ISSN: 1735-1308

Instant 2019&2020

REVIEW


Ramadan Fasting and Kidney Stones: A Systematic Review

Mohsen Amjadi, Farzin Soleimanzadeh, Hamidreza Ghamatzadeh , Sakineh Hajebrahimi, Hossein Hosseinifard, Hanieh Salehi Pourmehr, Fateme Tahmasbi

Urology Journal, , 1 January 2020 , Page 6373
https://doi.org/10.22037/uj.v16i7.6373

Purpose: Ramadan fasting in Muslims may contain several hours of abstaining from food and drinking in any kind. This can potentially increase the risk of urinary stone disease. Current literature on possible effects of Ramadan fasting on urolithiasis is rather limited. Having the gap in scientific background, we decided to evaluate the available comparative information in this systematic review. 


Materials and Methods: We included all studies comparing fasting and non-fasting conditions, studies evaluating stone formation and clinical manifestations of kidney stone disease. All the English studies published from January 1980 to the end of 2019 were included. The exclusion criteria were as followed: fasting out of Ramadan, non-comparative studies, animal studies, patients with bladder stones and studies evaluating conditions that are only indirectly related to the stone formation or clinical manifestations of it. Applying the Joanna Briggs Institute (JBI) methodology for systematic review showed the quality of included studies was not high.


Results: Only five studies remained after exclusion. Meta-analysis was not applicable due to the diversity in methods and evaluated population. 


Conclusion: Main trend of the included studies is toward showing no difference between fasting and non-fasting conditions in terms of renal stone formation. However, generalization of the findings to greater populations should be applied carefully considering the heterogeneity of results and quality of studies.

Association between Marital Status and Prognosis in Patients with Prostate Cancer: A Meta-Analysis of Observational Studies

Zhenlang Guo, Chiming Gu, Siyi Li, Shu Gan, Yuan Li, Songtao Xiang, Leiliang Gong, shusheng wang

Urology Journal, , 1 January 2020 , Page 6197
https://doi.org/10.22037/uj.v16i7.6197

Purpose: The impact of marital status on the prognosis amongst patients diagnosed with prostate cancer remains controversial. Thus, a meta-analysis was performed to determine whether marital status can influence the prognosis in patients with prostate cancer.


Materials and Methods: Literature search of the MEDLINE, PsycINFO, Embase and Cochrane Library databases was conducted to identify eligible studies published before April 2020. Multivariate adjusted risk estimates and corresponding 95% confidence intervals (CIs) were extracted and calculated using the random effects model.


Results: A total of 11 observational studies comprising 1,457,799 patients diagnosed with prostate cancer were identified. Results indicated that unmarried status (separated, divorced, widowed or never married) was associated with an increased risk of all-cause mortality (hazard ratio, HR = 1.39, 95% CI: 1.30–1.50; P < .001; I2 = 92.2%) compared with married status, especially for divorced and never-married patients. Similarly, being unmarried had an elevated risk of cancer-specific mortality (HR = 1.29, 95% CI: 1.17–1.41; P < .001; I2 = 82.5%) in patients with prostate cancer. A significant difference was also observed between unmarried status and shorter overall survival (HR = 1.37, 95% CI: 1.20–1.56; P < .001; I2 = 94.5%).


Conclusion: Results demonstrated that unmarried status is associated with a worse prognosis regarding mortality and survival in patients diagnosed with prostate cancer, particularly in divorced and never-married patients. Hence, further research should explore the potential mechanisms which can benefit the development of novel, more personalised management methods for unmarried patients with prostate cancer.

Urinary Microbiome and its Correlation with Disorders of the Genitourinary System

Aida Javan Balegh Marand, Gommert A van Koeveringe, Dick Janssen, Nafiseh Vahed, Thomas-Alexander Vögeli, John Heesakkers, Sakineh Hajebrahimi, Mohammad Sajjad Rahnama’i

Urology Journal, , 1 January 2020 , Page 5976
https://doi.org/10.22037/uj.v16i7.5976

Purpose: Until recently, the urine of healthy individuals was assumed to be sterile. However, improvement of bacterial detection methods has debunked this assumption. Recent studies have shown that the bladder contains microbiomes, which are not detectable under standard conditions. In this review, we aimed to present an overview of the published literature regarding the relationship between urinary microbiota and functional disorders of the genitourinary system.


Methods: We searched Medline, PubMed, Embase, The Cochrane library and Scopus to identify RCTs published, with MeSH and free keywords including microbiota, bladder pain syndrome, prostatitis, kidney stone disease, and bladder cancer until September 2020. Randomized controlled trials investigating microbiome and lower urinary tract symptoms were included. Non-randomized trials, cross-over trials and pooled studies were excluded. The articles were critically appraised by two reviewers.


Conclusion: The urine microbiome is a newly introduced concept, which has attracted the attention of medical researchers. Since its recent introduction, researchers have conducted many fruitful studies on this phenomenon, changing our perspective toward the role of bacteria in the urinary tract and our perception of the genitourinary system health.


Patient Summary: A deeper understanding of the urinary microbiome can help us to develop more efficient methods for restoring the microbiota to a healthy composition and providing symptom relief. Modification of the urinary microbiome without antibiotic use can be a possible venue for future research.

ORIGINAL PAPER (ENDOUROLOGY AND STONE DISEASE)


Purpose: Percutaneous-nephrolithotomy (PCNL), is the current modality of choice for large renal stones. Delayed post-op bleeding may herald pseudo aneurysm (PA) or arteriovenous fistula (AVF) necessitating costly and inconsistently available angioembolization, or prolonged hospitalization. The goal of this study is to identify criteria that may predict response to conservative therapy, for delayed bleeding from post PCNL intrarenal vascular lesions.


 


Materials and methods: We reviewed all data on patients re-admitted for post PCNL gross hematuria at our high volume center between 2011 and 2016. Perioperative findings, factors related to the stone and management details, were subjected to multifactorial analysis. Logistic regression for multivariable analysis and ROC curves to find thresholds predicting mandatory angioembolization.


 


Results: Of 4403 PCNLs, 83 (1.9%) with delayed bleeding were diagnosed with intrarenal vascular lesions: Arteriovenous fistulas in 54 (AVF, 65%) and pseudoaneurysm in 29 (PA, 35%). Overall 49 (59%) responded to conservative management but 34 (41%) eventually required angioembolization. On multivariable analysis, predictive factors for poor response to conservative treatment were requiring transfusion beyond initial stabilization, pseudoaneurysm, history of open renal surgery, longer interval-to-second-admission, and size of vascular lesion. The proposed POPVESL score (short for Post PNL Vascular Embolization selection) when below 11, correctly predicts success of conservative management with 81.6% sensitivity & 100% specificity.


 


Conclusions: Our findings including the proposed POPVESL score have the potential for clinical application and enhancing practical guidelines on the management of post-PCNL bleeding.

Is a Safety Guide Wire Necessary for Transurethral Lithotripsy using Semi-Rigid Ureteroscope? Results from a Prospective Randomized Controlled Trial

Abbas Basiri, Jean De la Rosette , Milad Bonakdar Hashemi, Hamidreza Shemshaki, Ali Zare, Nasrin Borumandnia

Urology Journal, , 1 January 2020 , Page 6511
https://doi.org/10.22037/uj.v16i7.6511

Background: Experts recommend us to keep a safety guidewire during the process of upper urinary tract endoscopy, though there is a lack of high-level evidence to support  the efficacy and safety of  this opinion. This study conducted to compare the outcome of ureteral stone breakage in the presence or absence of safety guidewire.


Materials and methods: Patients candidate for endoscopic breakage of ureteral stone using a semi-rigid ureteroscope, were randomly assigned in  two groups based on keeping a safety guidewire (group1)  or removing the guidewire (group2) before the process of breaking ureteral stone by lithoclast. Demographic factors, history of previous stone treatment, kidney function, stone location, symptoms duration and severity were recorded for each patient. Primary outcomes include success rate of stone treatment and secondary outcomes include number of attempts to enter to ureter, success rate of ureteral entry, success rate of stone achievement, stone migration rate and success rate of ureteral stent insertion.


The recorded data were entered to the SPSS software and descriptive statistical analysis including power calculation and non-inferiority design for the primary and secondary outcomes, was performed. P-value less than 0.05 was considered significant.


Results: From January 2016 till May 2018, 320 patients were randomized with 160 patients in each arm. Considering the cases who were missed due to follow-up loss, there were 153 patients in group 1 and 147 patients in group 2 at the end of the study. Baseline data were equally distributed in both groups. Based on the initial analysis, the studied variables had no significant difference between two groups; though, according to the subgroup analysis of patients with proximal ureter stones, patients in Group 1 had higher rates of ureteral injury comparing to the patients in Group 2 (p=0.03).


Conclusion: According to our findings, keeping the safety guidewire through the process of endoscopic stone breakage (stone size: less than 1.5Cm) seems to add no significant benefit to the procedure outcome, while it increases the ureteral injuries in the proximal ureter stones, but not in mid or distal ureter stones.

Reduction of Radiation Dose Received by Surgeons and Patients During Percutaneous Nephrolithotomy Surgery: A New Shielding Method

Shahriar Amirhasani, Rezgar Daneshdoost, Seyed Habibollah Mousavi-bahar, Karim Ghazikhanlou-sani, Roya Raeisi

Urology Journal, , 1 January 2020 , Page 5200
https://doi.org/10.22037/uj.v16i7.5200

Purpose: Due to high prevalence of urolithiasis, endourologic interventions have also been increased for the treatment of patients with urinary stones. During fluoroscopy-guided Percutaneous Nephrolithotomy (PCNL), the surgeon and the patient are exposed to X-ray and its harmful effects. The aim of this study was to assess the reduction of the radiation dose received by surgeons and patients after using the new shielding method.


Materials and Methods: In this study, the dose of radiation exposure by the surgeon and patient during PCNL under fluoroscopic procedure with conventional shielding methods was compared to a new shielding method designed by the researcher. For this purpose, shields and lead cone with a thickness of 0.5 mm were used. Also, to evaluate the dose of radiation received by surgeons and patients in different parts of the body, Thermoluminescent dosimeters (TLD) were used.


Results: By using new shielding method, a 37 ± 2% reduction was found in the dose exposure as compared to the conventional shielding method. The maximum reduction in radiation dose was specified to the surgeon's hands, while the lowest reduction in radiation dose was related to surgeon's thyroid gland. The maximum and minimum reductions in radiation exposure for patients were specified to patients' feet and chest respectively.


Conclusion: There is a significant difference between the total dose received by the surgeons and the patients following the use of the new shielding method and the standard shielding method. The new shielding method can reduce 37 ± 2% of the x-ray received by the patient and the surgeon during fluoroscopy-guided PCNL.

Purpose: To compare the efficiency and safety of two minimally invasive surgeries, laparoscopy and flexible ureteroscopy (fURS), in the management of renal parapelvic cysts.
Materials and Methods: Between January 2013 and April 2019, patients who suffered from parapelvic cysts and received fURS or laparoscopy at our hospital were recruited for this study. Computed tomography (CT) scans and intravenous urogram (IVU) were performed for cyst diagnosis. Two surgeons performed fURS and laparoscopy. All patients underwent biopsies of the cyst wall. Baseline characteristics and outcome measures were recorded. Primary outcome was treatment success, which was defined as symptomatic and radiological. During follow-up, telephone contact and CT scans were used to record any relevant symptoms and any recurrence, respectively. SPSS was used to analyze the data and two-tailed P < .05 were considered statistically significant.
Results: A total of 33 patients (22 in fURS; 11 in laparoscopy) were included in this study. There was no significant difference between the two groups with regard to age (P = .32), BMI (P = .91), gender (P = .11), cyst size (P = .10), and laterality of cyst (P = .80). Flank pain prior to the procedures were reported by 14/22 patients and 6/11 in fURS and laparoscopy, respectively (P = .62), and patients had complete pain relief after the operation. The complication rate was significantly lower in the fURS group than in the laparoscopy group (P = .01). Minor complications were observed in 3/22 and 5/11 patients (Grade 1 and 2) in the fURS and laparoscopy group, respectively. All patients were controlled by conservative treatment. However, 1/11 major complication (Grade 3b) was detected in the laparoscopy group and managed by ureteroscopy to remove the obstruction under general anesthesia. Significant differences were found in operative time (P = .01) and postoperative hospital stay (P = .01), while medical expenses were similar between the two groups (P = .42). No malignant pathologic findings were observed in biopsied specimens. During follow-up, no recurrence was detected in CT scans.

 


Conclusion: In the management of parapelvic cysts, two minimally invasive surgeries were comparable in efficiency. However, fURS was superior to laparoscopic unroofing with regard to the complication rate, operative time, and postoperative hospital stay.

ORIGINAL PAPER (LAPAROSCOPIC AND ROBOTIC UROLOGY)


Purpose: The aim of this study was to evaluate the efficacy of transvesical open prostatectomy (OP) compared with transurethral resection of the prostate (TURP) in patients with benign prostate hyperplasia (BPH) with a prostate weight of 40-65 grams. The short-term and long-term complications of these two procedures were also assessed.


Materials and Methods: In this retrospective study, we included 160 consecutive patients with BPH who had undergone TURP (n=80) or OP surgery (n=80) from 2006 to 2017 in Tohid and Kowsar hospitals, Sanandaj, Iran. Inclusion criteria were positive history of BPH, definite indication for prostatectomy, and prostate weight between 40 to 65 grams. Patients were evaluated for duration of hospitalization, need for re-operation, short-term and long-term postoperative complications, urinary flow rate, peak flow rate (Q max) and international prostate symptom score (IPSS).


Results: The mean age ± Standard Deviation (SD) of patients was 62.4 ± 3.7 and 67.2 ± 4.6 years old in the TURP and OP groups, respectively. Four (5%) and seven (8.7%) patients required transfusion in the TURP group and OP groups, respectively. Dysuria was significantly more frequent in the TURP group from week two to 12 months after surgery as compared with the OP group (P<.001). Hemodynamic changes and decrease in serum sodium level were not reported in either group. However, the urinary retention and need for urinary catheterization in the first year was significantly different between the two groups with 10 cases (12.5%) in the TURP group and no cases in the OP group (P<0.001). The need for reoperation in the TURP group was reported (27 procedures on 19 patients) (33.7%) of patients. Furthermore, retrograde ejaculation (RE) was reported in 65 (81.2%) and 80 patients (100%) of the TURP and OP group, respectively.


Conclusion: Despite the fact that TURP is the standard method of treatment for BPH when the prostate weighs between 40-65 grams, the results of our study showed that OP is a more efficient and safe surgery for these patients and is associated with less complications. Furthermore, the need for re-operation seems to be higher in patients with TURP.

ORIGINAL PAPER(UROLOGICAL ONCOLOGY)


Randomized, Double-blind Pilot Study of Nanocurcumin in Bladder Cancer Patients Receiving Induction Chemotherapy

Saleh Sandoughdaran, Abolfazl Razzaghdoust, Ali Tabibi, Abbas Basiri, Nasser Simforoosh, Bahram Mofid

Urology Journal, , 1 January 2020
https://doi.org/10.22037/uj.v0i0.5719

Purpose: To evaluate the feasibility and potential efficacy of nanocurcumin supplementation in patients with localized muscle-invasive bladder cancer (MIBC) undergoing induction chemotherapy.

Materials and methods: In this double-blind, placebo-controlled trial, 26 MIBC patients were randomized to receive either nanocurcumin (180 mg/day) or placebo during the course of chemotherapy. All patients were followed up to four weeks after the end of treatment to assess the complete clinical response to the chemotherapy as primary endpoint. Secondary endpoints were the comparisons of chemotherapy?induced nephrotoxicity, hematologic nadirs, and toxicities between the two groups. Hematologic nadirs and toxicities were assessed during the treatment.

Results: Nanocurcumin was well tolerated. The complete clinical response rates were 30.8 and 50% in the placebo and nanocurcumin groups, respectively. Although nanocurcumin was shown to be superior to placebo with respect to complete clinical response rates as the primary endpoint, there was no significant difference between the groups (p = 0.417). No significant difference was also found between the two groups with regard to grade 3/4 renal and hematologic toxicities as well as hematologic nadirs.

Conclusion: These preliminary data indicate the feasibility of nanocurcumin supplementation as a complementary therapy in MIBC patients and support further larger studies. Moreover, a substantial translational insight to fill the gap between the experiment and clinical practice in the field is provided.

Purpose: To report the 1-year functional outcomes, oncologic outcomes, and postoperative complications in patients who underwent modified robot-assisted radical prostatectomy (RARP) procedures for achieving early recovery of continence and potency postoperatively.


Materials and Methods: This study included 165 patients who underwent RARP. Overall, 98 patients underwent RARP using our modified detrusorrhaphy and intrafascial nerve-sparing techniques (group 1) and 67 underwent standard RARP (group 2). Continence and potency rates were assessed at 1 week, 1, 3, 6, and 12 months after RARP. Oncologic outcomes comprised positive surgical margins (PSMs) and biochemical recurrence (BCR) rate.


Results: The continence rates were 61.2% and 6.0%, 72.5% and 11.9%, 79.6% and 20.9%, 91.8% and 58.2%, and 97.9% and 74.6% at 1 week, 1, 3, 6, and 12 months in group 1 and 2, respectively. The potency rates were 66.3% and 11.9%, 78.6% and 38.8%, 85.7% and 50.8%, 92.9% and 70.2%, and 95.9% and 79.1% at 1 week, 1, 3, 6, and 12 months in group 1 and 2, respectively. Overall postoperative complication rates (< 10%) were similar between the  groups. The PSMs rate was 17.4% and 16.4% in the two groups. The rate of PSMs in the cohort of patients with stage pT2 disease decreased to 13.6% and 12.5% in groups 1 and 2,  respectively. BCR rate was 5.1% and 6.0% in groups 1 and 2, respectively.


Conclusion: The use of detrusorrhaphy and intrafascial nerve-sparing techniques is safe and feasible, with our results demonstrating early return to continence and potency. Further studies should be conducted.

Discrepancy between Needle Biopsy and Radical Prostatectomy Gleason Score among Patients with Prostate Cancer

Amir Reza Abedi, Abbas Basiri, Nasser Shakhssalim, Ghazal Sadri, Mahsa Ahadi, Seyyed Ali Hojjati, Samad Sheykhzadeh, sajjad askarpour, Saleh Ghiasy

Urology Journal, , 1 January 2020 , Page 5985
https://doi.org/10.22037/uj.v16i7.5985

Purpose: Gleason score (GS), as well as other prognostic and diagnostic modalities, can predict the possibility of tumor growth and metastasis during the life of patients with prostate cancer. Based on the prostate biopsy GS, clinicians choose the most appropriate therapy for managing patients. The objective of this cross-sectional study was to determine the discrepancy between needle biopsy and radical prostatectomy GS and to identify its predictive factors among the Iranian population.


Materials and Methods: A total of 1147 patients who underwent radical prostatectomy from 2009 to 2019 were initially enrolled in this study. After consideration of the inclusion and exclusion criteria, 439 patients were finally included. The demographic variables and clinical data including age, PSA level, prostate volume, PSA density, GS derived from ultrasonography-guided core needle biopsy specimen, and GS derived from radical prostatectomy specimen were collected from the medical records of patients with prostate adenocarcinoma and were reviewed by a urology resident. Statistical analysis was done by using the Social Sciences Software version 21.


Results: The average age of patients was 64.5 years (range 48‐84 years), and the average preoperative PSA level was 14.8 ng/mL. On histopathological examination, no changes in GS were observed in 237 (53.9%) patients, whereas GS was upgraded in 144 (32.8%) patients and downgraded in 58 (13.2%) patients at radical prostatectomy. The number of patients who had extracapsular extension, seminal vesicle invasion and positive lymph nodes was significantly higher in the upgraded group compared with the non-upgraded group. 


Conclusion: In this study, there was a steady decrease in GS upgrading with the prostate size extending up to 49.7 g. There was also an association between downgrading and extending prostate size. Due to the greater risk of high-grade disease in men with small prostates, smaller prostate bulks are most probably upgraded after radical prostatectomy. A higher maximum percentage of involvement per core was an independent predictive factor of upgrading from biopsy grade 1 to grade ≥ 2. Our study showed that patients’ age was not predictive of upgrading, which is consistent with other studies. Also, we demonstrated a non-significant relationship between PSA level and upgraded GS. Findings in this study did not demonstrate a significant relationship between PSA level and upgrading.

Pseudocapsule of Small Renal Cell Tumors: CT Imaging Spectrum and Correlated Histopathological Features

Gang Li, Xianqi Lu, Yunsheng Ding, Qiang Luo, Liang Xu, Dongsheng Zhu, Changyi Quan

Urology Journal, , 1 January 2020 , Page 5907
https://doi.org/10.22037/uj.v16i7.5907

Purpose: To systematically analyze histopathologic features of pseudocapsule in small renal cell tumor (diameter≤4cm), assess the integrity of pseudocapsules by Computed Tomography (CT), and provide theoretical basis for the safety of nephron sparing surgery.


Materials and Methods: The pathological data of 116 patients who underwent surgery with clear cell renal cell carcinoma admitted from May 2010 to October 2017 were retrospectively analyzed. All patients underwent a CT scan of the abdomen including an unenhanced and triple-phase (arterial, nephrographic and excretory) post contrast series."All patients underwent a CT scan of the abdomen including an unenhanced and triple-phase (arterial, nephrographic and excretory) post contrast series."All patients underwent a CT scan of the abdomen including an unenhanced and triple-phase (arterial, nephrographic and excretory) post contrast seriesAll patients underwent a CT scan of the abdomen including an unenhanced and three-phase (arterial, nephrographic and excretory) post contrast series. Thorough gross examination and histological sections were used to determine the integrity of the pseudocapsule by two uropathologists. The consistency between pathological findings and CT imaging were evaluated by Kappa consistency test.


Results: The mean diameter of tumor was 3.0cm, range (2.6 ± 0.8) cm. On CT the pseudocapsule can present with one of the three following feathers:1) A regular and distinct halo; 2)lobulated clear margins;3) blurred margins. On histopathology, complete psuedocapsule was found in 85 tumors, incomplete psuedocapsule in 25 and no psuedocapsule was found in 6 tumors; CT scan findings demonstrated a regular halo in 82 tumors, lobulated clear margins in 26 and blurred margins in 8 tumors(Kappa=0.833,P=0.000).


Conclusions: Most small renal cell tumors have an obvious psuedocapsule. Preoperative determination of the psuedocapsule’s integrity is particularly important. CT scan can reliably evaluate the tumor margins and demonstrate the psuedocapsule when present. The imaging results are well correlated with the pathologic findings.

Purpose: The conventional Trans-Peritoneal Radical Cystectomy (TPRC) harbors numerous postoperative complications, the most prevalent of which are Gastrointestinal (GI) problems. To reduce these morbidities we introduced our own version of extra-peritoneal approach and compared it with the conventional method. 


Materials and Methods: In a cross-sectional observational retrospective design, eligible bladder cancer patients whom underwent Extra-Peritoneal Radical Cystectomy (EPRC) or TPRC in our center, were considered for this study and were compared for early post-operative complications .


Results: Ninety nine patients in TPRC and 81 in EPRC were compared. The two techniques differed in their mean operation time (298.2±37.8 min TPRC vs. 262.8±37.2 min EPRC , P: 0.001). Early GI complications were lower in EPRC groups, including oral intake intolerance ( 21 vs. 8, P: 0.04), ileus (19 vs. 8, P: 0.04),  intestinal obstruction (3 vs. 0, P: 0.04) and anastomosis leak (8 vs. 1, P: 0.01). Urine leak (14 vs.7 , P: 0.02) and wound related complications (19 vs. 6 , P: 0.02) also favored EPRC group.


Conclusion: The extra-peritoneal technique is beneficial in reducing the post operative morbidity, especially the more prevalent GI complications. This approach is functionally safe and allows preservation of the peritoneal integrity.

Needle Tip Culture after Prostate Biopsy: A Tool for early Detection for Antibiotics Selection in Cases of Post-Biopsy Infection

Ian Seng Cheong, Yuh-Shyan Tsai, Chun-Hsiung Kang, Yeong-Chin Jou, Pi-Che Chen, Chang-Te Lin

Urology Journal, , 1 January 2020 , Page 5912
https://doi.org/10.22037/uj.v16i7.5912

Purpose: To investigate biopsy needle tip culture after prostate biopsies for bacteria prediction and antibiotics selection.


Materials and Methods: From May 2017 to April 2019, 121 patients who underwent a prostate biopsy were enrolled. All biopsy needle tips were sent for aerobic and anaerobic culture. Patients were divided into positive and negative culture groups. Perioperative data were recorded and compared between the two groups. The culture time and susceptibility of febrile patients were analyzed. Blood cultures were conducted for all patients who experienced fever after biopsy. The time and results of the needle and blood cultures were recoded for descriptive analysis.


Results: There were 59 (48.8%) positive needle cultures. Other than fever (p = 0.023), there were no statistical significances in clinical data between the two groups. Fever occurred in eight patients, and seven febrile patients had positive needle cultures, six of whom had positive blood cultures. These six needle and blood cultures were consistent with the susceptibility test results. As compared to the waiting time for blood cultures, target antibiotics were administered at an average of 48.0 h earlier based on needle cultures. None of the patients with positive anaerobic cultures developed a fever, while all eight febrile patients had negative anaerobic cultures.


Conclusion: Fevers developed at statistically significant higher rate among those who had positive needle cultures. Needle and blood cultures were consistent with the susceptibility test results. Needle cultures can help us administer target antibiotics earlier to febrile patients without the need to wait for blood cultures.

Interobserver Variability in Assessment of Renal Mass Biopsies

Łukasz Nyk, Wojciech Malewski, Krystian Kaczmarek, Piotr Kryst, Michał Pyźlak, Aneta Andrychowicz, Tomasz Zabkowski

Urology Journal, , 1 January 2020 , Page 6024
https://doi.org/10.22037/uj.v16i7.6024

Purpose: The main goal of this study was to assess the histopathological efficacy of renal mass biopsy and to check the concordance between pathological results and biopsy of the final specimen, as well as interobserver variability in the assessment of biopsy cores.


Materials and Methods: A hundred sets of core biopsies of postoperative specimens (renal masses) have been performed. Three core biopsies of the intact specimen had been performed once the kidney with the tumor, or the tumor alone were resected. The urologist aimed to obtain two cores from the peripheral sides of the tumor and one core from its center.


The surgical specimen was evaluated by a single pathologist, whereas biopsy samples were referred to three independent pathologists who were blinded to the final results of the renal mass biopsy.


Results: Nondiagnostic biopsy rates ranged from 13% to 22%. Sensitivity and specificity ranged 83-97% and 97-99% by excluding nondiagnostic results. The concordance between assessment of surgical specimen and biopsy in the Fuhrman grading system ranged 36.5-77.0%, respectively. Interobserver agreement between the three pathologists was substantial or moderate, depending on the tumor subtype. The Krippendorff's alpha coefficient, calculated by excluding the nondiagnostic results, was 0.28 (moderate agreement) for the Fuhrman grading system.


Conclusion: The agreement regarding grading of biopsies between three pathologists ranged from moderate to substantial. Therefore, a team of dedicated uropathologists should be engaged in final diagnosis of renal mass biopsy rather than single one before implementing the proper treatment.

Purpose: This work aims to investigate the effects of ΔNp63 gene down-expression on invasion of bladder carcinoma cells in vitro.


Materials and Methods: Bladder carcinoma cell lines UM-UC-3 and 5637 were cultured. The expression plasmids encoding ΔNp63 were constructed and transfected into UM-UC-3 and 5637 cells. The migration and adhesion of cells were detected. The expressions of ΔNp63 and invasion-related zonula occludens protein-1 (ZO-1) in cells were determined by real-time polymerase chain reaction (PCR) and western blot analysis. Confocal microscopy was used to observe the location of ZO-1 in cells.


Results: Results showed that the down-expression of ΔNp63 reduced the migration of UM-UC-3 and 5637 cells, decreased the heterogeneity adhesion, and increased homogeneous adhesion. After transfection with ΔNp63, the ZO-1 expression in cell membrane and cell cytoplasm was inhibited, also the ZO-1 mRNA and protein levels in cells were significantly decreased.


Conclusion: This study indicates thatΔNp63 gene down-expression can reduce the invasion of bladder carcinoma cells in vitro.

Influences of Different Operative Methods on the Recurrence Rate of Non-Muscle-Invasive Bladder Cancer

shoubin Li, Yi Jia, Chunhong Yu, Helong Xiao, Liuxiong Guo , Fuzhen Sun, Dong Wei, Panying Zhang , Jingpo Li, Junjiang Liu

Urology Journal, , 1 January 2020 , Page 5965
https://doi.org/10.22037/uj.v16i7.5965

Purpose: To compare the influence of three operative approaches [transurethral en bloc resection of bladder tumor by pin-shaped electrode (pin-ERBT), transurethral resection of bladder tumor (TURBT) and transurethral holmium laser resection of bladder tumor (HoLRBT)] on the recurrence rate of non-muscle-invasive bladder cancer (NMIBC) at low dimension (i.e. diameter below 3 cm).


Materials and Methods: A retrospective analysis was conducted for a total of 115 patients affected by solitary NMIBC, with a diameter <3 cm, who were submitted to operation between March 2013 to May 2017. The patients were divided according to the operative method applied (pin-ERBT, TURBT and HoLRBT groups, respectively). The 2-year recurrence rate was compared among the three groups, and multivariat Cox hazard model analysis was applied to analyze the influencing factor(s) for postoperative recurrence.


Results: The 2-year recurrence rate was 10.0% in ERBT, 38.5% in TURBT and 40.0% in HoLRBT group, with a significant difference (P =0.014). According to the Cox hazard model analysis, age(HR=1.058, 95% CI: 1.019~1.098,P=0.003), operative method(HR=2.974,6.508, 95% CI: 0.862~10.255,1.657~25.566, P=0.023), smoking(HR=2.399, 95% CI: 1.147~5.017, P=0.020) and pathological grade(HR=2.012,95% CI: 1.279~3.165, P=0.002) were risk factors for postoperative recurrence of bladder cancer.


Conclusion: Pin-ERBT can prominently decrease the postoperative recurrence rate of solitary NMIBC with a diameter <3 cm.

Multiparametric Prostate Magnetic Resonance Imaging before Radical Prostatectomy: Can IT Predict Histopathology?

Mehmet Sahin, Fuat Kizilay, Ezgi Guler, Banu Sarsik, Mustafa Harman, Serdar Kalemci, Adnan Simsir, Ibrahim Cureklibatir

Urology Journal, , 1 January 2020 , Page 6025
https://doi.org/10.22037/uj.v16i7.6025

Purpose: We aimed to investigate the histopathological correlation of the suspected prostate malignancy detected in multiparametric prostate magnetic resonance imaging (mpMRI).


Materials and Methods: The data of 93 patients underwent radical prostatectomy and had preoperative mpMRI were examined. Age and pre-operative Prostate-Specific Antigen value were retrospectively collected from patient files. The pathology specimens were examined again and post-operative ISUP grade group, other pathological findings (seminal vesicle invasion, lymph node involvement and extraprostatic extension), pre-operative mpMRI were re-examined and PIRADS score, extracapsular extension, seminal vesicle invasion, neurovascular bundle invasion, lymph node involvement and ADC values were recorded.


Results: 151 (92,07%) of 164 lesions detected in mpMRI were histopathologically correlated. 80% of patients with seminal vesicle invasion (P < 0.001), 28.8% of patients with extracapsular extension (P < 0.052) and 42.9% of patients with lymph node involvement (P = .001) in mpMRI were histopathologically correlated. A significant relationship was found between PIRADS scores and ISUP grade groups (P < 0.001). There was a negative correlation between ADC values and ISUP grade groups (P < 0.001).


Conclusion: Our study showed that the lesions detected by mpMRI showed a high histopathological correlation.

Responses to targeted therapy among Organs Affected by Metastasis in Patients with Renal Cell Carcinoma are Organ-Specific

Weixing Jiang, Hongzhe Shi, Lianyu Zhang, Jin Zhang, Xingang Bi, Dong Wang, Li Wen, Changling Li, Jianhui Ma, Jianzhong Shou

Urology Journal, , 1 January 2020 , Page 6129
https://doi.org/10.22037/uj.v16i7.6129

Purpose: Previous reports showed that targeted therapy efficacy varied due to different metastatic organs in patients with metastatic renal cell carcinoma (mRCC). This study aimed to further evaluate the response and progression-free time (PFT) of individual metastatic organs.


Materials and Methods: Data from mRCC patients, who were treated with sunitinib between January 2008 to December 2018, were retrospectively reviewed. Individual metastatic organs were assessed separately by The Response Evaluation Criteria in Solid Tumors criteria.


Results: We evaluated response heterogeneity and PFT as characteristics of 281 individual organs affected by mRCC in 213 patients. The objective response rates in these organs were 72.7% in pancreas, 63.7% in spleen, 14.3% in adrenal glands, 13.5% in bone and soft tissue, 11.6% in lymph nodes, 11.6% in lungs, and 9.1% in liver. The median PFT was 15.2 months (95% confidence interval [CI] 2.7–27.7 months) for adrenal glands, 13.2 months (95% CI 3.5–22.9 months) for bone and soft tissue, 9.0 months (95% CI 7.6–10.4 months) for lymph nodes, 8.6 months (95% CI 6.3–10.9 months) for lungs, and 5.2 months (95% CI 2.9–7.5 months) for liver. Median PFT was not reached in pancreas and spleen, but was > 22.8 months and > 20.6 months, respectively.


Conclusion: Our results indicated that organs affected by metastasis may have individual responses to sunitinib treatment. The pancreas and spleen may have the best responses, and liver may have the worst response. Further research is needed to verify these findings.

Purpose: To examine the correlation between prostate specific antigen (PSA) and the risk of Gleason sum upgrading (GSU) from biopsy Gleason sum (bGS) to prostatectomy Gleason sum (pGS).


Materials and Methods: Five electronic databases (Web of Science, Ovid Medline, Ovid Embase, SCOPUS and the Cochrane Library) were searched from inception until March 2020. Studies were included if they focused on the relationship between PSA and GSU analyzed in multivariable analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized. Quality of included studies was appraised utilizing the Newcastle-Ottawa Quality Assessment Scale (NOS) for case-control studies. The publication bias was evaluated by funnel plot and Egger’s test.


Results: Our search yielded 19 studies with high quality including 42193 patients. GSU was found in 28.2% of patients. Higher PSA level was associated with a significant increased risk of GSU (pooled OR = 1.14, 95% CI: 1.10–1.18; P < .05; I2 = 92%). For the definition of upgrading from bGS ≤ 6 to pGS ≥ 7, the odds of upgrading with higher PSA level as opposed to lower PSA level was 1.12 (95% CI: 1.11–1.14; P < .05; I2 = 13%), while the odds of upgrading with other definitions were 1.11 (95% CI: 1.05–1.18; P < .05; I2 = 89%).


Conclusion: Patients with high level of serum PSA are at high risk of undergoing pathologic upgrading at prostatectomy. Combined with other risk factors, PSA prompts risk reclassification and improve confidence of urologists in management decisions for optimal therapy. Nevertheless, further robust studies are necessitated to confirm these results.

Cytotoxic Effect of Saffron Stigma Aqueous Extract on Human Prostate Cancer and Mouse Fibroblast Cell Lines

Hassan Ahmadnia, Jamshid Tabeshpour, Mehdi Younesi Rostami, Ehsan Mansourian, Alireza Akhavan Rezayat, Azam Brook

Urology Journal, , 1 January 2020 , Page 6331
https://doi.org/10.22037/uj.v16i7.6331

Purpose: Several lines of experimental evidence have shown that saffron has anticarcinogenic effects. This study aimed at evaluating the possible anticancer effect of saffron stigma aqueous extract on human prostate cancer (PC3) and mouse fibroblast cells (L929) as non-cancerous control cells.


Materials and Methods: Saffron stigma aqueous extract at concentrations of 100, 200, 400, 600, 800, 1600 and 3200 μg/mL were prepared. PC3 and L929 cells were incubated with different concentrations of saffron extracts in different time intervals (24, 48, 72, 96 and 144 hours). MTT assay was used for each cell line to investigate the cytotoxic effect of saffron. Morphological alterations were also observed under light inverted microscope.


Results: In fibroblast cell line after 24 hours, Saffron extract did not affect significantly the normal cells and they were intact in morphologic view. After 96 hours in the cells with highest concentration (1600 μg/mL), cell death and cellular form changes as well as severe granulation was observed. In prostate cell line after 24 hours, the only changes were observed in cells with the concentration of 1600 μg/mL. The cells were granulated and the form of the cells were spherule. After 72 hours, in group with the concentration of 1600 μg/mL, severe granulation was observed and the cell count decreased and some cells were dead.


Conclusion: Saffron aqueous extract has an in vitro inhibitory effect on the proliferation of human prostate cell and mouse L929 cells which is dose-dependent.

ORIGINAL PAPER (PEDIATRIC UROLOGY)


Purpose: Concurrent valve ablation and bladder neck incision is suggested as an effective and safe treatment approach in posterior urethral valve children with prominent bladder neck. We evaluated chronic kidney disease risk factors in these children.


Materials and methods: We retrospectively reviewed medical records of children with posterior urethral valve and included those younger than 18 years old who underwent valve ablation and bladder neck incision at our institution. We recorded patient demographics, presenting symptoms, laboratory and radiographic data. Our primary outcome was chronic kidney disease defined as stage 3 chronic kidney disease or higher. Renal outcome risk factors such as preoperative vesicoureteral reflux and serum creatinine, age at diagnosis, adjuvant urinary diversion were analyzed.


Results: A total of 110 patients met our inclusion criteria. Median age at diagnosis was 10.4 months (range 14 days to 12 years). Prenatal diagnosis in 72.7% was the most common presentation. Mean follow-up duration was 3 years and 12(10.9%) patients progressed to chronic kidney disease. Preoperative serum creatinine greater than one mg/dL was the only factor associated with progression to chronic kidney disease.


Conclusion: In our group of children with posterior urethral valve ablation and bladder neck incision, initial creatinine value of greater than one mg/dL is more probably associated with renal impairment while; vesicoureteral reflux, age at diagnosis, presenting symptoms and adjuvant urinary diversion were not significant prognostic factors. Further randomized controlled evaluations are required to analyze the effects of concurrent valve ablation and bladder neck incision on renal outcome.

Objective:  Among the more serious problems in urological interventions among the pediatric age group is the requirement of general anesthesia. The advantages of removing a double-J stent (DJS) without anesthesia in ureteroneocystostomy (UNC) operations among children were investigated in this study.


Patients and Methods: In all, 25 patients who underwent UNC surgery between November 2016 and November 2018 were retrospectively divided into two groups according to the method used for the removal of the DJS. In Group 1, the stent was tied to the urethral catheter by a suture and retrieved postoperatively on the fourth day without anesthesia and cystoscopy. In Group 2, we inserted the stent according to the classical method with no suturing to the catheter and removed it 3 to 4 weeks after the first operation, with cystoscopy under anesthesia.


Results: A total of 16 girls and 9 boys were included in the study. The mean age was 4.3 and 6.3 years in groups 1 and 2, respectively. We did not observe statistically significant difference between the groups in long-term renal function or hydronephrosis regression.


Conclusion: We consider that the removal of a stent placed in pediatric intravesical UNC operations without anesthesia and cystoscopy is less invasive and affords safety and long-term results comparable to the standard method.

Long-Term Outcomes of Distal Hypospadias Repair: A Patients’ Point Of View

Alexis Belgacem, Laurent Fourcade, Romain Pelette, Etienne Bouchet, Victor Lescure, Walter Bertherat, Grazia Spampinato, Jean luc Alain, Aurélien Descazeaud, Quentin Ballouhey

Urology Journal, , 1 January 2020 , Page 6172
https://doi.org/10.22037/uj.v16i7.6172

Purpose: To assess the long-term outcomes of patients treated for distal hypospadias. Assessment of long-term follow-up for a homogeneous population with hypospadias is difficult and there has consequently been a paucity of publications in this regard.


Materials and Methods: A retrospective review was carried out to compile cases of distal hypospadias operated at our center between 1990 and 1999 according to the MAGPI procedure. Four parameters were evaluated based on four validated questionnaires: Health-related quality of life (SF-36), Genital self-perception (PPS), Self-esteem (Rosenberg Self-Esteem Scale), and Erectile function (IIEF).


Results: A total of 77 patients who had undergone MAGPI surgery for hypospadias during the specified period were selected. Sufficient clinical data were available for 51 patients and only 15 of these patients were included, after a median follow-up of 22 years (20-26). Their outcomes were compared with those for a population of 15 matched circumcised men and 15 matched uncircumcised men. No significant difference was found between the patients and the control groups in terms of the score for quality of life (p = .29). There were, however, significant differences in the scores for self-perception of the penile cosmetic appearance (13.3 vs. 15.8; p < .01), self-esteem (30.6 vs. 35.8; p < .01), and erectile function (31.4 vs. 33.7; p = .04) between the patients and the controls. Lower self-esteem correlated with poor genital self-perception (r  = .92).


Conclusion: This study confirms that adult patients operated for distal hypospadias have poor genital self-perception. This poor genital perception correlated with lower self-esteem.

ORIGINAL PAPER (FEMALE UROLOGY)


Assessing the Reliability and Validity of the Persian Version of the Chronic Pelvic Pain Questionnaire in Women

Mahboubeh Mirzaei, Azar Daneshpajooh, Mohammadali Bagherinasabsarab, Fatemeh Bahreini, Fatemeh Yazdanpanah

Urology Journal, , 1 January 2020 , Page 6212
https://doi.org/10.22037/uj.v16i7.6212

Purpose: There is a need for developing a standard and approved tool to assess chronic pelvic pain (CPP) in Iranian women. The aim of this study was to investigate the reliability and validity of the Persian version of the pelvic pain and urinary/frequency (PUF) questionnaire in Iranian women with CPP.


Materials and Methods: This cross-sectional study was performed on 50 females with CPP referred to the urology clinic of Kerman University of Medical Sciences from 2018 to 2019. Initially, the PUF questionnaire was translated into Persian and then back translated into English. The face validity of the tool was evaluated by being tested on 50 patients who had different literacy levels to ensure its understandability and acceptability by patients. The construct validity was evaluated through both exploratory and confirmatory factor analyses. The internal consistency was also analyzed by determining Cronbach's alpha coefficient and test-retest method.


Results: The Persian version of the questionnaire was compatible with the original English version. The Kisser sampling adequacy index was calculated on the data before extracting the factors indicating good factor accessibility of the questionnaire statements. The construct validity of the questionnaire was confirmed using exploratory and confirmatory factor analyses. The internal consistency parameters were also acceptable. Cronbach's alpha coefficient of the whole questionnaire, as well as the coefficients of the "signs/symptoms" and "unpleasant feelings" domains were 77%, 74%, and 78%, respectively.


Conclusion: The developed Persian version of the PUF questionnaire retrieved a good validity and reliability.

ORIGINAL PAPER (ANDROLOGY)


The Effect of L-Carnitine and Coenzyme Q10 on the Sperm Motility, DNA Fragmentation, Chromatin Structure and Oxygen Free Radicals During, Before and After Freezing in Oligospermia Men

Negin Chavoshi Nezhad, Zakaria Vahabzadeh, Azra Allahveisie, Khaled Rahmani, Amir Raoofi, Mohammad Jafar Rezaie, Masoumeh Rezaei , Maria Partovyan

Urology Journal, , 1 January 2020 , Page 6400
https://doi.org/10.22037/uj.v16i7.6400

Purpose: The aim of the present study is to assess the effect of L-carnitine and Coenzyme Q10 (CoQ10) on human sperm motility, DNA fragmentation, chromatin structure, and reactive oxygen species (ROS) during, before and after freezing in oligospermia men.


Materials and Methods: Semen was collected from 30 oligospermic men, who referred to infertility clinic of Beasat Hospital in Sanandaj, Iran. The samples of each individual were divided into 8 equal parts: 1. control group before freezing; 2. incubated with L-carnitine; 3. incubated with coenzyme Q10; 4. incubated with the combination of L-carnitine + CoQ10; 5. control freezing group; 6. the experimental freezing group with L-carnitine; 7. the experimental freezing group with coenzyme Q10 and 8. the experimental freezing with the combination of L-c + CoQ10. Sperm motility was assessed by WET MOUNT method. DNA fragmentation was evaluated by SCD (Sperm Chromatin Desperation), ROS, was evaluated by quantitative fluorescence reaction, and chromatin deficiency was determined by chromatin staining (CMA3).


Results: Antioxidant treatments, significantly reduced the number of ROS + in the pre and post freezing groups. Significant improvement was seen in the sperm motility of class B in the pre freezing groups with L-carnitine. Antioxidants also reduced the percentage of DNA fragmentation and protamine deficiency in pre-and post-freezing.


Conclusion: Addition of Coq10 and L-carnitine to human sperm medium significantly reduced the number of ROS. This reduction in ROS reduced sperm damage during cryopreservation.

ORIGINAL PAPER (RECONSTRUCTIVE SURGERY)


IS there a Difference in Platelet-Rich Plasma Application Method and Frequency to Protect Against Urethra Stricture?

Arif Aydin, Mehmet Giray Sonmez, Pembe Oltulu, Rahim Kocabas, Leyla Ozturk Sonmez, Hakan Hakki Taskapu, Mehmet Balasar

Urology Journal, , 1 January 2020 , Page 6100
https://doi.org/10.22037/uj.v16i7.6100

Material-Method:  Fifty rats were randomized into 5 groups, with 10 rats in each group. The urethras of all rats were traumatized with a pediatric urethrotome knife at 6 and 12 o’clock, except in the sham group. Group 1 was the sham group and had only urethral catheterization daily for 15 days, Group 2 was given 0.9% saline (physiologic saline [(UI+PS]) once a day after urethral injury (UI+ PS), Group 3 was injected with PRP submucosally after urethral injury, Group 4 was given PRP once a day as intraurethral instillation using a 22 Ga catheter sheath with urethral injury, and Group 5 was given PRP twice a day as intraurethral instillation using a 22 Ga catheter sheath with urethral injury.


Each administration of PRP was administered as 300 million platelets/150 microliters. On day 15, the penises of the rats were degloved to perform penectomy. Histopathologic evaluation was made for spongiofibrosis, inflammation, and congestion in vascular structures.


Results: When the sham group, UI+PS, UI+PRPx1, UI+PRPx2 and UI+PRPs groups are compared in total, there were significant differences identified for parameters other than edema. When the UI+PS, UI+PRPx1, UI+PRPx2 and UI+PRPs groups are compared, the UI+PS group was observed to have significantly more inflammation (mucosal inf. 2.42 ±0.53) and spongiofibrosis (2.42 ±0.53). All the PRP groups were identified to have significantly less mucosal inflammation (UI+PRPs 1±0, UI+PRPx1; 1.4±0.51, PRPx2; 1.33±0.5) and spongiofibrosis (UI+PRPs; 1.57±0.53, PRPx1; 1.2±0.42, PRPx2; 1.55±0.52). The group with lowest spongiofibrosis was seen to be the PRPx1 group.


Conclusion: This study showed that PRP significantly reduced mucosal inflammation and spongiofibrosis, independent of administration route, when applied to the urethra after urethral trauma

CASE REPORT


Epidermoid cyst (EPC) of the clitoris is a very rare cause of non-hormonal acquired clitoromegaly. Clitoral EPCs are extremely uncommon without prior history of genital surgery, trauma, circumcision, or piercing. Surgical removal with special care to avoid compromising neurovascular bundle of the clitoris is the preferred treatment. To our best knowledge, only three cases of adult female clitoral EPC without history of genital surgery, female circumcision, or medications including oral or implantable contraceptives have been reported. Herein, we describe three cases of primary EPC of the clitoris, their management, unique histopathology report, safe surgical approach, and their follow up course.

LETTER


Current Trends in Hypospadias Repair. Where are we Standing?

Parisa Saeedi Sharifabad, Vahid Poudineh, Mehran Hiradfar, Ahmad Mohammadipour, Reza Shojaeian

Urology Journal, , 1 January 2020 , Page 6081
https://doi.org/10.22037/uj.v16i7.6081

Purpose: Although several surgical approaches are suggested for hypospadias reconstruction but there is not a consensus on the best surgical method of hypospadias repair. This is a survey about technique of choice in treatment of various types of hypospadias.


Method and materials: We asked about preferred method of treatment for three different hypospadias scenarios. 170 surgeons completed the questionnaire and enrolled in this study.


Results: 51 general urologists, 61 pediatric surgeon, 16 plastic surgeons and 42 pediatric urologists joined the survey. Preferred method of surgery for a distal hypospadias was TIP in 53.5%. TIP was offered by 39.4% , Two stage Urethroplasty in 24.7% and Island On lay Flap in 21.2% to repair a proximal hypospadias without cordee. Two-stage Bracka or Durham Smith were common surgical options in proximal hypospadias surgery with cordee.


Conclusion: A growing trend was detected on TIP repair of distal and proximal hypospadias without cordee.

A survey on Current Procedural Terminology (CPT) by Iranian Urological Association

Farzad Allameh, Abbas Basiri, Amir reza Abedi, Seyyed Mohammad Ghahestani, saeed montazeri, Vahid Fakhar

Urology Journal, , 1 January 2020 , Page 6445
https://doi.org/10.22037/uj.v16i7.6445

Purpose: The purpose of Current Procedural Terminology (CPT) is to offer a universal language to describe medical services. The elaborate systems designed by high-income countries are not fully applicable in ones with limited resources. Therefore, in the current study we aimed to ask urologists' opinion about deploying relative value units in valuation of medical services in Islamic republic of Iran.


Materials and Methods: A group of appointed urologists first selected 15 urological surgeries as exemplar urological procedures. Next, urologists around the country were asked to fill out an online questionnaire comparing these procedures with standard one (varicocelectomy). Then, mean scores of four categories (Difficulty, duration, adverse events and legal issues) were determined separately for each of the 15 procedures. Subsequently, mean score for each surgery was measured using the calculated mean scores of the four aforementioned categories.


Results: 273 urologists completed an online questionnaire. All of the calculated codes were higher compared to the current codes. Urethroplasty showed the least increment with 25.22 equivalent to 51.69% while extracorporeal shock wave lithotripsy showed the most increment of 63.59 equivalent to 114.37%.


Conclusion:  Although CPT is an important tool in valuation of medical services, making modifications to it, especially in low-to-middle-income countries seems necessary. In this survey, we aimed to evaluate current surgical codes for urological procedures based on urologists' opinion. All of the calculated codes were higher compared with current codes. This, indicated the necessity of making changes in relative value units of urological procedures.

Prostate Cancer (PCa) is the most prevalent cancer in men. Radical Prostatectomy (RP) as a primary definitive treatment may be followed by adjuvant or salvage radiotherapy. However, there are some uncertainties about receiving immediate adjuvant radiation after RP in men with adverse pathological features versus early salvage radiation therapy. Decipher is a novel genomic classifier and almost all studies have confirmed Decipher as a reliable predictor of metastasis, recurrence and mortality. With the aid of Decipher, clinicians are able to determine the need for adjuvant versus salvage radiotherapy. Decipher has the potential to reduce decisional conflicts in clinical recommendations, and is cost-effective. However, further investigations are required to prove Decipher’s role in clinical outcome improvement in patients receiving Decipher-based course of treatment compared with those receiving usual care.


 

We read the article entitled ‘’Retrograde Intrarenal Surgery vs. Percutaneous Nephrolithotomy vs. Extracorporeal Shock Wave Lithotripsy for Lower Pole Renal Stones 10-20 mm: A Meta-analysis and Systematic Review’’  published in Urology Journal (1). The topic is still hot in urology regarding lower pole kidney stones in 10-20 mm diameters.  Although extracorporeal shock wave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) are the available options for the patients with lower pole renal stones 10-20 mm diameter, the decision making among the methods is still controversy. This manuscript is valuable in this regard.


 At the present manuscript, the authors prepared a very comprehensive meta-analysis of existing evidence to quantify and compare the safety and efficacy of PCNL, RIRS and ESWL for lower pole renal stones 10-20mm.  They emphasized the longer operative time of PCNL and RIRS compared to ESWL. They also reported a higher stone-free rate, the lower retreatment rate and auxiliary procedure following PCNL with the longest hospital stay for PCNL. 


When it comes to ESWL, the lowest SFR, the higher retreatment rate and auxiliary procedure rate, but a shorter operative time and the shortest hospital stay was reported. The authors indicated stone to skin distance (SSD) as an unfavourable factor for ESWL. This issue is also reported in current literature. SSD was calculated by measuring the distance from the stone to the skin in three angles (0°, 45° and 90°) and the cut-off value for SWL failure was reported in a wide-scale from 100 mm to 119 mm(2,3).


At the present study, the authors presented 10 mm as a predictive value for the criteria of SWL failure. This statement seems to be not correct totally also 10 mm is an impossible value for SSD. In our opinion, it was caused by a misspelling, and a correction may be informative for the readers.

UNCLASSIFIED


Background: Obturator nerve reflex is the surgery treatment side effect in patients with bladder cancers. This study is run to determine the obturator Nerve reflex by Thulium laser versus monopolar Transurethral Resection of Bladder Tumors (TURBT).


Materials and methods: After clinical trial approval code receiving IRCT20190624043991N4, one hundred and eighty-nine patients with bladder tumors from 2010 to 2016 were assessed and among them, 35 patients were randomly assigned into two groups in a blinded manner; the first group (16 patients) received thulium laser and the second group (19 patients) were patients undergoing monopolar transurethral resection of bladder tumor after spinal analgesia. Clinical data, including different variables such as; age, tumor characteristics, gender, operation duration, types of leg jerking, and some intraoperative complications, were recorded. The site of the obturator nerve was determined by nerve stimulation, anatomical landmarks, and ultrasonography. Leg jerking was compared in both groups.


Results: Of the 35 patients, 28 cases were male and 7 cases were female. The mean age was 62.0±6.9 (40-75) years in the Thulium laser group and 64.0±7.1 (41-77) years in the monopolar TURBT group. The mean operation time was no different between the two groups significantly (P > 0.05). Leg jerking was reported in 25% and 63.1% of the patients in Thulium laser and monopolar TURBT groups, respectively (P<0.05).


Conclusion:  Thulium laser is a more feasible and effective method to prevent leg jerking in patients with bladder cancer; so, it is recommended more than monopolar Transurethral.

Purpose: Intravesical BCG (Bacillus Calmette–Guérin) therapy is indicated as an effective treatment for patients with non-muscle-invasive bladder cancer, despite associate with the side effects. In this study, the incidence of BCG therapy adverse effects was compared among three groups of patients who received celecoxib, phenazopyridine, and oxybutynin with placebo.


Materials and Methods: The randomized controlled clinical trial was conducted on four groups using the parallel group method. A checklist is used for weekly assessment of urinary symptoms, systemic symptoms of BCG therapy, and adverse drug reactions.


Results: The study included 120 patients, 10 female and 110 male. The mean age 59.65 ± 6.2 years. The results of multivariate analysis show that there is a significant decrease in urinary frequency for patients who received phenazopyridine (95% CI: 0.09, 0.31, OR = 0.17, P <.001) and also celecoxib group (95% CI: 0.10, 0.43, OR = 0.21, P <.001) compared to those in placebo group. Patients in celecoxib group (95% CI: 0.02, 0.07 ,OR = 0.04, P <.001), phenazopyridine (95% CI : 0.07, 0.37,OR=0.16, P <.001) and oxybutynin (95% CI: 0.02, 0.12,OR = 0.05, P <.001) were less likely to have urgency than those in placebo. Moreover, significant decrease was found for dysuria in the three treatment groups in comparison with placebo group.


Conclusion: According to the results, celecoxib, phenazopyridine and oxybutynin can effectively decrease the side effects of BCG immunotherapy compared to placebo. Among these three treatments, the most effective and safest treatment option is celecoxib.

Purpose: To determine the empirical usage of antibiotics and analyze the pathogen spectrum during the perioperative period of flexible ureteroscopic lithotripsy (FURSL) with a focus on levofloxacin.


Materials and Methods: This retrospective analysis included 754 patients who underwent FURSL successfully in our hospital from January 2015 to July 2019. All patients were indicated urine cultures and prescribed antibiotics during the perioperative period. Patients with negative preoperative urine cultures were divided into levofloxacin (LVXG) and non-levofloxacin groups (NLVXG) based on the empirical use of antibiotics. Operative time, the length of postoperative hospital stays and total hospital stays, total hospitalization costs, postoperative fever rate and removal rate of stones were compared. Patients with positive urine cultures were analyzed for  pathogen distribution and antibiotic resistance.


Results: In the empirical use of antibiotics among 541 cases with negative urine cultures, the prescription rate of levofloxacin was 68.95%. Compared to that in NLVXG, LVXG had a lower cost of antibiotics but higher postoperative fever rate and longer hospital stay. There were no significant differences in operative time, the total hospitalization costs and the removal rate of stones between the two groups. The top two common pathogens were Escherichia coli (36.11%) and Enterococcus faecalis (24.07%), with resistance rates of 74.36% and 71.15% to levofloxacin, respectively.


Conclusion: Levofloxacin might be no longer suitable as the first-line choice of clinical experience when performing FURSL in our center.

A Comparative Study on the Clinical Efficacy of Modified Circumcision and Two Other Types of Circumcision

Quanxin Su, Shenglin Gao, Jiasheng Chen, Lu Chao, Mao Weijiang, Wu Xingyu, Lifeng Zhang, Li Zuo

Urology Journal, , 1 January 2020 , Page 6193
https://doi.org/10.22037/uj.v16i7.6193

Purpose: To compare the clinical effects of three methods of circumcision: modified circumcision, traditional circumcision, and disposable suturing device circumcision.


Materials and Methods: Male patients (n = 241) with redundant prepuce and/or phimosis were included in a clinical trial from January 2019 to March 2020. Patients were divided into 3 groups based on the surgical method: group A, traditional circumcision (n = 79); group B, modified circumcision (n = 80); and group C, disposable suturing device circumcision (n = 82).


Results: The operation times in groups A, B, and C were 25.2 ± 3.3 min, 10.2 ± 2.7 min, and 6.7 ± 1.4 min, respectively. The volumes of intraoperative blood loss in groups A, B, and C were 12.7 ± 2.3 mL, 8.1 ± 3.4 mL, and 2.2 ± 0.8 mL, respectively (P < 0.05). Groups A and B were superior to group C in terms of the 6-h postoperative visual analog scale score and appearance satisfaction (P < 0.05). There were no obvious differences in the 7-day postoperative pain score and total healing time (P > 0.05). The operating expenses in groups A and B were lower than that in group C (P < 0.05).


Conclusion: Modified circumcision, with its advantages of shorter operation time, less blood loss and pain, lower cost, and better postoperative penile appearance, is easily accepted by patients and deserves wide clinical application.

Purpose: To detect possible effects of magnetic resonance imaging (MRI) scans on the function of an InterStim Twin sacral nerve stimulation (SNS) device and on patient’s health. There is no authorization for MRI scans in InterStim Twin SNS at all.


Material and Methods: 10 patients with Interstim Twin sacral nerve stimulator implants underwent a singular MRI scan. Before the MRI was performed, the SNS device function was evaluated and the device was deactivated be the implanting urologist. A continuous monitoring took place during MRI procedure. Micturition-time chart pre- and post MRI procedures were conducted. After the MRI session was completed, the implanted device was examined once more and reactivated, function then was evaluated.


Results: A total of 10 patients required MRI examinations in 8 different body regions. No patient reported pain or discomfort during and after the MRI scan. After reactivation of the InterStim Twin device following the MRI, impedances and stimulation amplitude, micturition frequency, urgency, and incontinence episodes remained stable. No significant differences between pre- and post MRI were found (p>0.05).


Conclusion: This is the first report of patients successfully undergoing a MRI scan despite a previously implanted Interstim Twin sacral nerve stimulator. No negative effect of SNS function or negative side effects for the patients were observed.

A Investigating the Outcome of Surgery in Patients with Penile Fracture

Hamid Mazdak, Hanieh Salehi, Zahra Tolou Ghamari, Reza Kazemi

Urology Journal, , 1 January 2020 , Page 6347
https://doi.org/10.22037/uj.v16i7.6347

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 significant relation between erectile dysfunction with 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.

Video


To date, the optimal surgical technique for treatment of ureterocele remains unclear and the available options are variable. The endoscopic techniques that are gaining popularity mostly share major drawbacks including low success rate, high probability of mandatory secondary surgery and de novo vesicoureteral reflux to the ureterocele moiety. The Double-Puncture technique is shown to have promising outcomes in terms of long-term success and low rate of complications. In this video, a step-by-step guide to this technique is presented.