Purpose: The suctioning access sheath (SAS) is a novel access sheath connected to a negative pressure suction device and absorbs fragments. Some comparative studies have reported SAS with a higher stone-free rate and lower operative time. However, no higher-level evidence was published to support SAS. Hence, this systematic review and meta-analysis aimed to assess the clinical safety and efficacy of SAS versus traditional access sheath (TAS) for the treatment of renal stones in mini-percutaneous nephrolithotomy (MPCNL).

Materials and Methods: A systematic review of the literature was conducted using Pubmed, Embase(Ovid), Medline(EBSCO), Cochrane central register of controlled trials, and Sinomed to search comparative studies as recent as December 2020 that assessed the safety and effectiveness of SAS in PCNL. The quality of retrospective case-control studies (RCCs) and randomized controlled trials (RCTs) were evaluated by the Newcastle-Ottawa Scale (NOS) and the Cochrane risk of bias tool, respectively. The Oxford center set up evidence-based medicine was used to assess the level of evidence (LE). Statistical analyses were performed by the comprehensive meta-analysis program.

Results: Seven studies, with a total of 1655 patients, were included. Compared with the TAS group, the SAS group had a shorter operative time (MD= -17.30; 95%CI:-23.09,-11.51; P<.00001), higher stone-free rate (OR=2.37;95%CI:1.56,3.61;P<.0001), fewer total complication rate (OR=0.50;95%CI:0.35,0.70;P<.0001), lower auxiliary procedures rate  (OR=0.48;95%CI:0.36,0.64; P<.00001), and lower postoperative fever rate (OR=0.46;95%CI:0.34,0.62;P<.00001).

Conclusion: The SAS can significantly improve MPCNL in the stone-free rate, operative time, and total complication rate, especially for auxiliary procedures and postoperative fever rates.

Purpose: Although extracorporeal shockwave lithotripsy (SWL) has been confirmed to be effective in treating ureteral stone, a definitive conclusion on which patient’s position is the optimal option during SWL treatment remains unclear. We, therefore, performed this updated meta-analysis to further clarify it.

Materials and Methods: PubMed, Embase, and Cochrane library were performed to capture all potentially eligible studies from their inception to October 2020. After screening eligible studies, extracting essential data, and assessing the risk of bias, we used STATA 14.0 to complete all statistical analyses.

Results: We included 7 studies involving 8 cohorts in the final analysis. Our meta-analysis suggested that the prone position was inferior to the supine position in terms of stone fragmentation and stone clearance rate after completing the first treatment (95% CI: 0.30-0.63; OR = 0.44;), however, subgroup analysis indicated that the difference between supine and prone positions for stone fragmentation and the stone clearance rate was only getting statistical significance for distal ureteral stone (95% CI: 0.23-0.53; OR = 0.35). Moreover, subgroup analysis of two eligible randomized controlled trials suggested that the mean number of sessions per patient in the supine group was less than that in the prone group (95% CI: 0.11-0.48; WMD = 0.294). No major and severe complication was detected to be done with the association with positions.

Conclusion: SWL of the supine position may be the preferred option because this strategy can increase the distal ureteral stone-free rate compared to the prone position.


Purpose: To explore the risk factors and predictive factors of systemic inflammatory response syndrome (SIRS) after flexible ureteroscopy (fURS) for upper urinary tract stones.

Materials and Methods: Patients who underwent fURS from January 2014 to September 2019 were retrospectively analyzed, which were divided into the SIRS group and non-SIRS group. Clinical data of all patients, including gender, age, American society of anesthesia score, diabetes, etc., were collected. Univariate and multivariate logistic regression was used to determine the independent risk factors for SIRS after fURS, and the receiver operating characteristic (ROC) curve was drawn to verify the validity of the results. In addition, patients from October 2019 to January 2020 were prospectively collected to verify the results.

Results: A total of 369 patients were retrospectively included. Univariate analysis showed significant differences in postoperative stone residuals (P = 0.039), preoperative neutrophil/ lymphocyte ratio (NLR) (P < 0.001), and lymphocyte/monocyte ratio (LMR) (P = 0.001) between two groups. Further, preoperative NLR and postoperative stone residuals were independent according to multivariate logistic regression analysis. The optimal cut-off value of preoperative NLR by ROC curve was 2.61, and the area under ROC curve was 77.9%. Prospective analysis based on 53 patients showed that the incidence of SIRS in patients with NLR > 2.61 was significantly higher than that in other patients. (RR = 4.932, P = 0.040).

Conclusion: Preoperative NLR can be used as a predictive factor for SIRS in patients with fURS according to our study. It may provide an evidence for clinicians to make preoperative decisions or medical plans.

Characteristics of Double-J Stent Encrustations and Factors Associated with their Development

Jian Huang, Weizhou Wu, Shike Zhang, Yapeng Huang, Tao Zeng, Lingyue An, Yeping Liang, Jinkun Huang, Hans-Göran Tiselius, Guohua Zeng, Wenqi Wu

Urology Journal, Vol. 19 No. 01 (2022), , Page 22-27

Purpose: To evaluate the chemical composition of double-J stent encrustation and to assess risk factors associated with their development.
Materials and Methods: Patients who had double-J stents removed between July 2016 and June 2017 were recruited for this study prospectively. The clinical features of the patients were recorded and the composition of encrustation material was analyzed by infrared spectroscopy.

Results: Encrustments from a total of 372 double-J stents were collected. The mean age of patients was 50.4±13.1 years and deposits possible to analyze were obtained from 228 males (61.3%) and 144 females (38.7%). Calcium oxalate monohydrate was the most common constituent of stone and encrustments. The encrustation rate of vesical coils was significantly higher than that of renal coils (P<0.001). There was no significant difference in chemical composition between stone and encrustation regarding renal (P=0.086) and vesical coils (P=0.072). The only predictive risk factor for the development of encrustation on double-J stents was indwelling time. This phenomenon was observed in both renal (P<0.001) and vesical coils (P=0.021). Interestingly, patient with chronic kidney disease (CKD) was associated with less risk of encrustation on both renal (P<0.001) and vesical coils (P=0.001).

Conclusion: The chemical composition of double-J stent encrustation was the same as the urinary stone. The prevention strategy for stone composition is also suitable for the prevention of encrustation of double-J stent. The only predictive factor for double-J stent encrustation was the indwelling time. CKD patient was shown to be less at risk for the development of encrustation.   


Transperitoneal Laparoscopic Pyelolithotomy versus Percutaneous Nephrolithotomy for Treating the Patients with Staghorn Kidney Stones: A Randomized Clinical Trial

Mohammad Hossein Soltani, Amir Hossein Kashi, Saman Farshid, Seyyed Javad Mantegy, Rohollah Valizadeh

Urology Journal, Vol. 19 No. 01 (2022), , Page 28-33

Purpose: To compare the performance and outcomes of laparoscopic pyelolithotomy (LPL) versus percutaneous nephrolithotomy (PCNL) in the management of staghorn kidney stones.

Materials and Methods: This study was a parallel-group randomized clinical trial study carried out on 68 patients with staghorn stones (one single piece or maximally two-piece stones with large extra renal part) over 18 years referred to Labbafinejhad Hospital. Patients were randomly divided on a ratio of 1:1 into two groups of LPL and PCNL using random allocation software. The primary outcome was the stone free rate, which was evaluated with KUB, and ultrasonography. Secondary outcomes were duration of surgery, bleeding, fever, post-operative pain, length of hospital stay, and postoperative complications.

Results: The mean±SD age of patients in PCNL and LPL groups were 48.50 ± 13.33 years and 52.17 ± 15.74 years, respectively (P=.303). LPL was associated with a higher duration of surgery (196.55 ± 26.58 minutes versus 110.88 ± 34.82; P=.001). Hemoglobin drop in the PCNL group was higher than the LPL group (2.67 ± 2.61 g/dL versus -0.7912 ± 1.06 g/dL; P=.001). Stone free status was observed in 29 (85.3%) patients in the LPL group, which was significantly higher than the PCNL group (22 patients, 64.7%; P =.050).

Conclusion: The results of this study indicate that LPL offers a higher stone free rate with less bleeding in patients with single particle or limited particles staghorn stones with extrarenal pelvis but is associated with a higher duration of operation. The application of LPL in patients with multiple stones carries a lower achievement and is not encouraged.

“Two-zone and Three-segment” Laparoscopic Radical Cystectomy vs Conventional Laparoscopic Radical Cystectomy for Male Patients With Bladder Urothelial Carcinoma: A Retrospective Analysis

Shouzhen Chen, Jianfeng Cui, Haoyu Sun, Wenfu Wang, Xigao Liu, Dongqing Zhang, Xianzhou Jiang, Hu Guo, Nianzeng Xing, Yaofeng Zhu, Benkang Shi

Urology Journal, Vol. 19 No. 01 (2022), , Page 34-40

Purpose: The aim of this study was to introduce an advanced surgical technique for laparoscopic radical cystectomy (LRC), evaluate the perioperative outcome and compare it to that of conventional LRC (CLRC).

Materials and Methods: Between March 2018 and March 2020, sixty patients were divided into the “two-zone and three-segment” laparoscopic radical cystectomy (TTLRC) group or the CLRC group. Patient baseline characteristics, preoperative characteristics and postoperative complications were collected.

Results: The TTLRC technique was developed based on the pelvic anatomy of six formalin fixed male cadavers. None of the patient baseline characteristics, including ECOG-PS score, comorbidity, ASA score and Hb, were significantly different between the two groups (p>0.05). There were significant differences in the operating time and estimated blood loss (total time: 3±0.2 vs 3.8±0.4, p<0.001; time to cystectomy and lymph node dissection: 1.7±0.2 vs 2.2±0.3, p<0.001; estimated blood loss 182.1±18.8 vs 264.3±27.4, p<0.001). Although there were no differences in late complications, early complications were significantly different between the two groups (p = 0.033). No statistically significant differences were found between the two groups in other outcomes (p>0.05).

Conclusion: The TTLRC technique achieves a clearer surgical field, has a shorter operating time and produces less blood loss than CLRC. It is safe and feasible for urologists to perform this improved LRC procedure.


The Role of Kallikrein10 (KLK10) Polymorphism in Prostate Cancer Susceptibility

Seda Güleç Yılmaz, Faruk Yencilek, Asıf Yıldırım, Fatma Tuba Akdeniz, Altay Burak Dalan, Zerrin Barut, Turgay İsbir

Urology Journal, Vol. 19 No. 01 (2022), , Page 41-44

Purpose: The present study aims to investigate the potential role of Kallikrein 10 (KLK10) genotype and allele frequencies in predisposition to prostate cancer.

Materials and Methods: KLK10 (rs7259451) gene polymorphisms were determined by real-time polymerase chain reaction analysis in patients with prostate cancer (n=69) and controls (n=76).

Results: KLK10 gene frequencies were significantly different in the case and control groups (P = .028). GG carriers were significantly higher in the control group (P = .034), whereas TT carriers were higher in the prostate cancer group (P = .033). Furthermore, The patients with GG genotype had the lowest PSA levels while TT carriers had the highest (P = .005).

Conclusion:  According to the results, we suggested that carrying variant T allele and also carrying homozygote TT genotype could be a potential risk, while ancestral homozygote GG genotype and G allele are risk reducing factors for prostate cancer.

Prognostic value of HPV DNA in Urothelial Carcinoma of the Bladder: A Preliminary Report of 2-Year Follow-up Results

Mehmet Sarier, Sibel Sürmen Usta, Hasan Turgut, Sefa Alperen Öztürk, Ahmet Soylu, Mestan Emek, Erdal Kukul, Hakan Bozcuk, Nevgun Sepin

Urology Journal, Vol. 19 No. 01 (2022), , Page 45-49

Purpose: The association between the human papillomavirus (HPV) and anogenital carcinomas is well established. However, despite its anatomic adjacency, the relationship between HPV and urothelial carcinoma of the bladder (UCB) is less clear. Recent meta-analysis and case-control studies demonstrated a significant relationship between the presence of HPV DNA and UCB. The aim of this clinical study was to compare the 2-year follow-up results of HPV-positive and HPV-negative UCB patients to evaluate the prognostic value of HPV DNA positivity in UCB.

Methods: The study included patients with stage pTa and pT1 UCB who underwent polymerase chain reaction (PCR) analysis of HPV DNA between January 1 and November 30, 2018. Based on their PCR results, 19 HPV-positive and 38 HPV-negative UCB patients who had regular follow-up in our clinic were evaluated in terms of tumor recurrence and disease progression over a 2-year follow-up period.

Results: There was no significant difference between the groups in terms of age, follow-up time, smoking, or tumor grade (P= .576, P= .368, P= .080, and P= .454). Tumor recurrence was observed at least once in 47.3% (n=9) of the 19 HPV-positive patients and 36.8% (n=14) of the 38 HPV-negative patients (P= .445). There was no difference in disease progression between the groups during follow-up.

Conclusion: In our sample of UCB patients, the presence of HPV DNA was associated with a trend toward higher recurrence rate during the 2-year follow-up, though the difference was not statistically significant. No difference in disease progression was observed based on HPV DNA positivity.


Purpose: To determine hypospadias repair's cosmetic and functional outcome concerning the urethral plate width and glanular width.

Materials and Methods:  A prospective study including 38 patients. The urethral plate width (UPW) was measured preoperatively. The cosmetic outcome was evaluated by hypospadias objective penile evaluation [HOPE] score, and the urinary stream evaluated functional outcome. We included boys with distal penile hypospadias and excluded recurrent cases with severe chordee. All patients were operated on by Snodgrass tubularized incised plate repair (TIP); they were followed up for one year. Success was defined as slit-shaped meatus at the tip of the glans without fistula.

Results: The mean age of surgery was 4.5 ± 2.1 years. UPW was < 8 mm in 24 patients (63.2 %) (Group A), while 14 patients (36.8 % ) (Group B) had a UPW ≥ 8 mm. Overall, the mean ± SD of UPW was 4.84 ± 1.29 mm. The mean ± SD of GW was 9.52 ± 1.56 mm. Overall success was documented in 35/38 patients (92.1 %). No significant relation was founded between the complications and UPW of the patients (p-value = 0.7). Overall, the mean ± SD HOPE score was 39.1 ± 8.83. A significant relation was found between the cosmetic outcome of the two groups and the HOPE score (p-value = 0.02).

Conclusion: The pre-incision urethral plate width and glanular width were not correlated with the TIP outcome. A better HOPE score is associated with a wide urethral plate.


The Whitaker Test in the Follow-up of Complex Upper Urinary Tract Reconstruction: Is It Clinical Useful or Not

Xinfei Li, Kunlin Yang, Weijie Zhu, Yuke Chen, Yang Yang, Peng Zhang, Juan Wu, Pengjie Wu, Shiliang Wu, Xuesong Li, Liqun Zhou

Urology Journal, Vol. 19 No. 01 (2022), , Page 56-62

Purpose: To evaluate the feasibility and guiding significance in postoperative management of the Whitaker test after complex reconstruction of the upper urinary tract.

Materials and Methods: Patients who underwent complex ureteral reconstruction and received the Whitaker test after surgery between December 2018 and December 2019 were included. We judged it abnormal that the renal pelvis pressure was higher than 22 cmH2O or the pressure difference was greater than 15 cmH2O. The results were used as a reference for removing the nephrostomy tube. Based on whether the renal pelvic pressure was higher than 22 cmH2O, the patients were divided into the elevated pelvis pressure group and the normal group. Follow ups at 1 month and every 3 months were collected.

Results: A total of 19 patients were included. Fifteen patients did not present obvious abnormalities. One patient suffered from contrast infiltrating into the renal parenchyma, and the pressure was higher than 15 cmH2O. Ureteral stent implantation was performed. The other 3 patients had either elevated pelvis pressure or insufficient image, 2 of which prolonged the duration of nephrostomy tubes. The median follow-up time was 12.6 months. CTU/MRU after removing nephrostomy tubes indicated improved/stable hydronephrosis in all patients. The creatinine in the elevated pelvis pressure group was higher than that in the normal group (91.4 ± 27.6 vs 86.7 ± 16.5 μmol/L, P = .782), and the eGFR was lower (76.0 ± 14.0 vs 81.8 ± 24.1 mL/min/1.73m2, P = .695), but without significant difference. The change in creatinine during follow-up in the elevated renal pelvic pressure group was significantly different from that in the normal group (-13.6 ± 1.0 vs -0.2 ± 10.6 umol/L, P = .047).

Conclusion: Postoperative Whitaker test can help judge whether nephrostomy could be removed. Elevated pressure in upper urinary tract after reconstruction suggests the need to prolong the time of the nephrostomy tube or even re-intervene. Proper management for patients with elevated renal pelvis pressure can help restore the renal function.


Purpose: Neurogenic lower urinary tract dysfunction (NLUTD) is one of the most challenging problems in urology. In recent years, Onabotulinum toxin A (Botox) is considered a second-line treatment in these patients. This study aimed to evaluate the clinical effects of Abobotolinum toxin A (Dysport) into the bladder and urethra.

Materials and Methods: We classified our patients with NLUTD into three groups: neurogenic detrusor overactivity (group 1), detrusor sphincter dyssynergia (group 2), and patients with both symptoms (group 3). The severity of the patient’s symptoms was assessed using the Urinary Distress Inventory- Short form (UDI-6), urodynamic study, and post-void residual urine (PVR) at baseline. After injection of Dysport, the patients were evaluated by the change in UDI-6 score, PVR, and the patient’s general satisfaction. In group 1, 500-900 U diluted Dysport injected intra-vesical. If associated with detrusor sphincter dyssynergia (group 3), 100 U diluted Dysport injected peri-urethral. In group 2, only 100 U diluted Dysport injected peri-urethral.

Results: Data from 52 women with NLUTD were analyzed. The mean age was 51.3 ± 21.6 years. The prevalence of detrusor overactivity and the value of Q max was more in group 1. However, the amount of PVR was more in groups 2 and 3. The overall success rate was acceptable in all three groups. In addition, there were significant improvements in UDI-6 parameters.

Conclusion: Peri-urethral injection of Abobotolinum toxin A is effective and safe. However, the selection of the patients and the dose of toxin needs more studies.

Purpose:  Urinary incontinence (UI) is a fundamental health problem, can occur at any age but is especially common in older women. Depression and anxiety are also considerable problems for the elderly. UI is one of the geriatric syndromes that are thought to be related to depression and quality of life (QOL).

Materials and methods: This prospective study was conducted for a period of 2 months from February 2020 to April 2020. Women who applied to the outpatient clinic of geriatrics with UI symptoms were taken into the study. The type of UI was determined by using the 3 Incontinence Questions (3IQ). Only patients with urge incontinence were included in the study. Patients were evaluated for QOL, anxiety, depression, disability, and geriatric syndromes before and after treatment. Data analysis was done by using SPSS version 22. Results: The study population was 42 women; the mean age was 69.7 +/- 4.3 years.  QoL, anxiety, and depression symptoms, and ADL were revealed to be improved after treatment. ICIQ-SF, I-QOL, and HADs scores were associated with UI treatment when evaluated with one-way MANOVA (F [4, 79] =3.25, p=0.00, Wilk's Λ=0.859, partial η2=0.14). Conclusion: UI is a common problem in the elderly. Patients usually hesitate to tell this complaint to even doctors. That situation affects their physical and psychological condition negatively. In this study, we reached that anticholinergic treatment (fesoterodine) improved ADL, QoL, and psychological symptoms. Those findings represented us that proper treatment of UI is critical for healthy aging. 


The Effect of Phytosterols and Fatty Acids of Pistachio (Pistacia vera) Oil on Spermatogenesis and Histological Testis Changes in Wistar Adult Male Rats

Soudeh Khanamani Falahati-pour, Soheila Pourmasumi, Maryam Mohamadi, Zahra Taghipour, Mohammad Reza Mohammadinasab, Mojtaba Sajadian, Fatemeh Ayoobi, Ali Dini, Zahra Ahmadi, Sakineh Khanamani Falahatipour, Alireza Nazari

Urology Journal, Vol. 19 No. 01 (2022), , Page 75-82

Purpose: Oilseeds and their related products are known to have various bioactive and health-promoting ingredients. In this research, we investigated the effects of phytosterols and fatty acids of Pistacia vera on spermatogenesis process and testis histological changes in Wistar male rats for the first time.

Materials and Methods: A total number of 64 adult male Wistar rats were divided randomly into eight groups including one control group, and seven test groups. Test groups received phytosterols, fatty acids, and pistachio oil orally for 30 days. Then, LH, FSH, and serum testosterone levels were determined. Also, the spermatogenesis process and changes in testicular tissue in rats were investigated.

Results: The results of this research suggest that phytosterols in doses of 10 and 50 mg/kg reduce the spermatogenesis process. Fatty acid in a low dose of 10 mg/kg increases spermatogenesis, but when a high dose of 50 mg/kg was used, it harmed the spermatogenesis process. When low levels of phytosterols and fatty acids are used simultaneously in dose 5 mg/kg, improvement in spermatogenesis process is observed but when these were used together in the dose of 25 mg/kg, the spermatogenesis process was disrupted. Using pistachio oil alone also improved spermatogenesis process.

Conclusion: It seems that phytosterols reduce spermatogenesis at high and low doses, while fatty acids increase spermatogenesis when used in low doses and reduce this process when used in high doses. The use of fatty acids extracted from pistachios to treat infertility in men seems hopeful.


Purpose: Bipolar transurethral resection of the prostate (TURP) is an effective and safe alternative to monopolar TURP. The aim of this study was to investigate the influence of resected prostate weight on the clinical outcome improvement after bipolar TURP for benign prostatic hyperplasia (BPH) patients.

Materials and Methods: A total of 233 men with BPH who underwent bipolar TURP were included in this prospective study. International Prostate Symptom Score (I-PSS), quality of life (QoL), maximum flow rate (Qmax) and post-void residual urine volume (PVR) were assessed preoperatively and 3 months postoperatively. The relationship between the resected prostatic weight ratio (RPWR, %) and clinical improvement was investigated.

Results: Significant improvements in Qmax, PVR, I-PSS and QoL were found 3 months after operation, and Qmax was correlated with RPWR (r = 0.1521, P = .020). The RPWR was significantly higher in patients with postoperative Qmax > 20 mL/s (P = .049). Moreover, Qmax at 3-month follow-up was higher in patients with RPWR over 50% than patients with RPWR between 0–25% (P < .05). In addition, patients with larger prostate volume tended to gain better Qmax and I-PSS postoperatively (P < .05).

Conclusion: The RPWR exerts an influence on postoperative Qmax, rather than I-PSS and QoL score, and patients with larger prostate volume tend to gain better clinical outcomes from bipolar TURP than those who with smaller prostates.