique

Dario Del Biondo , Giorgio Napodano , Ferdinando Di Giacomo, Dante Dino Di Domenico , Bruno Feleppa , Sertac Yazici, Aniello Rosario Zito

Urology Journal, , , Page 7088
https://doi.org/10.22037/uj.v19i.7088

PURPOSE: Orthotopic neobladder is a well-established surgical solution for continent urinary diversion after radical cystectomy. Nevertheless, it still represents a challenging surgery. Some critical issues of orthotopic bladder substitution include relevant complication rates, renal function impairment, urinary incontinence and patient quality of life. We present a new ileal neobladder technique, Vesuvian Orthotopic Neobladder (VON), performed for the first time at our institution in 2020. The main purpose of this new surgical procedure is to simplify and speed up the reservoir reconstruction through a ten standardized technical steps and obtain an appropriate bladder capacity at the same time.


 


METHODS: Inclusion criteria were muscle-invasive bladder carcinoma or non muscle-invasive high risk bladder cancer patients fit for bladder substitution. The exclusion criteria were locally advanced cancer, presence of hydronephrosis, renal or hepatic impairment. A chest-abdominal CT scan and urinary cytology were performed before the procedure. Patients received neoadjuvant chemotherapy, as required. Overall, operative time, bladder reconfiguration time, hospitalization time, catheterization time were recorded. All complications associated with the procedure were classified according to the Clavien Dindo score. The bladder volume was evaluated by ultrasound three months after the surgery.


 


RESULTS: A total of six male patients diagnosed with non-metastatic muscle-invasive or high-risk non-muscle invasive bladder cancer who underwent radical cystectomy followed by VON reconfiguration were included in the study. Mean age was 62.8 (±4.9) years; all selected patients enjoyed good health conditions (Charlson Comorbidity Index 4-6). One patient presented with high-risk non-muscle invasive bladder cancer. Four patients received neoadjuvant chemotherapy. Mean overall operative time was 273.3 (±18.6) minutes. Average time for neobladder reconstruction was 63.7 (±16.1) minutes. There were no intraoperative complications. A single case of urethral anastomosis leakage occurred and was treated conservatively. Bladder volume on ultrasound evaluation ranged between 250 and 290 ml.  Day time and nocturnal continence were observed in four and three patients, respectively.


 


CONCLUSION: The new VON technique is a good alternative to traditional orthotopic bladder procedures. VON reconstruction seems to offer the advantage of speeding up the procedure, reducing intestinal compromise with good storage capacity. The ten surgical steps can be considered a good starting point for further improvements in surgical technique. More robust data regarding the number of procedures and the duration of follow-up is required.

Purpose: This study aimed to evaluate the predictive factors for perioperative and long-term renal functions after nephron-sparing surgery (NSS).


Materials and Methods: The clinical records of 379 patients who underwent NSS for a single renal tumor with a normal contralateral kidney between 2009 and 2016 were retrospectively analyzed. After surgery, the occurrence of acute kidney injury (AKI) within 7 days and the progression of chronic kidney disease (CKD) 5 years later were assessed using serum creatinine (S-Cr) levels. Perioperative AKI was defined as an increase in the S-Cr level by ≥ 0.3 mg/dL or 1.5–1.9 times the baseline value. CKD was defined as the estimated glomerular filtration rate (eGFR) decreasing from > 60 mL/min/1.73 m2 to < 60 mL/min/1.73 m2.


Results: Changes in the eGFR were assessed during 5 years after surgery. Among 379 patients, 81 (21.4%) patients presented diabetes mellitus (DM), and 30 (7.92%) experienced uncontrolled DM. The AKI occurrence and CKD progression were observed in 50 (13.2%) patients and 79 (20.8%) patients, respectively. Multivariable analyses revealed that female gender (95% confidence interval [CI]: 0.16–0.91, odds ratio [OR] = 0.39, P = 0.029), uncontrolled DM (95% CI: 1.05–6.60, OR = 2.63, P = 0.039), and intermediate NePhRO score (95% CI: 1.07–3.80, OR = 2.02, P = 0.03) were associated with perioperative AKI. In addition, old age (95% CI: 1.10–1.18, OR = 1.14, P < 0.001) and uncontrolled DM (95% CI: 1.84–11.4, OR = 4.57, P = 0.001) were associated with long-term CKD progression.


Conclusion: Uncontrolled DM is the only predictive factor for perioperative and long-term renal functions after nephron-sparing surgery.

ORIGINAL PAPER (FEMALE UROLOGY)


Purpose: To evaluate the associations among teenage childbearing (Age at first birth<=19 years old) with later-life risk of stress and urgency urinary incontinence (SUI, UUI) in American women using nationally representative data from America.


Materials and Methods: Data from the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2018 were merged to include 2673 women. The question, “How old were you at the time of your first live birth?” was used to assess teenage childbearing. Urinary incontinence was ascertained by self-report. Multivariable logistic regression models were used to assess the association between teenage childbearing and urinary incontinence in American women, controlling for potential confounders.


Results: Among the 2673 women with complete data, the prevalence of SUI was 27.3%, and the prevalence of UUI was 22.1%. Overall, 856 of female had given birth at or before the age of nineteen. Teenage childbearing was significantly associated with SUI (OR=1.9, 95%CI=1.5-2.3, p<0.001), but teenage childbearing was not associated with UUI (OR=1.2, 95%CI=1.0-1.5, p=0.0658).


Conclusion: After controlling for known risk factors, teenage childbearing seems to be significantly related to female stress urinary incontinence.

ORIGINAL PAPER (ANDROLOGY)


Purpose: To study the effect of female sexual abnormalities on the etiology of penile fracture, which is an important urological emergency.


Materials and Methods: The sexual function of the partners of patients with penile fracture (study group, n = 90) treated at our clinic and healthy women (control group, n = 90) were evaluated on a voluntary basis. In both groups, sexual function was evaluated with the Female Sexual Function Index (FSFI). Each substance of the FSFI was evaluated separately by comparing both groups and the effect on the development of penile fracture was investigated.


Results: There was no difference in demographic and clinical characteristics between the study and control groups. Evaluation of sexual function with FSFI revealed that the scores of vaginal lubrication, orgasm, satisfaction, and pain subscales were lower in the study group (p < .001). Among these subscales, anorgasmia was determined as the factor with the largest effect on the development of penile fracture (OR = 7.333, 95% CI = 2.666–20.166, p < .001). No correlation was found between the largest dimension of penile fracture and FSFI total and subscale scores in the study group.


Conclusion: We believe that female vaginal dryness and dyspareunia in particular are factors which could cause the development of penile fracture during sexual intercourse. The treatment could prevent the development of penile fracture in the male.

Background: This study aimed to develop and psychometrically validate the Sexual Health Instrument for Middle-Aged sexually active women (SHIMA).


Methods: This study was a mixed exploratory study consisting of two phases. In phase one, we interviewed 19 middle-aged women and reviewed the existing instruments to generate an item pool. Then, a panel of experts (n = 16) examined the items. In the second phase, the psychometric properties of the instrument were assessed. For content and face validity, a panel of experts (n = 8) and a group of middle-aged women (n = 10) reviewed the items. For construct validity, a cross-sectional study was carried out on a sample of 407 married women. Finally, SHIMA’s reliability was assessed.


Results: In the first phase, the sexual health concept was explored, and a provisional scale including 60 items was generated. Next, 21 items were removed based on content and face validity. Accordingly, the results obtained from the exploratory factor analysis (EFA) indicated acceptable loading for 34 items tapping into six factors that jointly explained 48.67% of the total variance observed. The internal consistency evaluation revealed that Cronbach’s alpha and McDonald’s omega were greater than 0.7, and the average inter-item correlation was greater than 0.4, except for one factor that showed borderline results. Test-retest reliability over a 2-weeks interval was 0.90, indicating its high stability.


Conclusion: The SHIMA is a reliable and valid scale for measuring sexual health in middle-aged married women. It can be used as a sexual health screening tool by healthcare professionals and for research purposes.

CASE REPORT


Percutaneous sclerotherapy is a safe and effective treatment for renal parapelvic cysts. However, if the cyst is in communication with the adjacent renal pelvocalyceal system, sclerotherapy is contraindicated and alternative treatment should be considered. Here, we report a case of a patient with a symptomatic renal parapelvic cyst that was treated using a novel technique involving percutaneous new tract formation between the cyst and renal pelvis.

LETTER


Publication Bias in Urology Systematic Reviews and Meta-Analyses

Amirmahdi Khayyamfar, Sepehr Khosravi, Robab Maghsoudi, Behnam Shakiba

Urology Journal, , , Page 7319
https://doi.org/10.22037/uj.v19i.7319

Background


Publication bias is one of the most important biases in systematic reviews and meta-analyses. This bias occurs when the results of an article affect its publication, in other words positive or significant findings are more likely to be published than the other probable results. Previous studies have shown that publication bias has been a matter of concern in the meta-analysis and systematic reviews conducted in some medical fields.  There is not a study that has evaluated the status of publication bias assessment in urology systematic reviews. We decided to assess the status of publication bias evaluation in systematic reviews and meta-analyses published in high impact urology journals.


 


Methods


This cross-sectional study was performed on 200 systematic reviews and meta-analysis published in four top urology journals based on their impact factor (European Urology, The Journal of Urology, BJU International and Prostate Cancer and Prostatic Diseases). Two independent reviewers performed data extraction about publication bias evaluation in included systematic reviews.


 


Results


From the 200 included studies only 65 (32.5%) evaluated the publication bias in the review process and 31 reviews had reported publication bias in their study. Visual inspection of a funnel plot was the most frequent method used for evaluation of publication bias (61 from 65, 93.85%); this method was used alone in 34 articles and in combination with other methods in 27 papers.


 


Conclusion


The present study confirms that publication bias was formally evaluated in a small number of reviews and meta-analysis published in urology journals, therefore, this may be a risk factor that could decrease the robustness of outcomes and results of these studies. It seems that there is an essential need for authors, reviewers, and editors to pay better attention to evaluation of publication bias besides reporting it based on the aforementioned reporting guidelines.


 

UNCLASSIFIED


Purpose: To evaluate the efficacy of botulinum toxin type A (BTX-A) injection in patients with chronic pelvic pain syndrome (CPPS) after transurethral resection of the prostate (TURP).


Materials and Methods: Six patients after TURP received the injection of BTX-A around the prostate capsule or pelvic floor under ultrasound guidance. The clinical outcomes including overall pain intensity (assessed by visual analog scale, VAS), the Functional Pelvic Pain scale (FPPS), and mental state by anxiety and depression questionnaires, the generalized anxiety disorder (GAD-7) and Hamilton depression rating scale (HAM-D)) were assessed at pre-treatment, and 1, 4, 12 weeks after treatment.


Results: Six male patients, aged 65 to 76 years were enrolled. The improvement of VAS pain score, the Functional Pelvic Pain scale, and mental assessment were observed at 1, 4, and 12 weeks after treatment for all six patients. All 6 patients had no safety concerns through 12 weeks visit, except 3 patients complained transient pain at injection site.


Conclusion: Injection of BTX-A around the prostate under ultrasound guidance may be effective and safe for patients with CPPS after TURP.