Urology Journal

Purpose: To choose the ideal ureteral access sheath (UAS) size for an unstented ureter in flexible ureteroscopic
lithotripsy (FURL).
Materials and Methods: A retrospective study was conducted in patients treated with FURL for renal calculi from 2005 to 2020. The patients were divided into two groups: smaller (10/12 Fr) vs. larger (12/14 Fr) calibre UAS. The outcomes were the insertion success rate, systemic inflammatory response syndrome (SIRS) complication rate after the operation, ureteral wall injury, operative time, and stone-free rate.
Results: Of the 1573 patients enrolled, 10/12 Fr UAS was used in 957 patients (Group A), and 12/14 Fr UAS was
used in the remaining patients (Group B). The insertion success rate was significantly better in Group A (91.2%
vs. 86.9%, P = .006), with no significant difference between the groups regarding the stone-free rate, postoperative pain, operative time or hospital stay. The severity of visible ureteral lesions with 10/12 Fr UAS was significantly lower than that with larger UASs (80.1% vs 85.2%, P < .001). Despite the lack of a significant difference in the incidence of SIRS between the two groups, the incidence of SIRS in the 10/12 Fr group showed a sharp increase with stones > 2 cm (17.0% vs. 8.5%, P = 0.037).
Conclusion: The use of 10/12 Fr UAS was beneficial with respect to insertion success rate, avoiding ureteral wall
injury and not increasing postoperative infectious complications in FURL. We recommend the use of a smaller
calibre (10/12 Fr) UAS in patients with renal calculi < 2 cm.

Purpose: To investigate factors determining the outcomes of endoscopic management for stone-related ureteral stricture.
Materials and Methods: Data of patients who underwent endoscopic surgery for ureteral stricture due to stones from January 2016 to April 2020 were retrospectively analyzed. We compared cases successfully treated with endoscopic surgery with cases that resulted in failure. We focused on factors associated with treatment success, including cause and length of stricture, methods of stricture treatment, surgical time, and duration of hydronephrosis before the treatment. Treatment success was defined as improvement in hydronephrosis status.
Results: Nineteen patients were treated for stone-related ureteral stricture. Hydronephrosis was successfully improved in 12 patients (63.2%). Seven patients with failed endoscopic management had ureteroscopic lithotripsy- related stricture, whereas 3/12 (25.0%) patients with ureteroscopic lithotripsy-related stricture and 7/12 (58.3%) patients with impacted stone-related stricture were successfully treated by endoscopic management (P = .004). The prevalence of stricture length > 15 mm was significantly higher in the patients with failed management than in the patients with successful management (71.4 vs 16.6%, P = .046). Intraoperative endoscopic observation demonstrated that the mucosa of the ureteroscopic lithotripsy-related stricture had ischemic appearance with relatively long stricture length (P = 0.13) compared to the impacted stone-related stricture. No association was observed between treatment outcome and method of endoscopic management, including laser incision, balloon dilation, or
both.
Conclusion: Ureteroscopic lithotripsy as a cause and stricture length > 15 mm could affect the success rate of
endoscopic management of ureteral stricture. In such cases, reconstructive management should probably be considered in the early stages.

Purpose: In spite of extraordinary developments in diagnostic and treatment methods for prostate cancer (PCa), the reason for this disease is not known. Our study aimed to compare men in the PCa group with a control group in terms of sexual behavior like partner numbers and ejaculation frequency, and inflammatory parameters examined in serum.
Material and Methods: This study was performed prospectively between 2013 and April 2020 and the record system was kept by a single doctor. Patients were prospectively recorded by a single person. Patients with diagnosis of PCa were compared with a control group in terms of sexual behavior and in terms of inflammatory parameters like neutrophil lymphocyte ratio (NLR, neutrophil count/lymphocyte count), systemic inflammatory index (SII, neutrophil count x platelet count/lymphocyte count).
Results: In this study, median marriage age was 18 ± 6 years in the control group and 20 ± 2.97 in the PCa group (P = .001). The median lifelong partner number was observed to be 1 ± 1 in the control group and 1 ± 9 in the PCa group (median ± IQR). Additionally, lifelong median ejaculation frequency was determined as 12 ± 5 for controls and 10 ± 4 for the PCa group. Inflammatory markers examined in serum and SII scores were observed to be statistically significantly increased in the cancer group.
Conclusion: The sexual behavior and inflammatory parameters among patients with PCa diagnosis were identified to be significantly high compared to the control group and appear to be possible correctable risk factors. Informing men about sexual behavior from an early age and taking precautions for people at risk in the early period may be protective against this disease.

Purpose: To compare the efficacy and complication rate of monthly instillations of Bacillus Calmette-Guerin (BCG) as maintenance therapy in intermediate and high risk Non-Muscle Invasive Bladder Cancer (NMIBC) patients with the current standard Southwest Oncology Group (SWOG) protocol.
Materials and Methods: In this observational retrospective study, 40 intermediate and high risk NMIBC patients, receiving standard BCG maintenance regimen, were compared with another 40 NMIBC patients, undergoing monthly intra-vesical instillations of BCG with regard to recurrence, progression and major and minor adverse effects.
Results: The two groups were similar in their basic characteristics except for the older age in the monthly instillation group ( 70.95 ± 9.66 years vs. 64 ± 8.8, p = 0.001). Study objectives between the monthly instillation group and the standard group, including recurrence ( 17.5 % vs. 25%, p = 0.34) and progression rate ( 7.5% vs. 10%, p = 0.54) did not show statistically significant difference. Major and minor complication rate also did not show any difference between the two groups.
Conclusion: In addition to the currently recommended standard protocol of BCG maintenance therapy, our study shows that the monthly regimen can be recommended in intermediate and high risk NMIBC patients without compromising the efficacy of the treatment.

Purpose: Cytoreductive nephrectomy (CN) was considered a well-established treatment modality for patients with metastatic renal cell carcinoma (RCC) in the interferon era. However, its role after the introduction of multiple targeted therapies is less well established. Herein, We evaluated the effect of CN on overall survival (OS) on patients with RCC who were identified through the Surveillance, Epidemiology, and End Results database (SEER).
Materials and Methods: A total of 5,483 patients with metastatic RCC were identified from 2010 to 2016 using
the SEER database. Factors pertaining to the following variables were collected: presence or absence of CN; age;
gender; grade; status of metastasis to bone, liver, lung and brain; tumor stage; nodal status; histological subtypes; and chemotherapy status. Subjects who had CN were matched with those who did not in all previously mentioned covariates using inverse probability weighting. These weights were then used in adjusted Cox regression models to report doubly robust estimates.
Results: CN was associated with 67% reduction in the hazards of death. Advanced T-stage, N1 disease, advanced tumor grade, non-clear histology and metastasis to bone, liver, lung or brain are independent risk factors for death. Patients with T4 disease benefited less of CN compared to those with T1 disease, while higher number of metastatic sites didn’t predict worse outcome among those who had CN.
Conclusion: CN could provide a survival advantage in favorable risk patients with RCC in the era of targeted
therapy.

Purpose: Urological complications are common and serious in kidney transplant patients. Correct diagnosis of urological complications and rapid intervention are very important to maintain the transplanted organ. Using endoscopic methods and rapid access to ureteral orifice can be effective in treatment and management of urological complications in transplant patients.
Materials and Methods: In this retrospective cohort study, 934 medical records of kidney transplant patients who underwent surgery through Posterolateral Extravesical Ureteroneocystostomy (PLEVUNC) and anterior extravesical ureteroneocystostomy (AEVUNC) techniques from 2011 to 2018 were evaluated. The outcomes of PLEVUNC and AEVUNC techniques were evaluated in 461 and 473 transplant patients, respectively. The patients were followed up for 60 months. Immediate and delayed complications, urological complications requiring endoscopic intervention, duration of access to ureteral orifice, as well as ureteroscopic and endoscopic outcomes were evaluated.
Results: The mean and ± SD (standard deviation) age of patients in PLEVUNC and AEVUNC groups were 46.2 7± 2.7 years and 47.3 ± 3.6 years, respectively. Urinary leakage and UTI were the most common immediate (7% and 6.2%) and delayed (5.5% and 5.5%) complications in both groups, respectively. The time to find ureteral orifice in patients requiring endoscopic intervention was significantly shorter in PLEVUNC group 3.5±1.2 compared with the AEVUNC group 10 ± 4.5 (P <.001). In 100% of PLEVUNC group and 62.6% of AEVUNC group, ureteral orifice of transplanted kidney was observed (P <.001). Ureteroscopy was reported successful in 94.5% and 37.4% of patients in PLEVUNC and AEVUNC groups, respectively.
Conclusion: Easy and safe access to the ureteral orifice and to the upper urinary tract in transplant recipients can be achieved with the PLEVUNC technique. In case of urological complications this method facilitates endoscopy.

Objectives: To present the early to midterm experience of two referral kidney transplantation centers with living and deceased kidney transplantations that were performed within the COVID-19 pandemic.
Materials and Methods: All cases performed in two referral centers in Iran within the COVID-19 pandemic
were investigated. Transplantations were performed from May 2020 to February 2021. The protocol for screening included nasopharyngeal RT-PCR with chest CT scan for living and deceased transplantations in center A and RTPCR for living transplantations and chest CT scan for deceased transplantations in center B. Patients were followed for 14-26 months after transplantation regarding COVID-19 infection and its outcomes in case of infection.
Results: 103 kidney transplantations were performed during the study period including 54 (52.4%) living and 49
(47.6%) deceased kidney transplantations. Twenty-four recipients (23.3%) and a living donor (1%) were infected
with COVID-19. The severity of COVID-19 infection was mild, moderate, severe, and critical in 16 (66.6%), 4
(16.6%), 2 (8.4%), and 2 patients (8.4%), respectively. Two mortalities were observed within transplantation recipients with COVID-19 infection (1.9%). 87.5% (7/8) COVID-19 infections in center B were observed in recipients of deceased transplantations who were screened only by chest CT scan.
Conclusion: The results of this study indicate a low frequency of COVID-19 mortality (1.9% for the whole cohort
and 8.3% within COVID-19 infected patients) for recipients of living and deceased kidney transplantation that
were performed within the COVID-19 pandemic. The above findings highlight for the first time in a large study
the probability of living kidney transplantation during the COVID-19 pandemic in case strict screening of donors
and recipients and close supervision of operating rooms and wards are implemented. We further hypothesize the inadequacy of chest CT scan for screening of COVID-19 in kidney transplantation surgery candidates.

Purpose: To compare two methods of laparoscopic sacrocolpopexy (LSCP) and sacrospinous ligament fixation
(SSLF) in terms of efficacy and safety in the treatment of vaginal apical prolapse.
Materials and Methods: This prospective, randomized controlled clinical trial was conducted on 32 patients with symptomatic vaginal apical prolapse, referred to the female urology clinic of Kerman University, Iran, during 2018-2019. The patients were re-examined at 12 months after surgery. Objective success was recorded using Pelvic Organ Prolapse Quantification (POP-Q) classification as primary outcome. The subjective success of the methods was determined by the quality-of-life parameters, based on Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Floor Distress Inventory (PFDI-20), and Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) scores as secondary outcomes. Moreover, complications were recorded in both groups.
Results: The amount of intraoperative bleeding was significantly higher in the SSLF group, compared to the LSCP group (P = 0.01). Persistent pain was observed in two (12%) patients in the LSCP group and five (31%) patients in the SSLF group (P = 0.2). The decrease in the total PFIQ-7 score was in favor of the LSCP group but not statistically significant (p = 0.06). The LSCP group showed bigger improvement in vaginal (p = 0.04) and bowel (p = 0.03) scores. The results of the PISQ-12 and PFDI-20 questionnaires as well as POP-Q examination were not different in two groups.
Conclusion: Although the surgical methods of LSCP and SSLF can be equally effective in the treatment of apical
prolapse, LSCP appears to be superior to SSLF regarding less bleeding.

Purpose: The purpose of this study was to compare the effectiveness of Dapoxetine, and Paroxetine as well as Dapoxetine/Tadalafil and Paroxetine/Tadalafil combinational therapies, for the treatment of patients with premature ejaculation.
Materials and Methods: In this clinical trial study, 120 patients with premature ejaculation were randomly divided into 4 groups: The first group was treated with Paroxetine (Pa), while the second group received Dapoxetine(Da). The third group received Paroxetine combined with Tadalafil(PT) whereas the fourth group's treatment involved the use of Dapoxetine and Tadalafil(DT) for one month. In the next 2 and 4 weeks, the cases were evaluated in terms of ejaculation duration, frequency of intercourse per week, and drug side effects.
Results: The mean age of the Da, Pa, PT, DT groups was 32 ± 6.9, 32.4 ± 7.2, 31.6 ± 1.9, and 32.9 ± 7.7 years, respectively. There was a significant difference between the Da and DT groups (p = .029) in the ejaculation latency in the 4-week follow-up. In the two weeks follow-up, a significant difference was observed between DA and DT (p = 0.043), Pa and PT (p = 0.006), and Pa and DT groups (p = 0.004) in terms of ejaculation latency. Four weeks after the intervention, a significant difference was detected in the intercourse frequency of Da and PT groups (p =0.033), Pa and PT groups (p = 0.043), Pa and DT groups (p = 0.02), and Da and DT groups (p = 0.016).
Conclusion: Combination therapy (Tadalafil plus Paroxetine or Dapoxetine) was more effective in IELT (Intra ejaculation latency time) than mono-therapy especially in younger patients despite its slightly more side effects.

Purpose: The aim of study was to investigate the outcome of surgery in patients with penile fracture in Al-Zahra hospital.
Materials and Methods: This cross sectional study was conducted on 187 patients with penile fracture underwent surgery in Al-Zahra hospital during 2016- 2020. Data such as penile fracture causes, erectile dysfunction, time of surgery after penile fracture, degree of penile curvature and etc were extracted from medical records.
Results: The most common reason of penile fracture in these patients was manipulation and trauma with frequency 70 (37.4%) and 69 patients (36.9%), respectively. Lower urinary tract symptom, urinary tract injury, penile curvature, penile nodule and erectile dysfunction were observed in 1 (0.54 %), 2(1.06 %), 76 (40.64%), 75 (40.1%), 43 (23%) patients, respectively. Mild and moderate erectile dysfunction was seen in 38 (88.3%) and 5 (11.62%) patients, respectively. There was a significant relationship between erectile dysfunction with the degree of penile curvature, surgical time and size of defect (P < .01). Furthermore, significant relation was observed between penile nodules and suture type (P = .000).
Conclusion: According to findings, erectile dysfunction was observed in 23 % of patients; however most of these patients had mild erectile dysfunction. Moreover, erectile dysfunction was influenced by penile curvature, surgical time and size of defect. Therefore, early surgery and special attention to patients with severe penile curvature are proposed for prevention of erectile dysfunction in these patients.

Purpose: Benign prostatic hyperplasia (BPH) is one of the most common problems in elderly men. Transurethral resection of the prostate (TURP) can be performed for most patients who need re-do prostate surgery, but open prostatectomy should be considered in patients with prostate size larger than 70 grams. This study assessed the feasibility of open prostatectomy (OP) after previous TURP in patients whose prostate size was larger than 70 grams.
Materials and Methods: We subdivided patients into two groups: group 1 included patients who had a history of prostate surgery presented with severe voiding symptoms and a large prostate (>70 gram). Patients who were candidate for open simple prostatectomy without a history of prostate surgery were allocated to group 2.
Results: Between June 2007 and April 2018, 2700 patients underwent TURP or open prostatectomy in our department. 152 of 2700 patients came to us because of severe voiding symptoms after previous prostate surgery, but only 30 patients met the criteria to be enrolled in this study. Perioperative complication (capsular perforation) occurred in 4 (13.3%) patients in group 1 whereas none of the patients in the group 2 had capsular perforation. Hemoglobin drop in group 1 was not significantly different from patients in group 2. The rate of blood transfusion did not differ between the groups (2 [6.6%] patients in group 1 and 41 (5.6%) patients in group 2). After 6-12 months, re-operation rate because of urethral/bladder neck stricture was done in 10 (30%) patients in group 1 and 15 (2%) patients in group 2 (p < 0.05). Four (13.3%) patients in group 1 complained of urinary leakage (more than one pad per day) 6 months after the operation whereas 5 patients in group 2 used more than one pad per day (0.7%) (p > 0.05). Hospital stay was slightly longer in patients in group 1. Six months after the operation, the patients’ quality of life was better in group 2 compared with group 1 (p < 0.05).
Conclusion: Open simple prostatectomy was a feasible procedure in patients with large prostate after previous TURP, but it was associated with more complications in the long term.

Purpose: To evaluate the effectiveness of a modified disposable circumcision suture device (DCSD) with application of plastic sheet to avoid severe bleeding after circumcision and compare the surgical effects and other postoperative complications of two DCSDs.
Materials and Methods: A total of 943 excess foreskin patients from January 2018 to January 2020 who underwent circumcision using two different DCSDs were recruited. Preoperative characteristics (patient age, height and weight), main surgical outcomes (surgical time, intraoperative blood loss, incision healing time) and postoperative complications (postoperative hemorrhage and hematoma rate, edema rate, incision infection rate, residual staples rate) were collected and analyzed. Patients' "satisfaction" or "dissatisfaction" was also investigated.
Results: Preoperative characteristics showed no significant statistical difference. The modified DCSD group has
a lower intraoperative bleeding, postoperative hemorrhage or hematoma rate and residual staples rate compared with the conventional group. Incision healing time and incision infection rate between the two groups were similar. Nevertheless, conventional group has a shorter surgical time, a lower edema rate and a higher satisfaction rate.
Conclusion: The modified DCSD with application of plastic sheet can avoid severe bleeding after circumcision
effectively and can be served as a new choice for circumcision.

Lumen diameter reduction which is called urethral stricture has several causative agents including iatrogenic,
inflammatory, traumatic, and idiopathic factors. The main treatment options are transurethral or open surgical interventions.The UroLume which was introduced around 33 years ago is an intraurethral stent and as a temporary treatment approach has a maximum 9-month durability, but here we present the first ever reported forgotten 16-year remained UroLume without any complication.