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 No. 04 (2023), 2 October 2023, Page 191-202

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.


Storz Medical Lithotripsy Index Predicts Success of Shock Wave Lithotripsy in Ureteric Stones

Sarp Korcan Keskin, Mandy Spencer, Benjamin W Turney

Urology Journal, Vol. 20 No. 04 (2023), 2 October 2023, Page 203-207

Purpose: 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 were 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 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 No. 04 (2023), 2 October 2023, Page 208-214

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 the CT-ultrasound group and 22 in the ultrasound
group. The ultrasound screening time in the CT-ultrasound group was significantly shorter than that in the
ultrasound group (P < .001). In addition, the success rate of puncture in the CT-ultrasound group was significantly
higher than that in the ultrasound group (P =.015). Furthermore, in the 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 the CT-ultrasound image fusion technique was a feasible and safe method
to guide PCNL puncture. Compared with traditional ultrasound guidance, the 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.


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 No. 04 (2023), 2 October 2023, Page 215-221

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 ages 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.

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 No. 04 (2023), 2 October 2023, Page 222-228

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.


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 No. 04 (2023), 2 October 2023, Page 229-233

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.


Outcomes of Artificial Urinary Sphincter Implantation in Patients with Detrusor Underactivity and Postprostatectomy Incontinence

Kyu Hun Han, Joon Chul Kim, Woong Jin Bae, Jin Bong Choi, Jun Sung Koh, Kang Jun Cho

Urology Journal, Vol. 20 No. 04 (2023), 2 October 2023, Page 234-239

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.


Experiences with an Extraperitoneal Transvesicoscopic Repair of a Vesicovaginal Fistula

Hongwook Kim, ChangHee Hong, JangHwan Kim

Urology Journal, Vol. 20 No. 04 (2023), 2 October 2023, Page 240-245

Purpose: A vesicovaginal fistula (VVF) is a debilitating condition for women in terms of both its personal and
social impacts. A reported transperitoneal laparoscopic approach to treatment has some limitations such as risk of
intra-peritoneal organ injury and unnecessary bladder dissection. We here report on our experiences with an extraperitoneal transvesicoscopic approach to a VVF repair, which overcomes these drawbacks.
Materials and Methods: Seven VVF patients were treated using the transvesicoscopic approach. Under general
anesthesia, patients were placed in the dorsal lithotomy position. The VVF orifice was obstructed via the vaginal
canal using a Foley catheter. The bladder was then filled with normal saline under cystoscopic inspection, and a
5 mm trocar was inserted into it at the suprapubic area. The bladder wall was next fixed to the anterior abdominal
wall. Thereafter, two 3 mm ports were punctured at the interspinous skin crease allowing the fistula margin to be
cut and sutured in layers.
Results: Six of the study subjects in whom we attempted a transvesicoscopic repair of VVF had undergone a
hysterectomy due to myoma and one had an intraabdominal abscess removal with Behcet's disease. One myoma
patient who had a preexisting vesicoperitoneal fistula was converted to an open transabdominal VVF repair. The
mean age of the 6 remaining patients was 46.0 ± 7.2 years (range, 35-57). The mean operation time was 273 ±
40.6 minutes (range, 223-323). There was no instances of significant pain or other immediate complications. Five
patients showed no recurrence of the fistula during the follow-up period (8.7 ± 5.1 months).
Conclusion: A transvesicoscopic approach is an effective modality for the repair of a VVF that is more minimally
invasive and has a lower morbidity than a transabdominal procedure.


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.


Sildenafil Vs. Tadalafil for The Treatment of Benign Prostatic Hyperplasia: A Single-arm Self-controlled Clinical Trial

Mazyar Zahir, Mohammad Samzadeh, Amirhossien Poopak, Ali Reza Khoshdel, Arash Armin

Urology Journal, Vol. 20 No. 04 (2023), 2 October 2023, Page 255-260

Purpose: To compare the efficacy and adverse events of sildenafil monotherapy for benign prostatic hyperplasia
(BPH) with its FDA-approved counterpart, tadalafil.

Materials and Methods: In this single-arm self-controlled clinical trial, 33 patients were enrolled. All patients
underwent a 6-week treatment with sildenafil, followed by a 4-week washout period and finally a 6-week treatment
with tadalafil. Patients were examined on each appointment and post-void residual (PVR) urine, International
Prostate Symptom Score (IPSS) and Quality of life index (IPSS-QoL index) were recorded subsequently. Efficacy
of each drug regimen was then evaluated by comparing these outcome parameters.

Results: Both sildenafil and tadalafil were shown to improve PVR (both p < .001), IPSS (both p < .001) and IPSS-
QoL index (both p < .001) significantly. Sildenafil was more effective than tadalafil in reducing PVR (mean
difference (95%CI) = 9.91% (4.11, 15.72), p < .001) and ameliorating IPSS-QoL index (mean difference (95%CI)
= 19.3% (4.47, 34.41), p = .027). Moreover, although not significant, sildenafil reduced IPSS more than tadalafil
(mean difference (95%CI) = 3.33% (-0.22, 6.87), p = .065). Concurrent erectile dysfunction did not affect responsiveness to therapy with either sildenafil or tadalafil but age was inversely related to post-treatment IPSS in both sildenafil (B = 0.21 (0.04, 0.37), p = .015) and tadalafil (B = 0.14 (0.02, 0.26), p = .021) regimens with a more
prominent role in responsiveness to sildenafil (β = 0.31) compared to tadalafil (β = 0.19).

Conclusion: Considering the significantly better improvement of PVR and IPSS-Qol index with sildenafil, this
drug can be nominated as a suitable alternative for tadalafil as a BPH treatment, especially in younger patients who
don’t have any contraindications.

Purpose: Our aim is to compare N-butyl cyanoacrylate (NBCA) glue and non-spherical polyvinyl alcohol (PVA)
particles for prostatic artery embolization (PAE) for patients with benign prostatic hyperplasia (BPH) to treat lower
urinary tract symptoms (LUTS) and report their feasibility, safety, and short-term effectiveness.

Materials and Methods: 110 patients (mean age: 72.6 years) with BPH related to LUTS were divided into two
groups, PAE was performed in one group with 250 - 355 μm non-spherical PVA particles. Whereas, the other
group received a mixture of NBCA glue/ lipiodol for PAE.

Results: PAE was technically successful in all 110 patients (100 %). During 6 months follow up, we found that
in patients who received NBCA glue, the mean of prostatic volume (PV) was significantly reduced compared to
baseline (67.1 ± 8.5 to 40.2 ± 5.4), International Prostate Symptom Score (IPSS) (25.7 ± 4.3 to 7.2 ± 1.09), Quality
of life (QoL) (4.43 ± 0.27 to 1.58 ± 2.27); whereas, the mean of Peak urinary flow (Qmax) increased significantly
from baseline to 6 months (8.6 ± 2.3 to 15.4 ± 2.3), International Index of Erectile Function (IIEFS) (9.46 ± 1.51 to
19.3 ± 1.33). Meanwhile, non-spherical PVA particles used in the other group show that PV significantly reduced
from baseline to 6 months (68.2 ± 8.32 to 38.8 ± 6.13), IPSS (25.0 ± 3.59 to7.24 ± 0.83), QoL (4.43 ± 0.24 to1.56
± 0.55). The mean for Qmax increased from baseline to 6 months (7.19 ± 1.67 to15.1 ± 2.42), IIEFS (9.22 ± 1.30
to 19.5 ± 0.96).

Conclusion: PAE with NBCA glue and non-spherical PVA particles is feasible, safe, and effective for patients
with BPH related-LUTS. This gives the physicians options to choose between embolizing agents based on the
architecture of the prostatic artery.


Unroofing of Lower Pole Native Kidney Cysts in Patients with Autosomal Dominant Polycystic Kidneys at the Time of Kidney Transplantation

Abbas Basiri, Nasser Simforoosh, Amirhossein Nayebzade, Hamed Marufi, Amir Hossein Kashi

Urology Journal, Vol. 20 No. 04 (2023), 2 October 2023, Page 269-273

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.