Urology Journal

Purpose: High-intensity focused ultrasound ablation (HIFU) is emerging as more data on its efficacy arises for prostate cancer (PCa). However, it is indefinite whether to combine endoscopic resection and uncertain to say who the ideal candidates are for the combined treatment. Therefore, we aimed to conduct a meta-analysis to compare outcomes of sole HIFU therapy with that of HIFU in combination with endoscopic resection in patients with localized PCa.
Materials and Methods: Electronic databases were searched following the PRISMA guidelines and PICOS formats. The inclusion criteria were as follows: 1) studies on HIFU for PCa patients; 2) comparative studies on HIFU in combination with endoscopic resection for localized PCa men. Exclusion criteria include non-comparative studies and salvage HIFU therapy. Meta-analysis results were mainly present using forest plots. Sensitivity analysis and Egger's test were adopted to determine the stability and assess the publication bias.
Results: Six comparative studies with 767 patients were eligible, including 487 cases in the combination therapy group and 280 cases in the monotherapy group. There was no statistical difference in age, preoperative PSA levels, and prostate volume between two groups. No statistical difference was found in postoperative PSA nadir (MD = -0.02, 95%CI: -0.35 to 0.31, P = 0.90), disease-free survival rate (RR = 0.95, 95%CI: 0.83 to 1.09, P = 0.47), and preoperative IPSS score (MD = -0.69, 95%CI: -1.63 to 0.26, P = 0.15; I2 = 8%) between two groups. The combination therapy group had significantly lower postoperative IPSS score (MD = -5.49, 95%CI: -6.47 to -4.51, P < 0.001) and shorter catheterization time (MD=-13.70, 95%CI: -19.24 to -8.16, P < 0.001) than the monotherapy group. The rates of urinary incontinence (7.4% vs. 13.9%, RR = 0.45, 95%CI: 0.29 to 0.70, P = 0.0004; I2=4%), acute urinary retention (6.8% vs. 10.5%, RR=0.36, 95%CI: 0.14 to 0.89, P = 0.03; I2 = 0%), urinary tract infection (10% vs. 33%, RR = 0.27, 95% CI: 0.18 to 0.4, P < 0.001; I2 = 0%), epididymitis (1.2% vs. 15.7%, RR=0.11, 95% CI: 0.02 to 0.59, P = 0.01; I2 = 0%), and urethral stricture (7.1% vs. 23.2%, RR = 0.3, 95%CI: 0.18 to 0.51, P < 0.001; I2 = 0%) in the combination therapy group were all significantly lower than that in the monotherapy group. Sensitivity analysis revealed findings were convincing and no publication bias (P = 0.62) was observed using Egger’s test.
Conclusion: It appears that the addition of endoscopic resection to the HIFU operation might not impact oncologic outcomes and could show better functional outcomes compared to the HIFU monotherapy in localized PCa patients.

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.

Purpose: To evaluate the one-step prone split-leg position compared to the traditional prone position for percutaneous nephrolithotomy (PCNL).
Materials and Methods: This study retrospectively analyzed the clinical data for 102 patients with upper urinary tract calculi who underwent PCNL at our hospital from April 2019 to December 2022. All PCNL procedures were performed by the same senior urologist. According to different surgical positions, the patients were divided into a one-step prone split-leg position group (observation group, n = 39) and a traditional bladder lithotomy position followed by prone position group (control group, n = 63). Then, the two groups were compared regarding the time of catheter insertion and channel establishment, channel size, time required for double-J stent placement, total operative time, postoperative hospital stay, stone removal rate, secondary operation rate and postoperative complications.
Results: There was no significant difference in the preoperative baseline characteristics of the patients between the two groups (all P > .05). Patients in the observation group had shorter total operative times, higher stone removal rates (76.9% [30/39] vs. 57.1% [36/63], P = .042), and lower secondary operation rates (10.3% [4/39] vs. 28.6% [18/63], P = .029) than those in the control group. There were no significant differences in the time of working channel establishment, channel size, postoperative hospital stay, or postoperative complications between the two groups (all P > .05).
Conclusion: The one-step prone split-leg position is a safe and reliable surgical posture for treating upper urinary calculi in PCNL patients. It can not only shorten the overall operation time of PCNL but also improve the stone removal rate of the operation, thus reducing the secondary operation rate of multiple renal stones.

Purpose: To propose a standardized scoring system of renal tumors suitable for partial nephrectomy based on
mini-invasiveness and retroperitoneal approach.
Materials and Methods: One-hundred and five patients in retroperitoneal group were prospectively enrolled from
January 2017 to December 2018. Perioperative characteristics of all patients were collected: age, gender, BMI,
preoperative blood test and imaging results, operation time (the time period starts from the skin incision to the final
skin closure), estimated blood lost, clamping time, complications within 30 days, American Society of Anesthesiologists (ASA) score, pathology. An algorithm was extracted, and it was used to predict the risk of complications.
Results: Symptoms, ASA score and RETRO score were significantly correlated to postoperative complications,
excluding tumor size, ischemia time and operation time. Adjusted RETRO points were an independent factor to
predict complication rate (p = 0.006). Limitation was that it did not analyze the relationship between the RETRO
score and the long-term outcomes.
Conclusion: The RETRO score simplifies the risk evaluation of partial nephrectomy for patients with renal tumor,
especially benefits those surgeries performed under robot-assisted laparoscope via retroperitoneal approach. The
new RETRO score system that we developed is a selection criterion to perform surgery via different approaches,
and an accurate system to evaluate the complexity during partial nephrectomy.

Purpose: Much progress has been made by directing against the adrogen receptor (AR) pathway in the treatment
of prostate cancer in past decades. However, AR-interactors related metastatic castration resistant prostate cancer
eventually developed. Here, we aimed to characterize the aberrations and therapeutic implication in advanced
disease.
Materials and Methods: STRING database, UALCAN web portal and cBioPortal platform was used to analyze
the AR interaction network, gene alterations, as well as the prognostic significance. GO and KEEG analysis was
performed to characterize the functional enrichment of the identified AR-interactors.
Results: Ten first shell AR-interactors were identified, among of which FOXA1 and PELP1 was significantly
up-regulated, while CCND1, CTNNB1, NCOA4 and HSP90AA1 exhibited a significantly decreased pattern. The
median survival period of altered group (n = 227) was 70 months (95% CI, 60-105M), while that of non-altered
group (n = 545) was 141 months (95% CI, 115.13-NA, P < 0.001). GO and KEGG enrichment showed that the
identified AR-interactors were particularly enriched in prostate cancer and thyroid hormone signaling pathway, as
well as endocrine resistance.
Conclusion: The AR-interactors might be useful markers for prostate cancer diagnosis and prognosis, and provide
a new sight for revealing the molecular mechanism of CRPC progression.

Purpose:  The Prostate Imaging-Reporting and Data System (PI-RADS) category 3 is the most ambiguous lesion with a variable clinically significant prostate cancer (CsPCa) detection rate. Prostate-specific antigen density (PSAD) has been investigated as an adjunctive factor to improve the diagnostic efficiency of PI-RADS categories. This study aimed to investigate the utility of PSAD as an adjunctive factor in predicting CsPCA risk in patients with PI-RADS 3 lesions.

Materials and Methods: The patients with an initial PI-RADS 3 category lesion (n=142) scheduled for systematic and magnetic resonance imaging-guided prostate biopsy between 2018 and 2022 were retrospectively evaluated. Demographic and clinical variables, including PSAD, were collected. The rate of CsPCa was the primary outcome. The impact of PSAD on the CsPCa detection rate was the secondary outcome.

Results: The median age was 62 years. The rate of CsPCa was 8.5% (n=12). The patients with CsPCa have significantly lower prostate volüme and higher PSAD levels than those without CsPCa (p=0.016 and p=0.012). The cut-off values of PSAD in predicting CsPCa in all PI-RADS 3 patients and patients with CsPCa and clinically insignificant prostate cancer (n=26) were ≥0.181 ng/ml². The sensitivity and specificity values for PSAD ≥0.181 ng/ml² were of 75% (95% CI: 42.8%-94.5%) and 81.5% (95% CI: 73.4%-88.0%) in predicting CsPCa among PI-RADS 3 category.     

Conclusion: PSAD values higher than 0.181 ng/ml² can be used as an adjunctive clinical parameter in predicting CsPCa in patients with PI-RADS 3 lesions and differentiating CsPCa from clinically insignificant prostate cancer cases. 

Purpose: This study aimed to assess the importance of computed tomography (CT) imaging in the diagnostic and
prognostic evaluation of renal epithelioid angiomyolipoma (EAML).
Materials and Methods: This study comprised 63 patients diagnosed with renal EAML in the First Affiliated
Hospital of Soochow University during 2010-2021, who met the inclusion criteria. The clinical, pathological, and
therapeutic features were analyzed to determine the optimum diagnostic and therapeutic approaches.
Results: Of the 63 participants, 20 were men and 43 women aged 24-74 years (average, 45.5 years). In 35 and
28 participants, the tumor was located on the left and right sides, respectively. All the patients underwent CT
scanning. Most of the patients (54/63) with EAMLs demonstrated hyperattenuation, one showed isoattenuation,
and eight showed hypoattenuation compared with renal parenchyma on unenhanced CT images. The diameter of
each tumor was 2-25 cm (average, 5.6 cm). All the participants underwent surgical treatment. Of these, 53 were
followed up for 4-128 months (median, 64 months). Among the followed-up patients, one died of the tumor, one
died due to acute severe pancreatitis, and two had an ipsilateral recurrence.
Conclusion: EAML is a relatively rare renal angiomyolipoma depleted in fat. A characteristic of hyperattenuation
on unenhanced CT images in EAML can help distinguish this tumor from clear cell renal cell carcinoma. Surgical
resection is the main treatment. Most EAMLs are benign, and only a few have malignant potential. However,
post-surgery recurrence and metastasis may occur, especially in elderly patients, and thus close follow-up is recommended.

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.

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 a 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 regimens.
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: Varicocele is considered one of the causes of male infertility. Though varicocelectomy is supposed to
improve semen parameters in adult infertile men, some patients with varicocele were still infertile after varicocelectomy. Previous studies showed Traditional Chinese Medicine, Liver-regulating herb compounds (LRHC) could improve the semen quality and increase fertility rates of infertile patients with varicocele. This study aimed to
throw light on the mechanism of LRHC on varicocele-associated infertility.
Materials and methods: Rats with varicocele-induced were treated with LRHC at dosage of 1mL/100g by intragastric administration for 90 days. The effects of LRHC on hormones and spermatocytes apoptosis were examined using ELISA assay, Western blotting, and flow cytometry.
Results: Rats induced with varicocele showed a higher level of follicle stimulating hormone (FSH) in serum,
which was brought back to normal level by LRHC. After treatment with LRHC, both testicular tissue in vivo and
Sertoli cell TM4 cells in vitro showed elevated expressions of FSHR. Cell viabilities of TM4 cells and spermatocyte
GC-2 cells were improved by LRHC treatment under normoxia and hypoxia conditions. Moreover, LRHC
protected GC-2 cells from apoptosis induced by hypoxia. The expression of Bax reduced, while that of Bcl-2
increased after treatment with LRHC.
Conclusion: This study revealed that LRHC had protective effects on spermatogenic disturbance caused by varicocele through regulating hormones and reducing spermatogenic cell apoptosis under hpoxia conditions.

Purpose: To compare the long-term (two-year) efficacy between transurethral resection of the prostate (TURP)
after prostatic artery embolization (PAE) and TURP only for patients with giant (>100 mL) benign prostatic hyperplasia.
Materials and Methods: We retrospectively analyzed data from 61 and 150 patients with giant benign prostatic
hyperplasia treated with PAE+TURP or TURP alone, respectively, from January 2015 to March 2020. We compared
index changes before and after surgery.
Results: The operative time, intraoperative blood loss, postoperative bladder irrigation time, and catheter retention
time in the PAE+TURP group were lower than those of the TURP group, while the speed of resection of the
lesion and hospitalization costs were more significant (P < 0.05). International prostate symptom score (IPSS),
quality of life (QoL), prostate volume, maximum urinary flow rate, detrusor pressure of maximum urinary flow
rate, prostate-specific antigen, and urodynamic obstruction were better in the PAE+TURP group than the TURP
group at 24 months (P < 0.05). Regarding IPSS and QoL scores at 24 months postoperatively compared with the
preoperative period, the PAE+TURP group was better than the TURP group in terms of the storage period, voiding
period, and QoL (P < 0.05). The distribution of postoperative adverse event severity classes was comparable
between the groups (P = 0.984).
Conclusion: In contrast to TURP alone, PAE + TURP is more expensive but provides better postoperative outcomes;
there is no significant difference in terms of the severity grade distribution of postoperative complications.