Aim: The aim of this study is to evaluate the factors affecting treatment success in patients who underwent Shock wave lithotripsy (SWL) for ureter stones and to investigate the effect of Storz Medical Lithotripsy Index (SMLI) on treatment effectiveness in ureteric stones.

Method: Prospective data was collected on patients undergoing SWL treatment for ureter stones between January 2013 and May 2021. Stone location, number, and size were determined with Non contrast CT (NCCT) for all patients. All patients underwent SWL with a Storz Modulith SLK lithotripsy machine with local anaesthesia. The total amount of energy applied to the stone was calculated using the Storz Medical Lithotripsy Index (SMLI). All patients were evaluated for stone-free status by X-ray at least 2 weeks after treatment. The success of the procedure was defined as the patient being completely stone free (SF) or detection of residual fragments < 4 mm that did not require further treatment

Results: A total of 1199 patients with ureter stones were included in the study. The mean age of the patients was 43.11±10.65(18-73), and the mean BMI was 27.87±8.12(19.02-38.65). During SWL, 89.3% of patients demonstrated excellent pain tolerance (1070/1199). A total of 119 patients could not tolerate pain during SWL (10.7%).

Treatment success was associated with fewer treatment sessions (2.04±1.64 vs. 2.50±1.48; p<0.001), smaller stone size (7.35±2.99 vs. 9.02±3.81; p<0.001) and higher SMLI/stone size (29.70±17.48   vs. 24.98±16.01; p<0.001). In the univariate and multivariate regression analysis, the factors affecting the success of the treatment were the number of sessions (OR: 1.147), stone size (OR: 1.112), SMLI/stone size (OR: 1.115) and pain tolerance (OR: 0.740).

Conclusion: In the treatment of ureteral stones with SWL, number of sessions, stone size, SMLI/stone size, and pain tolerance are the factors affecting success. SMLI per stone size is a statistically significant factor for predicting SWL success.

A A Novel Computed Tomography-Ultrasound Image Fusion Technique for Guiding the Percutaneous Kidney Access

Xiaobo Shen, Kaiwen Li, Zhenyu Wu, Cheng Lu, Hao Yu, Cong Lai, Zhuang Tang, Kuiqing Li, Kewei Xu

Urology Journal, Vol. 20 (2023), , Page 7465

Purpose: To describe the feasibility of computed tomography (CT)-ultrasound image fusion technique on guiding percutaneous kidney access in vitro and vivo.

Materials and Methods: we compare CT-ultrasound image fusion technique and ultrasound for percutaneous kidney puncture guidance by using an in vitro pig kidney model. The fusion method, fusion time, ultrasound screening time, and success rate of puncture were compared between the groups. Next, patients with kidney stones in our hospital were randomized in the study of simulated puncture guidance. The general condition of patients, fusion method, fusion time, and ultrasound screening time were compared between the groups.

Results: A total of 45 pig models were established, including 23 in CT-ultrasound group and 22 in ultrasound group. The ultrasound screening time in CT-ultrasound group was significantly shorter than that in ultrasound group (P < .001). In addition, the success rate of puncture in CT-ultrasound group was significantly higher than that in ultrasound group (P =.015). Furthermore, in simulated PCNL puncture study, baseline data including age, BMI, and S.T.O.N.E score between the two groups showed no statistical difference. The ultrasound screening time of the two groups was (2.60 ± 0.33) min and (3.37 ± 0.51) min respectively, and the difference was statistically significant (P < .001).

Conclusion: Our research revealed that CT-ultrasound image fusion technique was a feasible and safe method to guide PCNL puncture. Compared with traditional ultrasound guidance, CT-ultrasound image fusion technique can shorten the learning curve of PCNL puncture, improve the success rate of puncture, and shorten the ultrasound screening time.

The Effect of Ventilation Mode in Anesthesia on Renal Mobility During Retrograde Intrarenal Surgery. Single-Blind Randomized Study

Cagri Dogan, Murat Akgül, Ayhan Şahin, Cenk Murat Yazıcı, Mehmet Fatih Şahin, Enes Altın, Anıl Keleş

Urology Journal, Vol. 20 (2023), , Page 7478

Purpose: Renal mobility can present challenges for surgeons during stone fragmentation. The respiratory setup of the mechanical ventilator during RIRS might affect renal mobility. The aim of this study was to evaluate the effect of high ventilation (HV) and standard ventilation (SV) modes on renal mobility during RIRS.

Materials and Methods: Patients who underwent RIRS at a single center between November 2020 and November 2021 were retrospectively included in the study. Renal mobility was measured under fluoroscopic view in HVandSV modes during retrograde pyelography. The surgeon, who was absolutely blind about mechanical ventilation modes, was asked to assess the renal movement grade. After the ventilation mode was changed, the surgeon reassessed renal mobility. The data and the surgeon’s assessment were recorded and compared to each other.

Results: A total of 86 patients with a mean age of 48.6 ± 15.7 years were included in the study. There was a significant difference between the SV and HV modes in terms of renal mobility in fluoroscopic view (17.1±6.1 mm and 13.6 ± 5.2mm, respectively; p=0.007). According to the surgeon’s assessments, the grade of renal mobility was found to be significantly higher in the SV group 2.8 ±1.1 compared to the HV group 2.2 ± 0.8 (p=0.001). Renal movement increased significantly under fluoroscopic vision as the renal grading of the surgeon increased(p=0.013). This data demonstrated that the surgeon’s assessment of renal mobility was significantly correlated with fluoroscopic kidney movement.

Conclusion: Kidney movement was decreased significantly in HV mode during RIRS according to both fluoroscopic findings and surgeon assessment. Most surgeries of mobile kidneys were performed in HV mode, due to the surgeon’s preference.



The Rate of Phosphatase and Tensin (PTEN) Gene Expression Loss in Prostate Cancer and its Link to Tumor Upgrading

Atoosa Gharib, Atefeh Aziminejad, Fatemeh Pourmotahari, Behrang Kazeminejad, Mohammad Soleimani

Urology Journal, Vol. 20 (2023), , Page 7412

Purpose: Recent studies have provided reliable evidence for a relationship between loss of PTEN gene expression and prognosis in patients suffering from prostate cancer, although the results have been somewhat diverse in different populations. We aimed to assess PTEN gene expression loss by immunohistochemistry in prostate cancer and also its link to tumor upgrading in a group of affected patients undergoing radical prostatectomy.

Materials and Methods: This cross-sectional study was performed on 58 tissue samples sourced from the patients with prostate cancer and undergoing radical prostatectomy. TRUS-guided needle biopsies of the cancer tissue samples with histological grade groups of I to IV (the Gleason scores of 6 to 8) were prepared as the study samples. 29 patients with Gleason score (6 to 8) whose tumors on needle biopsy upgraded to Gleason score 7, 8 or 9 at prostatectomy (cases) were compared with 29 patients with Gleason scores of 6, 7 or 8 on both biopsy and prostatectomy samples (controls). Immunohistochemistry (IHC) technique was employed to determine PTEN gene expression status. 

Results: Loss of PTEN gene expression was found in 62.1% of upgraded cases compared with 27.6% of controls, indicating a statistically significant difference, revealing a meaningful association between the loss of PTEN gene expression and tumor upgrading. Furthermore, we demonstrated that deletions of PTEN gene expression and increased Gleason score in control and upgraded case groups, did not reach statistical significance.

Conclusion: A high rate of PTEN gene expression loss can be detected in prostate cancer tumor tissue, and this loss of gene expression is associated with tumor upgrading.

Upfront Androgen Receptor-Axis-Targeted Therapies in Men with De Novo High-Volume Metastatic Hormone-Sensitive Prostate Cancer

Natsuo Kimura, Yuki Kaneko, Takahiko Tetsuka, Akinori Takei, Takato Uchida, Hirokazu Abe, Yoshiyasu Amiya, Takayuki Shima, Noriyuki Suzuki, Satoru Hayashi, Hiroomi Nakatsu

Urology Journal, Vol. 20 (2023), , Page 7402

Purpose: The extent of effectiveness of upfront androgen receptor-axis-targeted therapies (ARAT) versus total androgen blockade (TAB) in improving prostate cancer-specific survival (CSS) and progression-free survival (PFS) in a real-world sample of Japanese patients with high-volume mHSPC remains unclear. We, therefore, investigated the efficacy and safety of upfront ARAT versus bicalutamide for de novo high-volume mHSPC in Japanese patients.
Material and Methods: This was a multicenter retrospective study that analyzed CSS, clinical PFS, and adverse events (AEs) in 170 patients with newly diagnosed high-volume mHSPC. Fifty-six patients were treated with upfront ARAT, and 114 of them were prescribed bicalutamide in addition to ADT between January 2018 and March 2021. The primary and secondary endpoints were CSS and PFS, respectively. A 1:1 nearest neighbor propensity score matching (PSM) with a caliper of 0.2 was performed to match the ARAT group to TAB patients.
Results: During the follow-up for a median of 21.5 months, the median CSS was not reached and 37 months in the upfront ARAT and total androgen blockade (TAB) groups, respectively (log-rank test: P=0.006) by propensity score matching (PSM). Moreover, while the PFS of ARAT was unreached, the median PFS of TAB was 9 months (log-rank test: P<0.001). Nine patients discontinued ARAT owing to grade ≥3 AEs; one patient who was treated with TAB had a grade 3 AE.

Conclusion: Upfront ARAT significantly prolonged the CSS and PFS of patients with high-volume mHSPC better than TAB, although ARAT was associated with a higher rate of grade ≥3 AEs. Upfront ARAT can be more beneficial for patients with de novo high-volume mHSPC than TAB.

Survival Differences in High-Risk Prostate Cancer By Age

Clara García Fuentes, Ana Guijarro, Virginia Hernández, Álvaro Gonzalo , Estíbaliz Jiménez, Enrique de la Peña, Elia Pérez, Elia Pérez, Carlos Llorente

Urology Journal, Vol. 20 (2023), , Page 7393

Purpose : Age is an established determining factor in survival in low-risk prostate cancer (PC), being this evidence weaker in high-risk tumors.

Our aim is to evaluate the survival of patients with high-risk PC treated with curative intent and to identify differences across age at diagnosis.

Methods: We did a retrospective analysis of patients with high-risk PC treated with surgery (RP) or radiotherapy (RDT) excluding N+ patients. We divided patients by age groups: <60, 60-70 and >70 years.

We performed a comparative survival analysis.A multivariate analysis adjusted for clinically relevant variables and initial treatment received was performed.

Results: Of a total of 2383 patients, 378 met the selection criteria with a median follow-up of 8.9 years: 38 (10.1%) <60 years, 175 (46.3%) between 60-70 years, and 165 (43.6%) >70 years.

Initial treatment with surgery was predominant in the younger group (RP:63.2%, RDT:36.8%), and with radiotherapy in the older group (RP:17%, RDT:83%) (p=0.001).

In the survival analysis, significant differences were observed in overall survival, with better results for the younger group. However, these results were reversed in biochemical recurrence-free survival, with patients <60 years presenting a higher rate of biochemical recurrence at 10 years.

In the multivariate analysis, age behaved as an independent risk variable only for overall survival, with a HR of 2.8 in the group >70 years (95%CI: 1.22-6.5; p=0.015).

Conclusion: In our series, age appeared to be an independent prognostic factor for overall survival, with no differences in the rest of the survival rates.

Introduction: Penile cancer is a rare malignancy, where extranodal extension in inguinal or pelvic lymph nodes is associated with decreased 5-year cancer-survival rate in this study, we try to assess survival and quality of life in a penile cancer patient with bulky lymph node.

Method: We retrospectively reviewed data from penile cancer patients with bulky lymph nodes who underwent treatment between July 2016 and July 2021 at tertiary referral hospital care. The inclusion criteria (age >18 yr, histologically proven penile cancer, and completion of last treatment 6 months prior to this study) yielded a cohort of 20 eligible penile cancer patients with bulky lymph nodes (> 4 cm/bilateral mobile/unilateral fixed). Only patients who had completed therapy at least 6 months prior to the study were included. After obtaining consent, they were asked to complete the EORTC QLQ-C30 questionnaire to evaluate the patient quality of life.

Results: Out of 20 patients, 5 patients underwent direct ILND and 15 patients underwent chemotherapy. Median follow-up after primary diagnosis was 114+32 months in patient with early ILND and 52+11 months in patients who underwent delayed lymph node dissection. Out of 5 patients underwent early ILND, all of them survived during follow-up, and achieve cancer-free status without residual tumor and with excellent functional outcome (Karnofsky 90). There is no significant difference in social function (p value = 0.551), physical function (p value = 0.272), role function (p value = 0.546), emotional function (p value = 0.551), cognitive function (p value = 0.453), and global health status (p value = 0.893) between patient which treated with early ILND and Neoadjuvant Chemotherapy. However, patient who underwent early ILND showed a relatively better clinical outcome.

Conclusion: Early ILND followed by adjuvant chemotherapy for penile cancer with palpable lymph nodes is more favourable than neoadjuvant TIP chemotherapy.


Clinical Study of Modified Devine’s Surgical Technique in the Treatment of Concealed Penis

Ziyi Zhang, Hao Wu, Weijiang Mao, Sheng-Lin Gao, Li Zuo, Li-Feng Zhang

Urology Journal, Vol. 20 (2023), , Page 6900

Purpose: This study aimed to observe the clinical effect of modified Devine’s surgical technique in the treatment of concealed penis.

Materials and Methods: From July 2015 to September 2020, fifty-six children with concealed penis were treated with modified Devine’s technique. Recorded the penile length and the satisfaction score preoperatively and postoperatively to confirm the effect of the surgery. Followed up the penis for bleeding, infection and edema one week and four weeks after the operation. Twelve weeks after the operation, we measured the length of the penis and observed whether there was a retraction.

Results: The length of the penis has been effectively lengthened(P<0.001). There was significant improvement in parents’ satisfaction grades (P<0.001). All the patients had different degrees of penile edema after the operation. Most of the penile edema subsided about four weeks after the operation. No other complications occurred. No obvious penile retraction was found twelve weeks postoperative.

Conclusion: The modified Devine’s technique was safe and effective. As a treatment for concealed penis, it is worthy of wide clinical application. 

What is the Critical age for the Improvement of Parenchymal Thickness after Pyeloplasty?

Derya Yayla, Gokhan Demirtas, Bilge Karabulut, Huseyin Tugrul Tiryaki

Urology Journal, Vol. 20 (2023), , Page 7301

Purpose: The most important point in cases of ureteropelvic junction obstruction (UPJO) is to decide on the need and timing of surgical treatment. Renal damage may become irreversible as the duration of the obstruction is prolonged. Worsening of hydronephrosis and decrease in renal parenchymal thickness after pyeloplasty may herald an irreversible renal damage. It is important to know at what age this damage begins. In this study, we aimed to determine the relationship between the age of the patients at the time of pyeloplasty performed for UPJO and parenchymal recovery.

Materials and Methods: In our study, 156 patients (mean age: 43.5 months) who underwent pyeloplasty with the diagnosis of UPJO between 2007 and 2019 were evaluated retrospectively. Demographic characteristics, ultrasonographic (USG) and nuclear renal scintigraphy findings, previous surgeries  ​of the patients  were recorded.

Results: Numerical variables were evaluated statistically, and the best cut-off point was determined. Parenchymal thickening was determined as the most important criterion in postoperative renal recovery which was more evident at early ages. Based on statistical assessments , the cut-off age for renal parenchymal recovery was determined as 38 months. While parenchymal recovery was inadequate after pyeloplasty performed in patients older than 38 months, the most significant improvement in renal functions was seen in children younger than 13 months of age.

Conclusion: Pyeloplasty should be performed in patients with UPJO before development of severe renal damage. Statistically, the best parameter to evaluate the recovery after pyeloplasty is the change in parenchymal thickness. With advancing age, it is impossible to reverse the obstructive nephropathy


The Efficacy and Safety of Single-Incision Mini-Slings for Stress Urinary Incontinence: A Network Meta-Analysis

Yuxin Chen, Jiecheng Zhang, Yankai Zeng, Weidong Chen, Fei Liu, Jinchun Xing, Bili Zhang, Yuedong Chen

Urology Journal, Vol. 20 (2023), , Page 7218

Purpose: To evaluate the efficacy and safety of single-incision mini-sling for stress urinary incontinence based on network Meta-analysis.

Materials and Methods: We searched PubMed, Embase, and Cochrane libraries from August 2008 to August 2019. Randomized controlled trials comparing two or more indicators of Miniarc (Single Incision Mini-slings), Ajust (Adjustable Single-Incision Sling), C-NDL (Contasure-Needleless), TFS (Tissue Fixation System), Ophria (Transobturator Vaginal Tap), TVT-O (Transobturator Vaginal Tape), and TOT (Trans-obturatortape) in treating female stress urinary incontinence were collected.

Results: Totally, 3,428 patients from 21 studies were included. Ajust had the highest subjective cure rate (Rank=0.52), while Ophira had the worst (Rank=0.67). TFS had the highest objective cure rate, and the worst was found in Ophira. TFS required the shortest operating time (Rank=0.40), while TVT-O required the longest operating time (Rank=0.47). Miniarc had the least bleeding (Rank=0.47), while TVT-O had the most bleeding (Rank=0.37). C-NDL had the shortest postoperative hospital stay (Rank=0.77), while Ajust had the longest postoperative hospital stay (Rank=0.36). For postoperative complications, TFS performed best in groin pain (Rank=0.84), urinary retention (Rank=0.78), and repeat surgery (Rank=0.45). TVT-O performed worst in groin pain (Rank=0.36), and urinary retention (Rank=0.58). Miniarc had the highest repeat surgery rate (Rank=0.35). Ajust had the lowest probability of tap erosion (Rank=0.30), while Ophira had the highest tap erosion level (Rank=0.45). Miniarc showed the greatest advantage in urinary tract infections (Rank=0.84) and de novo urgency (Rank=0.60), while C-NDL had the highest incidence of urethral infections (Rank=0.51). Ophira performed worst in de novo urgency (Rank=0.60). C-NDL performed the best in sexual intercourse pain (Rank=0.79) while Ajust was the worst (Rank=0.49).

Conclusions: In view of comprehensive efficacy and safety, we recommend that TFS or Ajust should be selected first for single-incision sling and the application of Ophria should be minimized.


To report our experience with unroofing of ipsilateral lower pole kidney cysts in five patients with adult-type polycystic kidneys [ADPKD] when free implantation of kidney allograft interfered with lower pole native kidney cysts. In all of these patients, the native kidneys extended to the ipsilateral pelvis and bilateral ADPKD caused enlargement of the abdomen on gross examination. Unroofing of lower pole kidney cysts was performed during the same session of allograft transplantation. The decision to unroof lower pole cysts of the ipsilateral kidney was made after observing interference of lower pole cysts with free implantation of the allograft. In patient A, bilateral native nephrectomy was performed 6 weeks after kidney transplantation after consultation with the patient, when there was evidence of the good function of the allograft and the recipient was on a low dose of immunosuppressive medications. In other patients, no need for native nephrectomy observed. This experience suggests the possibility that when large ipsilateral kidney cysts interfere with safe implantation of the allograft, there is an option of performing cyst unroofing at the same session and proceeding with allograft implantation.  In many patients, there would be no need for native nephrectomy and of deemed necessary, it will be performed later, when there is evidence of the good function of the allograft and the patient is on good kidney function with a low dose of immunosuppressive medications and a less risk profile for the operation. To our best knowledge, there is no prior such report in the literature.

Purpose: To investigate the impact of reducing post-operative oral corticosteroid regimen on associated postoperative surgical complication rate, patient and graft survival in kidney transplant patients.

Materials and Methods: In this retrospective cohort study, we enrolled patients who received kidney transplant during two periods of distinct corticosteroid protocols. 592 patients in group 1 received prednisone 2 mg/kg (maximum dose 120 mg) on post-operative days (POD) 1, 2 and 3, 1mg/kg for a week, and tapered it to 10 mg by 3 months post-transplant and sustained the daily 10mg from 3 months post-transplant as maintenance therapy. 639 patients in group 2 received prednisone 50 mg on POD 1, 40mg on POD 2, 30mg on POD 3, 20mg on POD 4, 15mg on POD 5 and continued with 10mg daily from POD 6, as maintenance therapy. The two groups were similar in terms of other immunosuppression drug regimen.  

Results: 75 (12.7%) patients in group 1 and 24 (3.4%) patients in group 2 developed corticosteroid-related postoperative surgical complications (P < .001). Wound infection (P = .035), incisional hernia (P = .003), infectious collection (P = .004), post-op hemorrhage (P = .005) and ureteral fistula (P = .076) occurred with lower frequency in group 2. Patient survival (1-year: 97.3% vs 97.1%, respectively; P = .85, 5-year: 89.9% vs 94.9%, respectively; P = .06) and graft survival (1-year: 94.6% vs 93.3%, respectively; P = .29, 5-year: 81.2% vs 85.1%, respectively; P = .39) were similar in both groups.

Conclusion: Post-operative corticosteroid dosage decrement through our protocol would lessen the serious associated postoperative surgical complications, without negative impacts on overall patient and graft survival.


Purpose: This study aims to find candidates for testicular spermatozoa retrieval biomarkers among the seminal plasma exLncRNA pairs.

Materials and Methods: A set of exLncRNA pairs with the best potential biomarkers was selected and validated in 96 NOA samples. Weighted correlation network analysis (WGCNA) and Least Absolute Shrinkage and Selection Operator were used to identify possible biomarkers for these pairs (LASSO). These pairs' potential biomarkers were identified using receiver operating curves. Confusion matrices and sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), FP, false-negative rates (FNR), and F1 scores are calculated. Through F1 scores, we selected the best threshold value.

Results: The relative differential expression of each pair in testicular spermatozoa retrieval (+) and testicular spermatozoa retrieval (-) men were validated.

The six pairs displayed the best biomarker potential. Among them, CCDC37.DT-LOCI00505685 pair and LOC440934- LOCI01929088 (XR_001745218.1) pair showed the most significant potential and stability for detecting testicular spermatozoa retrieval in the selected and validated cohort.

Conclusion: CCDC37.DT-LOCI00505685 pair and LOC440934- LOCI01929088 (XR_001745218.1) pair have the potential to become new molecular biomarkers that could help to select clinical strategies for microdissection testicular sperm extraction.


Purpose: There is insufficient evidence for postoperative outcomes of artificial urinary sphincter (AUS) implantation for postprostatectomy incontinence (PPI) with detrusor underactivity (DU). Thus, we assessed the impact of preoperative DU on the outcomes of AUS implantation for PPI.

Materials and Methods: Medical records of men who underwent AUS implantation for PPI were reviewed. Patients who had bladder outlet obstruction surgery before radical prostatectomy or AUS-related complications that required revision of AUS within three months were excluded. Patients were divided into two groups based on the preoperative urodynamic study including pressure flow study, a DU group, and a non-DU group. DU was defined as a bladder contractility index less than 100. The primary outcome was postoperative postvoid residual urine volume (PVR). The secondary outcomes included maximum flow rate (Qmax), postoperative satisfaction, and international prostate symptom score (IPSS).

Results: A total of 78 patients with PPI were assessed. The DU group consisted of 55 patients (70.5%) and the non-DU group comprised 23 patients (29.5%). Qmax was lower in the DU group than in the non-DU group and PVR was higher in the DU group as per a urodynamic study before AUS implantation. There was no significant difference in postoperative PVR between the two groups, although the Qmax after AUS implantation was significantly lower in the DU group. While the DU group showed significant improvements in Qmax, PVR, IPSS total score, IPSS storage subscore, and IPSS quality of life (QoL) score after AUS implantation, the non-DU group showed postoperative improvement in IPSS QoL score.

Conclusion: There was no clinically significant impact of preoperative DU on the outcome of AUS implantation for PPI; thus, surgery can be safely performed in patients with PPI and DU.