Scrotal strangulation in the differential diagnosis of acute scrotum: A case report

BACKGROUND

Acute scrotal pain and swelling are common presentations in the emergency department. Urgent surgical intervention is justified in up to one-third of cases, whereas two-thirds of them should be treated conservatively.

CASE SUMMARY

We report a case of scrotal only strangulation in a child and review the available literature.

CONCLUSION

Due to its rarity, scrotal strangulation can be a diagnostic challenge. Skin ulceration and edema may well indicate the presence of a strangulation object. A high index of suspicion and appropriate physical examination, especially in patients with a mental disability or behavioral disorder, are key to early diagnosis and treatment.

Perinephric urinoma, an unusual upper tract presentation of a lower tract injury following retroperitoneoscopy: A case report

BACKGROUND

A 66-year-old lady was referred to urology for a suspected urinoma after retroperioneoscopy done for debridement of a retroperitoneal abscess that developed following a duodenal perforation.

CASE SUMMARY

Serous contents of the drain sent for fluid creatinine were elevated confirming this and computed tomography urography findings suggested an upper tract injury with urinoma around the kidney. However, the antegrade nephrostogram suggested otherwise and on flexible cystoscopy and cystogram, an extraperitoneal bladder perforation was instead identified, with tip of retroperitoneal drain sitting inside the bladder.

CONCLUSION

This case identifies a limitation in the usual diagnostic approach for such injuries and emphasizes the need to exercise caution when managing them especially when they occur after several surgical procedures and in the presence of multiple surgical drains.

Estimation of successful capping with complete aspiration of bladder via nephroureterostomy tube

BACKGROUND

Ureteral stent and nephroureterostomy tube (NUT) are treatments of ureteral obstruction. Ureteral stent provides better quality of life. Internalization of NUT is desired whenever possible.

AIM

To assess outcomes of capping trial among cancer patients with complete aspiration of retained contrast from bladder via NUT.

METHODS

Our Institutional Review Board approved retrospective review of all NUT placement, NUT exchange and conversion of nephrostomy catheter into NUT performed during June 2013 to June 2015 (n = 578). Cases were excluded due to lack of imaging of bladder (n = 37), incomplete aspiration of bladder (n = 324), no attempt at capping NUT (n = 166), and patients with confounding factors interfering with results of capping trial including non-compliant bladder, bladder outlet obstruction and catheter malposition (n = 14). Study group consisted of 37 procedures in 34 patients (male 19, female 15, age 2-83 years, average 58, median 61) most with cancer (prostate 8, endometrial 5, bladder 4, colorectal 4, breast 2, gastric 2, neuroblastoma 2, cervical 1, ovarian 1, renal 1, sarcoma 1, urothelial 1 and testicular 1) and one with Crohn’s disease. Medical records were reviewed to assess outcomes of capping trial. Exact 95% confidence intervals (95%CI) were calculated.

RESULTS

Among patients with complete aspiration of retained contrast, 30 (81%, 95%CI: 0.65-0.92) catheters were successfully capped (range 12-94 d, average 40, median 24.5) until planned conversion to internal stent (23), routine exchange (5), removal (1) or death unrelated to catheter (1). Seven capping trials (19%, 95%CI: 0.08-0.35) were unsuccessful (range 2-22 d, average 12, median 10) due to leakage (3), elevated creatinine (2), fever/hematuria (1) and nausea/vomiting (1).

CONCLUSION

Capping trial success among patients with complete aspiration of retained contrast/ urine from bladder via NUT appears high.

Patients with ureteral obstruction are best treated with cystoscopic placement of ureteral stent because of a better quality of life. When ureteral stent placement is not possible, a nephroureterostomy tube (NUT) is placed. Once the acute clinical problem is resolved, internalization is sought in order to improve patient’s quality of life. Currently all patients undergo NUT capping trial which is needed before internalization. This work helps urologists and interventional radiologists to estimate success of capping trial. It helps define the endpoint of NUT placement or exchange interventions with potential benefits to patients and health care systems.

Evaluation of patient reported outcome measures post urethroplasty: Piloting a “Trifecta” approach

BACKGROUND

Buccal mucosal graft urethroplasty is the gold standard treatment for urethral stricture disease. Toowoomba has obtained a fellowship trained urethroplasty surgeon who has been performing urethroplasties for the last two years. Patient reported outcome measure (PROM) questionnaires allow for a detailed and standardized analysis of success and morbidity post urethroplasty and can be used as a reference point against which urethral surgeons can benchmark their performance.

AIM

To assess whether patient compliance rates improved with the use of an abridged PROM questionnaire.

METHODS

Our database of urethroplasty patients was searched to identify patients who had completed the original PROM. This is routinely requested to be completed at the 3-, 6- and 12-mo mark. All patients are asked to complete the questionnaire and to bring it back to their next appointment. Our original PROM consists of the international prostate symptom score, the sexual health index measure and the Global Response Assessment. An abridged version of the questionnaire was derived focusing on urinary flow, sexual function and overall quality of life and consisted of three questions.

RESULTS

Sixty-six patients were included in our study. Fifty-four patients had been invited to complete the original PROM with an overall compliance rate of 30%. Compliance rates improved to 91% with the introduction of the modified PROM. No correlation between non-compliance and patient factors were found. There was also no significant difference in patient reported quality of life when comparing urinary flow and sexual function.

CONCLUSION

We recommend the use of PROMs pre- and post-operatively to accurately determine the level of patient satisfaction. We acknowledge the aversion of patients in completing PROMs due to the length of these questionnaires. We propose a simplistic version aimed at the “Trifecta” of urethroplasty comprising of three questions focusing each on urinary flow, sexual function and quality of life. Our modified PROM demonstrated markedly improved compliance rates and can be used as a screening tool to identify patients who might have had a poor outcome and who require a more in-depth assessment.

Prostate resection speed: A key factor for training and broad outcomes?

BACKGROUND

Trans-urethral resection of prostate (TURP) is one of the most commonly performed operations in urology to treat bladder outflow obstruction (BOO) in men. TURP surgery is also a key for endo-urological training in the British National Health Service (NHS) for training junior urologists. The working hypothesis is that prostate resection speed (PRS) in the context of bipolar TURP surgery, is not a key factor in major complication rates or broad patient outcomes at 3 mo after surgery, and therefore supervising consultants should not focus primarily on resection speed when teaching TURP.

AIM

To investigate objective differences in consultants vs trainees PRS and whether PRS affected complication rates/outcomes after TURP.

METHODS

Retrospective descriptive study analyzing patient case-notes, operative and electronic records, study undertaken at Burton Queen’s Hospital NHS Foundation Trust, United Kingdom, a secondary care centre in the public sector of the NHS. Participants included: all Bipolar TURPs undertaken between 13/04/2016 and 27/06/2017. Exclusions: patients undergoing concomitant operations or where intra-operative equipment problems occurred. Resected prostate (g), operative time, post-operative complications and outcomes at 3-mo were obtained from electronic records. Clavien-Dindo Grade II complications or above considered significant. Binary successful yes/no outcome at 3-mo after surgery included both patients who reported moderate to significant symptom improvement, or being catheter-free for those catheterized before TURP.

RESULTS

157 patients were identified. After exclusion a total of 125 patients were included from analysis. The mean PRS for trainees (0.34 g/min) was found to be lower than the mean PRS for consultants (0.41 g/min). The operating urologist’s PRS was not observed to be related to the number of TURPs that they performed during the period of the study. The trainee vs consultant means post-operative success rates (86.5% vs 90.5%) were comparable. The Trainees’ patients did not suffer any significant complications as defined by the study. There was no clear relationship observed between PRS and the rate of significant post-operative complications or patients’ 3-mo binary successful outcome. PRS was noted to increase with increasing intra-operative experience for both Trainees 1 and 2 when comparing the first half of their TURPs to their latter half.

CONCLUSION

Consultants have a higher PRS in comparison to trainees. There is no trend between PRS and significant post-operative complication rates or 3-mo outcomes.

Neutrophil-lymphocyte ratio in the management and prediction of outcomes in renal cell carcinoma

Renal cell carcinoma (RCC) is one of the ten most common malignancies. The prognosis of RCC is poor when the disease is in advanced stages, with five-year survival of less than 10%. However current assessment approaches are limited in their ability to prognosticate and guide therapeutic decision-making. Cellular-mediated inflammatory response is increasingly being recognised to have an important role in carcinogenesis of RCC. Various inflammatory markers have been found to identify patients with RCC at high risk of recurrence and predict survival. Neutrophil-lymphocyte ratio (NLR) is a simple and inexpensive inflammatory marker that has been shown to be of value in the assessment of patients with RCC. An elevated pretreatment NLR has been found to be associated with reduced overall survival, recurrence-free survival and progress-free survival and risk of recurrence in localized RCC. In addition, lower pretreatment NLR has been demonstrated to be associated with better clinical response to systemic therapy including vascular endothelial growth factor inhibitors, among patients with metastatic RCC. However, NLR has not been found to differentiate whether small renal masses of less than 40 mm are benign or malignant. Further research is needed to determine the cut-offs for NLR to predict different clinical outcomes and how post-treatment NLR can be used. In addition, more work is also needed to evaluate combining NLR with other biomarkers in a model to predict patients’ clinical outcome or response to treatment for RCC.

Urinary supersaturation as a diagnostic measure in urolithiasis

AIM

To demonstrate that urinary supersaturation per se is not a reliable diagnostic measure of the risk for stone formation.

METHODS

Available physical and chemical data for calcium oxalate monohydrate (COM) and calcium hydrogen phosphate dihydrate (brushite, BRU), and urinary supersaturations with respect to COM and BRU in healthy individuals and stone formers, were obtained from the literature. Classical theory of nucleation was used for calculations.

RESULTS

It was found that the rate of homogeneous nucleation (unaided by substrates) of COM and BRU is nil at all conceivable supersaturations of urine. Consequently spontaneous formation of crystals in urine requires the presence of nucleation substrates for (heteronuclei).

CONCLUSION

Urinary supersaturation with respect to lithiatic compounds is a necessary, but not a sufficient condition for nephrolithiasis. The absence of crystallization inhibitors and the presence of efficient nucleation promoters (heteronuclei) in urine are further necessary conditions of urolithiasis occurrence. Urinary supersaturation per se is not a reliable diagnostic measure of the risk of kidney stone formation.

Recirculating chemohyperthermia as a treatment for non-muscle invasive bladder cancer: Current and future perspectives

About 75% of all bladder cancer diagnosed are non-muscle invasive bladder cancer (NMIBC), recurring over 50% of them after transurethral resection of the bladder tumor. In order to prevent recurrences, adjuvant intravesical chemotherapy with mitomycin C and immunotherapy with bacillus Calmette-Guérin (BCG) is traditionally used. Unfortunately, many patients relapse after receiving these treatments and a significant proportion of them require surgery. After a one-to-three years BCG maintenance, the risk for progression at 5 years was 19.3% for T1G3 tumors. Many new treatment approaches are being investigated to increase the effectiveness of adjuvant intravesical therapy. One of the developing treatments for intermediate and high-risk NMIBC is the combination of intravesical chemotherapy and hyperthermia, called chemohyperthermia. This article provides a review of the mechanism of action, current status and indications, results and future perspectives.

Combined urethral and suprapubic catheter drainage improves post operative management after open simple prostatectomy without bladder irrigation

AIM

To compare outcomes after open simple prostatectomy without bladder irrigation, in subjects drained by combined 2-way urethral catheter and suprapubic catheter (SPC) vs those drained by 2-way urethral catheter only.

METHODS

A total of 84 participants undergoing Freyer’s simple prostatectomy over an 18-mo period were randomized into 2 groups (n = 42). Subjects in group 1 were managed with 2-way urethral catheter and in situ 2-way SPC while subjects in group 2 had a 2-way urethral catheter drainage only. In group 1 subjects, the SPC was spigotted and only used for drainage if there was clot retention. The primary outcomes were number of clot retention episodes, and number of clot retention episodes requiring bladder syringe evacuation. Other secondary outcomes evaluated were blood loss, requirement of extra analgesics, duration of surgery, hospital stay and presence or absence of post-op complications.

RESULTS

The mean age in the groups was 65.7 (± 7.6) in group 1 vs 64.8 (± 6.8) in group 2. The groups were similar with respect to age, prostate specific antigen, prostate volume, blood loss, duration of surgery, blood transfusion and overall complication rate. However statistically significant differences were observed in clot retention episodes between group 1 and 2: 0.8 (± 1.5) vs 3.5 (± 4.4), P < 0.000, clot retention episodes requiring evacuation with bladder syringe 0.4 (± 0.9) vs 2.6 (± 3.8), P = 0.001, requirement of extra analgesics 0.4 (± 0.5) vs 4.0 (± 1.5), P < 0.000 and duration of admission 8.6 d (± 1.2) vs 7.3 d (± 0.6), P < 0.000.

CONCLUSION

Subjects drained with a combination of urethral and SPCs have fewer clot retention episodes and reduced requirement of extra analgesics but slightly longer hospital stay.

Chronic kidney disease after radical nephrectomy for suspected renal cancers

Nephrectomy is the treatment of choice for early stage renal cell carcinoma. However, radical nephrectomy is consistently associated with higher rates of new-onset chronic kidney disease (CKD) than the general population, regardless of the method used in measuring renal function. The higher rates of CKD are associated with worsened survival because of increased risk of cardiovascular diseases and mortality. Comorbidities and adjacent non-neoplastic kidney diseases are important risk factors for the development of CKD after nephrectomy. Partial nephrectomy has become the standard of care for patients with stage 1a tumours (diameter < 4 cm) and an attractive option for those with stage 1b (diameter 4-7 cm). Therefore stratifying the risk of postoperative CKD before surgery is important and ongoing monitoring of kidney function after radical nephrectomy is needed in addition to oncological surveillance. More research is needed to better understand the risk of CKD after radical nephrectomy and develop effective strategies to optimize kidney function after such surgery.

Radical cystectomy and en-bloc resection of enterovesical fistula from bladder cancer

Enterovesical fistulae secondary to benign or malignant bowel disease are not uncommonly reported in the literature. However, bladder malignancy as the primary pathology is exceedingly rare. We report a case of muscle invasive urothelial carcinoma of bladder with an enterovesical fistula to a loop of small bowel. The patient first presented with signs and symptoms of per rectal bleeding, haematuria, pneumaturia, faecaluria and rectal micturition. Her initial biochemistry test revealed significant metabolic acidosis with normal anion gap and hypokalemia. A computed tomography abdomen/pelvis with rectal contrast demonstrated an enterovesical fistula from the dome of bladder to a loop of small bowel. The patient underwent radical cystectomy with en-bloc resection of a loop of involved ileum and sigmoid colon due to the intraoperative findings of the sigmoid colon adherent to the tumour. The published literature is reviewed, focusing on the incidence, diagnostic modality and treatment strategies available for this rare condition.

Urine chemokine levels correlate with treatment response to phosphodiesterase 4 inhibitor in prostatitis

AIM

To investigate the association of urinary chemokines with the treatment response in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients.

METHODS

Between 2007-2011, 18 out of 21 male CP/CPPS patients met the exclusion/inclusion criteria of the 16 wk longitudinal study on twice daily oral treatment with Phosphodiesterase 4 inhibitor called Apremilast for 12 wk. Symptom scores and urine specimen were collected at baseline and every visit at 4 wk interval from CP/CPPS patients who completed at least 8 wk of drug treatment. Urine collected at each visit was frozen and then analyzed together after thawing for chemokines and growth factors using MILLIPLEX™ MAP immunoassay. Cross sectional association of Chronic Prostatitis Symptom Index (CPSI) and visual analog scale (VAS) with chemokine levels in urine collected at baseline was assessed in 18 CP/CPPS patients relative to 10 asymptomatic male subjects. Longitudinal association between urine chemokine levels and symptom scores was assessed in 8 treatment-adherent CP/CPPS patients at baseline and at 4, 8, 12 and 16 wk.

RESULTS

Urine chemokines levels of CXCL-1 (GRO-a), CXCL-8 (IL-8), CXCL-10 (IP-10) and CCL5 (RANTES) in CP/CPPS patients at baseline were significantly elevated relative to asymptomatic subjects, whereas levels of sIL-1RA in CP/CPPS were significantly lower compared to controls (P < 0.05). Quantitatively, urine levels of CXCL-10 were higher than other chemokines in CP/CPPS, but its 5 fold change relative to controls was lower than the 20 fold change noted for CXCL-8. The mean age of enrolled patients who completed at least 8 wk of treatment (n = 8) was 46.5 ± 9.4 years and analysis found that elevation of CXCL-8 and CCL5 increased the odds for higher score of CPSI by 54% and 25%, respectively (F test, P = 0.00007). Urine levels of CCL2 (MCP-1) and CXCL-10 together explained approximately 85% of variance in longitudinal data on multivariate analysis. Bivariate analysis of 5 patients who fully complied and completed the assigned dose regimen, showed strong linear correlation of reduced urine levels of CXCL-10, CXCL-8, CCL5, CCL2 and PDGF with improvement in clinical activity as measured by pain VAS and CPSI (Pearson r = 0.83-0.97; P < 0.05).

CONCLUSION

Urine levels of CXCL-10, CCL2 and PDGF can be sensitive, objective and non-invasive markers of response to new therapeutic intervention in CP/CPPS patients.

Contemporary management of upper tract urothelial cell carcinoma

Upper tract urothelial cell carcinoma (UTUCC), formerly known as transitional cell carcinoma of the upper urinary tract, is a rare oncologic disease in Western countries. Thus its disease process and its management are not as well defined as other urologic cancers. We are reviewing the current evidence based literature available to develop a plan for the treatment of UTUCC. A PubMed search was completed using the key words “upper tract urothelial cell carcinoma”, “epidemiology”, “risk factor”, “treatment” and “prognosis”. Six hundred fifty two articles were found. We narrowed our search to articles published between January 2004 and June 2016 for a more contemporary review of the topic. Four hundred seventy articles were then available for review. Further detailed search was performed for relevance on the topic and hundred one articles were selected for the review. Many risk factors have been found to be associated with the development of UTUCC, including tobacco use. Patients are often asymptomatic and may only present with microscopic or gross hematuria. Tumor grade and stage are pivotal in determining the treatment options for UTUCC. Advancements in endoscopic techniques have aided in the diagnosis, grading and treatment of this disease. Treatment options include topical therapy, with combinations of methotrexate, vinblastine, doxorubicin and cisplatin or gemcitibine or cisplatin, endoscopic resection, segmental ureterectomy and ureteral implantation, and nephroureterectomy, including bladder cuff. Treatment recommendations depend on tumor grade and stage, renal function, tumor location and the patient’s prognosis. There are currently no tissue or blood-based biomarkers available to accurately monitor the disease. Further studies of gene expression and biomarkers may hopefully improve the management of this disease. Although rare in many countries, UTUCC is becoming more prevalent due to exposure to carcinogenic herbal remedies and other identifiable risk factors. Numerous treatment modalities, both surgical and chemotherapeutic, have been utilized to treat both low and high grade UTUCC tumors. Additional clinical trials are necessary to further develop methods for screening, treatment, and surveillance to improve management.

Classical seminoma in a 92-year-old patient

Seminoma is a germ cell tumour which primarily affects the testes. Seminomas are treated by orchidectomy with usually excellent outcomes. We report the occurrence of a classical seminoma in a 92-year-old man, who is currently the oldest patient with this histology reported in literature. He presented with a painful, swollen testis. Scrotal ultrasound scan revealed a testicular mass. A left inguinal orchidectomy was carried out and histological examination confirmed the diagnosis of a classical seminoma. Further staging by computerised tomography revealed pulmonary lesions suspicious of metastases. The patient declined further treatment in view of his age and co-morbidities.

Enuresis and sleep disordered breathing: An old and new link

The causes of nocturnal enuresis (NE) are likely multifactorial. It has been related to several (urological-nephrological-hormonal) reasons but clear and univocal pathogenesis remains mostly undetermined. Sleep disordered breathing (SDB) is a syndrome of upper airway dysfunction that occurs during sleep and is characterized by snoring and/or increased respiratory effort secondary to increased upper airway resistance and pharyngeal collapsibility. Adenotonsillar hypertrophy is the main cause of SDB in children. To date, several studies have associated childhood NE with coexistent SDB. Adenotonsillectomy was successful for both SDB and NE in about half of patients. Unfortunately, practical consensus guidelines for the management of primary NE do not mention, or marginally concern, SDB in these children, particularly in those who have treatment resistance and comorbidities. The concerns regard the concomitant presence of two relatively frequent sleep disorders, raising the question whether they are really coincidental problems of childhood.

Splenunculi mimicking metastases in a patient with locally advanced prostate cancer

A 61-year-old man with locally advanced prostate cancer was found to have multiple solid intra-abdominal solid lesions during staging investigations. While some were in the pelvis, they were not located in the common landing sites for prostate cancer metastases, and his prostate specific antigen was not significantly elevated to suggest a high burden of metastatic disease. He reported a history of a blunt abdominal trauma due to a motor vehicle accident more than forty years ago which had been conservatively managed. His staging imaging revealed a lack of a discrete spleen in his left upper abdomen and this raised the suspicion that these solid lesions may represent ectopic splenic tissue. Imaging with nuclear medicine scintigraphy confirmed the lesions in his upper abdomen and pelvis to be splenunculi. He proceeded with a combination of androgen deprivation therapy and external beam radiotherapy for locally advanced, non-metastatic prostate cancer. Although it has been described in patients with low risk prostate cancer, this is the first case report of splenunculi mimicking metastases in a patient with locally advanced prostate cancer.

Does the molecular classification of breast cancer point the way for biomarker identification in prostate cancer?

There is significant variation in clinical outcome between patients diagnosed with prostate cancer (CaP). Although useful, statistical nomograms and risk stratification tools alone do not always accurately predict an individual’s need for and response to treatment. The factors that determine this variation are not fully elucidated. In particular, cellular response to androgen ablation and subsequent paracrine/autocrine adaptation is poorly understood and despite best therapies, median survival in castrate resistant patients is only approximately 35 mo. We propose that one way of understanding this is to look for correlates in other comparable malignancies, such as breast cancer, where markers of at least 4 distinct gene clusters coding for 4 different phenotypic subtypes have been identified. These subtypes have been shown to demonstrate prognostic significance and successfully guide appropriate treatment regimens. In this paper we assess and review the evidence demonstrating parallels in the biology and treatment approach between breast and CaP, and consider the feasibility of patients with CaP being stratified into different molecular classes that could be used to complement prostate specific antigen and histological grading for clinical decision making. We show that there are significant correlations between the molecular classification of breast and CaP and explain how techniques used successfully to predict response to treatment in breast cancer can be applied to the prostate. Molecular phenotyping is possible in CaP and identification of distinct subtypes may allow personalised risk stratification way beyond that currently available.

Efficacy and safety of onabotulinum toxin A for overactive bladder

Overactive bladder (OAB) syndrome is a condition which affects 16.9% of women and 16.2% of men with a significant negative impact on quality of life. It is a condition characterized by urgency, with or without urge incontinence, frequency and nocturia. Behavioral modifications and oral anti-muscurinic medications are first and second-line therapies for OAB but are frequently ineffective or poorly tolerated. For refractory cases of OAB, onabotulinum toxin can be offered and this therapy was approved by the Food and Drug Administration in January of 2013. In this editorial, we will review the indications, usage, efficacy and safety data for intradetrusor injection of onabotulinum toxin A.

Cost effectiveness of robot-assisted urologic oncological surgery in the United States

Urology has been on the forefront of technological advances in minimally invasive surgery, from laparoscopy to robot-assisted surgeries. As with all new technological advances in medicine, the results of new advances are compared to previously established gold standards. When it comes to robot-assisted urology, morbidity, oncological outcomes, and cost between the same surgeries performed in an open fashion vs with robot-assistance should be assessed. Because healthcare spending is increasingly under more scrutiny, there is debate on the cost effectiveness of robot-assisted surgeries given the high acquisition and maintenance cost of robotic systems. This articles aims to critically evaluate the cost effectiveness of robot-assisted surgeries for prostatectomies, cystectomies, and partial nephrectomies in the United States.

Use of synthetic grafts in pelvic reconstruction: A path of continued discovery

Since the 1990s, mesh has been used in pelvic reconstruction to augment repairs for stress urinary incontinence and pelvic organ prolapse (POP). In 2008 and 2011, the United States Food and Drug Administration (FDA) issued Public Health Notifications ultimately informing providers and the public that complications associated with the use of synthetic mesh in the transvaginal repair of POP are not rare. In this review, we (1) examine literature characterizing surgical practice-patterns subsequent to the FDA announcements; (2) describe presentation of mesh-associated complications and outcomes of management; (3) discuss the most recent materials science research; and (4) seek to characterize whether or not mesh has lived up to the long-term efficacy promise of a permanent implant. Durability of mesh-augmented anatomical outcomes do not consistently translate into improved patient satisfaction and subjective outcomes. This, when coupled with the possibility of mesh-associated complications, emphasizes the need for continued innovation beyond the status quo of current synthetic grafts.

Chylous ascites in laparoscopic renal surgery: Where do we stand?

Postoperative chylous ascites, which is caused by the disruption of lymphatic channels and persistent lymphatic leakage, was a rare complication in the urologic field before laparoscopic surgery was introduced. Now that laparoscopic urologic surgery, especially laparoscopic nephrectomy, is widely performed, chylous ascites as a complication of laparoscopic renal surgery has been reported more frequently. With these accumulated experiences and data comes knowledge about the proper diagnosis and management of chylous ascites, although there is still some debate regarding the correct protocol for diagnosis and management. Therefore, we performed a systematic review of the current literature regarding the etiology, incidence, diagnosis, management, and prognosis of chylous ascites after laparoscopic renal surgery, as well as strategies used to prevent it, and discuss current perspectives on overcoming this complication in the laparoscopic age.

Bladder cancer exosomes: Getting the message across

Bladder cancer is the seventh most common cancer in men and the seventeenth most common in women. It is also the most expensive cancer to treat over the lifetime of a patient, partially due to the necessity of frequent cystoscopy to monitor for tumor recurrence. There have also been no new developments for the treatment of bladder cancer in the last several decades. Exosomes are small, secreted, membrane-bound vesicles representative of the donor cell. Increasing understanding of the role of exosomes in cancer biology has inspired interest in their potential use as a non-invasive diagnostic tool, prognostic markers and/or indicator of recurrence of bladder cancer, and even for use in the treatment of bladder cancer. Exosomes can be readily isolated from urine. Several groups have already demonstrated differences in the protein and micro RNA content of exosomes in bladder cancer patients compared to normal healthy volunteers. Furthermore, cancer cell-derived exosomes mediate tumor progression through the delivery of their biologically active content to recipient cells. Exosomes may be useful for the delivery of targeted molecules for the treatment of bladder cancer.

Management of penile urethral strictures: Challenges and future directions

The anatomy of the penile urethra presents additional challenges when compared to other urethral segments during open stricture surgery particularly because of its unsuitability for excision and primary anastomosis and its relatively deficient corpus spongiosum. Stricture aetiology, location, length and previous surgical intervention remain the primary factors influencing the choice of penile urethroplasty technique. We have identified what we feel are the most important challenges and controversies in penile urethral stricture reconstruction, namely the use of flaps vs grafts, use of skin or oral mucosal tissue for augmentation/substitution and when a single or a staged approach is indicated to give the best possible outcome. The management of more complex cases such as pan-urethral lichen-sclerosus strictures and hypospadias “cripples” is outlined and potential developments for the future are presented.

Adjuvant radiotherapy for pathologically advanced prostate cancer improves biochemical recurrence free survival compared to salvage radiotherapy

AIM: To evaluate the long-term outcomes of patients receiving adjuvant and salvage radiotherapy following prostatectomy with adverse pathologic features and an undetectable prostate specific antigen (PSA).

METHODS: A retrospective review was performed of patients who received post-prostatectomy radiation at Loyola University Medical Center between 1992 and 2013. Adverse pathologic features (Gleason score ≥ 8, seminal vesicle invasion, extracapsular extension, pathologic T4 disease, and/or positive surgical margins) and an undetectable PSA following prostatectomy were required for inclusion. Adjuvant patients received therapy with an undetectable PSA, salvage patients following biochemical recurrence (BCR). Post-radiation BCR, overall survival, bone metastases, and initiation of hormonal therapy were assessed. Kaplan-Meier time-to-event analyses and stepwise Cox proportional hazards regression (HR) were performed.

RESULTS: Post-prostatectomy patients (n = 134) received either adjuvant (n = 47) or salvage (n = 87) radiation. Median age at radiotherapy (RT) was 63 years, and median follow-up was 53 mo. Five-year post-radiation BCR-free survival was 78% for adjuvant vs 50% salvage radiotherapy (SRT) (Logrank P = 0.001). Patients with radiation administered following a detectable PSA had an increased risk of BCR compared to undetectable: PSA > 0.0-0.2: HR = 4.1 (95%CI: 1.5-11.2; P = 0.005); PSA > 0.2-1.0: HR = 4.4 (95%CI: 1.6-11.9; P = 0.003); and PSA > 1.0: HR = 52 (95%CI: 12.9-210; P < 0.001). There was no demonstrable difference in rates of overall survival, bone metastases or utilization of hormonal therapy between adjuvant and SRT patients.

CONCLUSION: Adjuvant RT improves BCR-free survival compared to SRT in patients with adverse pathologic features and an undetectable post-prostatectomy PSA.

Diagnosis of voiding dysfunction by pressure-flow study in women

Pressure-flow study (PFS) of micturition is the best method to quantitatively analyse voiding function. It allows us to distinguish voiding lower urinary tract symptoms and low urine flow rate caused by bladder outlet obstruction (BOO) from those caused by detrusor underactivity (DU). Voiding dynamics are significantly different in men and women and the established criteria for urodynamic diagnosis in men do not apply to women. Basic principles of voiding mechanics and voiding patterns in asymptomatic women are analyzed. Although attempts have been made to establish a consensus for diagnosis of BOO in women with pressure-flow cutoff, video-urodynamics criteria and nomograms, currently there is no consensus. There is no standard urodynamic test to diagnose and quantify DU in women for which further investigations are needed. Modified projected isovolumetric pressure (to assess detrusor contraction strength) and pressure-flow cutoff criteria have been used. The diagnosis of voiding dysfunction in women is challenging, requiring PFS with very good quality control and often involves integrating clinical and radiographic data to make the final assessment.

Pre-transplant treatment of large polycystic kidney

AIM: To evaluate the indications, optimal timing and outcomes of native nephrectomy and other techniques in pretransplant treatment of autosomal dominant polycystic kidney disease (PKD).

METHODS: A literature review was conducted using the PubMed and Epistemonikos databases. Keywords for pre-transplant surgical management of polycystic kidneys were: Transplant, treatment and PKD. Keywords for pre-treatment embolization of PKD were: Embolization, transplant and polycystic kidney disease. The inclusion criterions were all articles found using this search method. The exclusion criterions were articles found to include bias and not attending pre-transplant treatment options. Fifteen articles were included in our final analysis. Ten articles were found regarding embolization of PKD of which three reviews were selected for final analysis. The reviews were divided into pre transplant and intra transplant treatment for the surgical treatment of PKD. All articles meeting inclusion criteria were thoroughly analyzed by two independent reviewers. A third independent reviewer was consulted if the reviewers did not agree upon the inclusion or exclusion of a specific article. No statistical analysis was performed.

RESULTS: Studies vary regarding the technique used (open or laparoscopic), laterality (single or bilateral) and temporality of nephrectomy with respect to renal transplant (pre-transplant or simultaneous to transplant). Several groups argue in favor of simultaneous nephrectomy and kidney transplant since it avoids the deleterious effects of being anefric. Long-term results and patient satisfaction are acceptable. However, it is associated with increased operative time, transfusion rate, morbidity and length of hospital stay. Based on small sample studies, bilateral nephrectomy prior to transplant has been associated with a higher risk of morbidity and mortality. Studies on laparoscopic approach report it as a feasible and safe alternative to the open surgery approach, highlighting its lower complication rate, transfusions and shorter hospital stay. Arterial embolization of the kidney appears as an effective and low morbid alternative for the management of large native kidneys. The reduction in renal size allow transplant in a significant number of patients, which makes it an appealing alternative to surgery.

CONCLUSION: There is limited evidence regarding best pretrasnplant treatment of large PKD but to date embolization seems an appealing alternative to augment space for renal graft allocation.

Case of intramedullary spinal cord metastasis of renal cell carcinoma

Intramedullary spinal cord tumors are rare. The improved survival resulting from more effective treatments for many cancers has led to an increased number of publications concerning intramedullary spinal cord metastasis (ISCM), including case reports and literature reviews; however, ISCM remains extremely rare in renal cancer. A 69-year-old man with a medical history of renal cell carcinoma (RCC) presented with urinary retention and bilateral paralysis of the lower extremities. A neurological examination revealed bilateral paraparesis below L1. Although brain magnetic resonance imaging (MRI), bone scintigraphy, and abdominal contrast-enhanced computed tomography revealed no abdominal findings, the thracolumbar MRI indicated a spot on the spinal cord at the Th12 level that exhibited hyperintensity on T2-weighted imaging and gadolinium diethylenetriaminepentaacetic acid enhancement on T1-weighted imaging. Accordingly, an ISCM of RCC was diagnosed. The patient rejected all treatments for these metastases except the steroid therapy. The patient’s condition deteriorated owing to metastatic progression, and he died 3 mo after the appearance of ISCM symptoms. The prognosis of this condition was poor. The mean survival durations were 8 mo with surgical treatment, 4 mo with irradiation, and 2 mo with palliative treatments. In cases involving neurological features and if brain or bone metastasis or spinal cord compression is not clearly observed, gadolinium-enhanced MRI should be performed to determine the existence of ISCM. Recently, some authors have reported the efficacy of ISCM resection. Surgical treatment could potentially yield improvements in the nervous symptoms or a longer survival after treatment. Although the prognosis was poor in most cases of ISCM, surgical treatment may improve the patient’s quality of life.

Perioperative outcomes and survival of radical cystectomy as a function of body mass index

AIM: To evaluate the perioperative and long term outcomes of cystectomy in obese patients.

METHODS: This is a retrospective review of 580 patients for whom radical cystectomy (RC) was performed for primary urothelial bladder cancer between November 1996-April 2013 at a single institution. Body mass index (BMI) was available for 424 patients who were categorized as underweight (< 18.5), normal (18.5-24.9), overweight (25.0-29.9), and obese (≥ 30). Baseline demographics, perioperative outcomes, and survival were assessed. Overall survival (OS) and disease specific survival (DSS) was estimated by Kaplan-Meier method. Medians were compared using the Mann-Whitney U Test. Categorical variables were compared using the χ² test. A P-value of < 0.05 was considered statistically significant. Statistical analyses were performed using the Software Package for the Social Sciences (SPSS), Version 20 (International Business Machines SPSS, Chicago, IL, United States).

RESULTS: The median age of all patients was 69 years (inter-quartile range 60-75) and median follow-up was 23.4 mo (8.7-55.1). Patients were characterized as underweight [9, (2.1%)], normal [113, (26.7%)], overweight [160, (37.8%)], or obese [142, (33.5%)]. Estimated blood loss during RC was higher in the obese group (800 mL) as compared to the normal weight group (500 mL). However, need for transfusion (47.7% vs 52.1%), number of lymph nodes resected (32 vs 30), length of stay (9 d vs 8 d), and 30-d readmission (29.7% vs 25.2%) between obese and normal BMI patients were similar. Obese patients underwent ileal neobladder diversion in 42% of cases, compared to 24% of normal BMI patients (0.003). Normal BMI and obese patients had comparable urinary incontinence (21.4% vs 25.6%, P = 0.343), and need for intermittent catheterization (14.3% vs 5.2%, P = 0.685) at 2 years follow-up. Overall survival was better in obese compared to normal BMI patients on univariate analysis, with median survival of 67 mo vs 37 mo, respectively (P = 0.031). Disease specific survival in these populations followed the same Kaplan Meier curve, with the obese group having a significantly improved OS, P = 0.016. Underweight patients had a significantly worse prognosis, with a median overall survival of 19 mo (P = 0.018). Disease specific survival was significantly worse in the underweight group compared to the obese group, P = 0.007. On multivariate analysis underweight patients remained at increased risk for death (HR = 3.1, P = 0.006), as were older patients (HR = 1.6, P = 0.006), those with multiple nodal metastases (HR = 3.7, P = 0.007), and those who had received neoadjuvant chemotherapy (HR = 2.0, P = 0.015).

CONCLUSION: Perioperative outcomes and survival following RC in obese patients is comparable with non-obese patients. Underweight patients have the worst OS and DSS.

Robotic-assisted laparoscopic partial nephrectomy: A comparison of approaches to the posterior renal mass

AIM: To evaluate outcomes of robotic-assisted laparoscopic partial nephrectomy performed for posterior renal tumors via a transperitoneal or retroperitoneal approach.

METHODS: Retrospective review was performed for patients who underwent robotic-assisted laparoscopic partial nephrectomy (RALPN) for a posterior renal tumor between 2009-2015. Patient demographic characteristics, operative factors, pathology, oncologic outcomes, renal function, and tumor complexity were obtained. Radius of the tumor, exophytic/endophytic properties of the tumor, nearness of tumor to the collecting system, anterior/posterior position, location relative to the polar line (RENAL) nephrometry scores were calculated. nephrometry scores were calculated. The operative approach was determined by the primary surgeon.

RESULTS: A total of 91 patients were identified who underwent RALPN for a posterior renal tumor. Fifty-four procedures were performed via the retroperitoneal (RP) approach, and 37 via the transperitoneal (TP) approach. There were no significant differences in patient factors (race, sex, age and body mass index), RENAL nephrometry scores, tumor size, conversion rates, or margin status. Among procedures performed on-clamp, there was no significant difference in warm ischemia times. Total operative time (180.7 min for RP vs 227.8 min for TP, P < 0.001), robotic console time (126.9 min for RP vs 164.3 min for TP, P < 0.001), and median estimated blood loss (32.5 mL for RP vs 150 mL for TP, P < 0.001) were significantly lower via the RP approach. Off-clamp RALPN was performed for 31 (57.4%) of RP procedures vs 9 (24.3%) of TP procedures. Oncologic and renal functional outcomes were equivalent.

CONCLUSION: The RP approach to RALPN for posterior renal tumors is superior with regard to operative time and blood loss and the ability to be performed off-clamp.

Is continuous bladder irrigation after prostate surgery still needed?

Continuous bladder irrigation (CBI) is commonly prescribed after certain prostate surgeries to help prevent the clot formation and retention that are frequently associated with these sometimes hemorrhagic surgeries. However, it remains unknown how effective CBI is in preventing clot formation/catheter blockage because these complications still frequently occur in the presence of CBI. On the other hand, the outcome of prostate surgeries has significantly improved over the years, and these surgeries have generally become much safer and, in many hands, less hemorrhagic. Newer surgical options such as holmium laser enucleation of the prostate with associated improved hemorrhagic control have also been introduced, further creating the opportunity to eliminate CBI. Furthermore, there is a lack of review articles on CBI. Hence, this article will review the evolution and contemporary role of CBI in prostate surgeries. To eliminate CBI after prostate surgeries, it is important to achieve good hemostasis during the surgeries. Having in place a policy of non-irrigation after prostate surgeries is also important if less CBI is to be the norm. A non-irrigation policy will hopefully help reduce those cases of CBI prescribed out of long-standing surgical tradition while allowing for cases prescribed out of compelling necessity. The author’s policy of a consistent non-CBI during prostate surgeries over the last 9 years will be highlighted.

Clinical perspective on renal elasticity quantification by acoustic radiation force impulse: Where we are and where we are going

Recent interests have focused on the exploration of the mechanical properties (elasticity, stiffness and deformity) of parenchymatous organs using tissue strain imaging techniques and elastosonography. Measures of the mechanical properties of the kidneys have given conflicting results. There are various conditions that affect the variability of renal parenchymal measures, the main target of the investigations. They can be classified as intrinsic (depending upon the patient), extrinsic (depending upon the operator) and mixed (both intrinsic and extrinsic). Indeed, the mechanical properties of the kidney depend on various conditions that alter its histology, mainly the amount of fibrosis in the renal parenchymal interstitium. Anatomical factors play an important role because the kidney is a highly anisotropic organ with important differences when considering the cortex and the medulla. Physical factors include the frequency of the probe, compression and distance from source to target. Many factors can affect measurements and it is necessary to find an accurate technique in order to avoid mistakes and to obtain reproducible data. Indeed, it is imperative to define a standardized examination technique in order to get comparable results. Therefore, the utility of acoustic radiation force imaging technique to predict only renal fibrosis or progression of chronic kidney disease is of dubious value because several variables - blood perfusion and urinary pressure - can contribute to a given measure, even with a standardized method able to minimize intra- and inter-operator variability.

Sweet side of bladder cancer

The malignant transformation of cells is often accompanied by deranged expression of the sugar chains, i.e., glycans, attached the cancer cell surfaces or attached to secreted proteins. The aberrant expression of specific glycans in bladder cancer has also been reported by several research groups. Similarly to other cancers, glycans such as the sialyl Tn antigens have been suggested as diagnostic and prognostic biomarkers of bladder cancer, and associated with disease progression and patient’s response to treatment. At present our understandings about the role of glycans in bladder cancer is still limited, but at the same time it is now assumed that this understanding urges and it will fuel the development of novel strategies of diagnostic and therapy.

Nothing like data showing significant death reduction can better support prostate cancer screening

At 13 years of follow-up, the European Randomized Study of Screening for Prostate Cancer shows a 21% decrease in prostate cancer deaths in the prostate-specific antigen-screened group compared to control. This difference increases to 27% when non compliance is taken into account. The benefits of screening compared to control are higher at 28% (compared to 21%) when duration of follow-up ranges between 8 and 12 years. Such data obtained following an average rate of one screening performed once every 5.7 years in quite impressive and strongly supports the use of screening for a successful fight against a cancer which grows to an advanced and non curable stage without any specific sign or symptom.

Update summarising the conclusions of the international consultation on male lower urinary tract symptoms

The International Consultation on Urological Disease have recently published comprehensive conclusions, based on evidence reviewed by eight committees, on aspects of male lower urinary tract symptoms (LUTS). In this review, we summarise the conclusions from four of the committees, namely, the evidence regarding the epidemiology of male LUTS, patient assessment, nocturia and medical management. It is indisputable that with an expanding and ageing global population the prevalence of male LUTS is likely to increase. Therefore symptom prevention and preservation of quality of life (QoL) feature highly in the guidelines. There are now a number of different medical options, proven to lead to significant improvements in symptom scores, flow rate and QoL available to men with LUTS. Meta-analyses have shown the benefits for alpha blockers, antimuscarinics, 5-α reductase and phosphodiesterase-5 inhibitors. High level evidence also exists for combinations of all of the above with alpha blockers and so men with concomitant storage symptoms, prostate volume > 30 mL, PSA > 1.4 or erectile dysfunction may be considered for combination treatment of an alpha blocker with an antimuscarinic, 5-α reductase inhibitor or phosphodiesterase-5 inhibitor respectively. In an era of personalised medicine, appropriate patient selection is likely to provide the key to the most effective clinical management strategy.

Infectious complications after prostate biopsy: Time to rethink our clinical practice

Prostate biopsy is a very common procedure performed worldwide which still represents the only way for prostate cancer diagnosis and reference point for subsequent treatments. Even if transrectal prostate biopsy is considered a safe procedure, it may be accompanied by infective complications, ranging from asymptomatic bacteriuria to symptomatic urinary tract infections and sepsis. During the recent decade we observed an increasing number of infectious complications and subsequent hospitalizations after and transrectal prostate biopsy. The most probable reason for the increasing rate of infectious complications after prostate biopsy is the increasing antimicrobial resistance, especially to the current first-line recommended fluoroquinolone antibiotics. We believe the time has come to re-think our current practice of diagnosing prostate cancer. We need to focus on the selection of patients at higher risk of infective complications, on microbiological sampling of the faecal flora prior to biopsy to identify resistance to specific agents, on the number of biopsy cores, on the biopsy route (perineal or transrectal approach) and, finally, consider alternative antibiotics with improved susceptibility to be used for prophylaxis.

Barbed polyglyconate vs monocryl suture in vesico-urethral anastomosis during robot-assisted radical prostatectomy

AIM: To compare outcomes using barbed polyglyconate (V-Loc 180) vs monofilament monocryl suture in forming vesico-urethral anastomosis (VUA) during robot assisted radical prostatectomy.

METHODS: Review of prospectively collected robot assisted radical prostatectomy data between July 2011 and September 2012. VUA technique: VUA was performed using 2 cm × 15 cm 2/0 V-Loc 180 continuous sutures or 3/0 monofilament monocryl sutures. Anastomotic integrity was tested intra-operatively with a water leak test. All patients had a post-operative cystogram at day 7 to 10.

RESULTS: There were 189 patients in the study with 113 in the V-Loc group and 76 in the monocryl group. Demographics were similar for both groups P > 0.05). The median operative time for V-Loc group was 130 min and monocryl group was 145 min, which was statistically significant (P < 0.001). The median blood loss for both groups was 200 mL with no significant difference (P = 0.260). The pathology results of the 2 groups were similar (P = 0.537). Four patients in the V-Loc group and two patients in the monocryl group had radiological urinary leak. This was not statistically significant (P = 1.00) and all patients improved with conservative management. The continence rates were comparable for both groups.

CONCLUSION: V-Loc suture significantly reduced operative time facilitating ease of VUA formation. Overall functional outcome and urinary morbidity were not significantly different from the monofilament group.

Urodynamic test and female urinary stress incontinence: An open debate

In this editorial we discussed the pros and cons of urodynamics in the assessment of female stress urinary incontinence.

Role of transperineal template biopsy in prostate cancer

Prostate cancer is the most common neoplasm diagnosed in men. Whilst treatment modalities have progressed, diagnostic investigations in terms of biopsy methods have been assessed but there is no consensus of when the different diagnostic methods in terms of transrectal ultrasound (TRUS) or transperineal template (TPT) should be utilised. TPT biopsy has a higher diagnostic yield than TRUS in those with a primary biopsy, in those with previous negative biopsies with TRUS as well as those undergoing saturation biopsies. Despite the increased likelihood of diagnosing cancer with TPT than TRUS this maybe secondary to the increased number of biopsies being utilised. However there is no consensus regarding the ideal number of biopsies that should be utilised with TPT. Furthermore it is felt that the increased number of biopsies utilised with TPT is associated the higher complication rates with TPT. The role of TPT biopsy is recognised in those with previous negative biopsies with transrectal ultrasound but further work is required regarding the ideal number of biopsies. Furthermore, it is felt that TPT biopsy may have a role in primary biopsy.

Value of preoperative MRI for prostate cancer staging and continence outcomes prior to prostatectomy: A review of the literature

Pelvic imaging in newly diagnosed prostate cancer is primarily used for staging prior to definitive treatment. Over the past decade use of magnetic resonance imaging (MRI) for pre-surgical planning has increased, as well has he technology and methods for performing prostate MRI. To investigate and define the different MRI technologies available and further assess MRI technology ability to predict pathologic stage. Searching PubMed, we identified current published literature, where the cohort population underwent pre-operative MRI followed by prostatectomy. Keywords used in the PubMed literature search included: MRI, prostate cancer, prostate cancer staging, multiparamentric MRI and incontinence. Papers were included for review if they discussed use of MRI prior to prostatectomy and had corresponding pathologic data, staging, incontinence, and surgical outcomes. Primary information noted was MRI sensitivity, specificity and overall accuracy for detecting extracapsular extension (ECE) and seminal vesicle involvement (SVI). Secondary information derived included assessing the surgical influence of staging information, and identifying predictors of urinary incontinence recovery. Review of the literature showed that in regards to extracapsular extension the reported MRI accuracy ranged from 76%-98%, sensitivity from 20%-90% and specificity from 82%-99%. As for seminal vesicle involvement the reported MRI accuracy ranged from 76%-98%, sensitivity from 20%-90% and specificity from 82%-99%. There is a widely varying sensitivity and specificity for both ECE and SVI and the wide variability in the MRI technology used in the literature supports that use of MRI technology for prostate cancer remains investigational.

Reconstructive surgery in Peyronie’s disease: What’s new?

Surgical treatment of Peyronie’s disease (PD) is still a challenge and a gold standard approach does not exist; however the main goal is to straight penile shaft, and to restore penetrative and coital capacity. The less invasive approach aims to correct curvature without intervening directly on the fibrous plaque while the more complex “corporoplasty” applies specific geometric criteria and uses different autologous and heterologous grafts. Each approach has its pros and cons and decision-making should be tailored to the individual patient’s expectations. Other surgical options include different use of patches to cover the tunica albuginea defect, with the choice depending on the surgeon’s personal experience. Despite the wide range of autologous (buccal mucosa, vein, dermis, etc.) and heterologous grafts (bovine pericardium, swine intestinal submucosa, porcine dermis, etc.) none currently represents the real “gold standard” because the data are extremely variable and frequently not representative. Several factors seem to favor buccal mucosa grafts over inert biocompatible materials: as vital tissue, buccal mucosa tends to heal rapidly, immediately integrating with the surrounding albuginea tissue. This translates into a more rapid resumption of spontaneous erections (after 3/4 d) and sexual activity and into a reduced risk of curvature relapse and erectile dysfunction after surgery. Another advantage of the buccal mucosa graft is its low cost. In conclusion, despite the recent development of some exciting new surgical techniques we are still unable to deliver a definitive take-home message about reconstructive surgery in PD because the majority of the studies reported insufficient data. However, since it is clear that major outcomes, besides the cosmetic result, are the patient’s and partner’s satisfaction and the economic impact of each technique, we recommend they be included among the outcome assessment parameters in further studies

Role of PCA3 test in clinical decision making for prostate cancer diagnosis

AIM: To assess the role of PCA3 urine test in the management of patients with suspected prostate cancer after repeat negative prostate biopsies.

METHODS: Patients with suspected prostate cancer either due to high or rising prostate specific antigen (PSA) levels and with a history of prostate biopsy who were candidates for repeat procedure were prospectively recruited to undergo PCA3 urine test. The recommendations on further management including the decision whether to proceed or not to the biopsy were made based on the PCA3 score. Patients’ adherence with the recommendations and influence of the PCA3 test on clinical decision making were assessed. The contribution of the multivariate model was measured with a decision curve analysis.

RESULTS: Three hundred and fifty-six patients were recruited to the study and underwent the PCA3 test. Twenty-six percent of 263 patients underwent prostate biopsy despite the low risk designation by PCA3 and 30% of 93 men did not proceed to biopsy despite a high risk result, rendering overall adherence of 73%. The variables that significantly correlated with adherence were positive family history of prostate cancer and PSA more than 10 ng/mL. Pre-test clinical stage, the number and the results of previous biopsies were not associated with the adherence. The decision curve analysis gave identical results for cut-off points of 25 and 35. On multivariate analysis the model that included PCA3 score, serum PSA, family history and result of the previous biopsy best performed with Area Under the Curve of 0.77.

CONCLUSION: PCA3 urine test markedly outperforms PSA in a repeat biopsy setting. Urologists and patients demonstrate substantial confidence in this analysis and tend to follow its recommendations.

Vasectomy reversal: A review of the evaluation, techniques, and outcomes

This review highlights the evaluation and treatment of men who have undergone vasectomy and desire vasectomy reversal to father children. For surgeons offering this treatment, the appropriate evaluation and treatment are crucial for acceptable outcomes. Although variations on surgical approaches have evolved over the years, one constant is the need for a high level of training and skill in microsurgical techniques.

Transurethral bipolar prostatectomy: Where do we stand now?

Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment of symptomatic benign prostatic hyperplasia. TURP has gained ground in urologic centers of excellence for its effective long term results with low incidence of complications. Far away from excellence, it associated with blood loss, and TUR syndrome particularly in patients with larger prostates. For this reasons, many minimally invasive new techniques have been implemented in recent years. Bipolar technique has recently been introduced, to minimize the complications of the standard TURP technique.

Genetics and male infertility

The goal of this review is to explain the requirement for understanding the genetic structure of infertility arising from male factor and to discuss the essentials of these genetic elements (2). The majority of the population is affected by this disorder caused by male factor infertility (1); but the etiologies are still unknown. After the primary genetic structure in infertile phenotypes is searched, an evaluation can be made. Thus the reasons causing infertility can be discovered and patients can benefit from effective therapies (1). Publications about male infertility within the recent 10 years in the Pubmed database were discussed (1). There are some approachments for describing the function of specific genes, but no adequate study is present to be useful for diagnosing and treating male infertility (1). Male fertility and fertility in offspring of males are considerably affected by the exact transition of epigenetic information (1). When the genetic factors playing a role in male infertility were analysed, significant steps will be taken for treating patients and determining the reasons of idiopathic infertility (1). Developments in technology associated with the impact of genetics may enable to specify the etiology of male infertility by determining specific infertile phenotype marks (1).

Adherence to immunosuppressor medication in renal transplanted patients

Non-adherence is a priority public health concern. Non-adherence means not taking medications, missing medications, taking too much, not taking enough, wrong timing, wrong dose and/or wrong pill, but may also refer to missing appointments, not booking appointments, not doing blood work, not returning calls and/or refusal to follow the treatment regimen. In renal transplantation, adherence to immunosuppressive medication is a fundamental requisite in order to preserve graft function, since non-adherence is one of the main causes for late acute rejection, incomplete recovery after rejection treatment, chronic graft dysfunction, graft loss, and death. Transplantation failure due to treatment non-adherence is economically, socially, ethically and morally unjustifiable. This is a very prevalent issue: in some studies, its incidence is as high as 70% of patients. The self-reported nonadherence levels found in certain studies, including those performed immediately after transplantation show the need for early and continued intervention after kidney transplantation in order to maximise adherence and consequently clinical outcomes. There is not a single method to assess non adherence, thus combining several measures increases diagnostic accuracy. Electronic monitoring with a microdevice that records each time a pill bottle is opened is considered the “gold standard” for measuring adherence, but self-report at a confidential interview was the best measure of adherence. Thus non-adherence risk can be effectively assessed using clinically available assessment tools. Medication Adherence Scale, Brief Medical Questionnaire, Immunosuppressant Therapy Adherence Scale, Immunosuppressant Therapy Barrier Scale, Long-Term Medication Behavior Self-Efficacy Scale and Simplified Medication Adherence Questionnaire are some of the self-reported questionnaires. There are multiple factors associated with non-adherence in immunosuppressant therapy: Younger patients (adolescent, especially), poor health coverage, poor social support, unmarried, no family, non-Caucasian, immigrant, lower income, lower socioeconomic class, greater parental distress and lower family cohesion; complex medical regimens, higher number of drugs, longer time after transplant, toxicity, side effects, poor tolerance to medication, higher number of physicians involved, poor provider-patient rapport; psychological (dependency, high levels of anxiety and hostility, poorer behavioral functioning and greater distress in children) and psychiatric (depression) illnesses, low self-efficacy with medicine intake, perception of immunosuppressive therapy as not been necessary to preserve kidney function, forgetfulness, rebelliousness, poor perception of health, poor satisfaction, low Health-related Quality of life, addictions, lack of coping strategies and avoidance behavior; patient morbidity: comorbidity, receiving a transplant from a live donor, retransplantation, and non-insulin-dependent diabetes. The most frequent strategies to promote medication-taking must focus on modifiable risk factors. Reasons for non-adherence are complex and diverse and any successful intervention aimed at improving adherence must be multidimensional. Although effective intervention strategies are needed to improve immunosuppressant therapy adherence, few intervention studies have been conducted in the adult renal transplant population. In this study, we perform an exhaustive review of the different strategies reported in the literature. A number of key reasons for non-adherence are also provided.

Urological manifestations and treatment of the primary systemic vasculitides

The primary systemic vasculitides (PSV) are a group of rare inflammatory disorders affecting blood vessels of varying size and multiple organs. Urological manifestations of PSV are uncommon. Testicular vasculitis is the most commonly reported finding and is associated with Polyarteritis Nodosa (PAN), Henoch-Schönlein Purpura (HSP), anti-neutrophil cytoplasm antibody associated Vasculitides (AAV), Giant Cell Arteritis (GCA) and Kawasaki disease. Prostatic vasculitis has been reported in association with GCA and AAV. Ureteric involvement has been noted in PAN, HSP and AAV. Other urogenital manifestations of PSV include genital ulceration and bladder dysfunction in Behçets Disease and haematuria which is commonly seen in many of the PSV. Finally, therapies used to treat the PSV, especially cyclophosphamide, are associated with urological side-effects including haemorrhagic cystitis and urothelial malignancy. The aim of this review is to examine how the urological system is involved in the PSV. Each PSV is examined in turn, with a brief clinical description of the disease followed by a description of the urological manifestations and management. Identification of urological manifestations of PSV is important as in many cases symptoms may improve with immunosuppressive therapy, avoiding the need for invasive surgery. Additionally, patients who present with isolated urogenital PSV are at higher risk of developing subsequent systemic vasculitis and will need to be followed up closely.

Functional and metabolic complications of androgen deprivation therapy

Prostate cancer is the most common non-cutaneous cancer in men worldwide. Several different treatment strategies are available including minimally invasive procedures for localized tumors such as radical prostatectomy, radiotherapy, and androgen deprivation therapy, among others. All these strategies can be given as mono-therapy or as combination therapy. For this review, we will focus on the side effects of androgen deprivation therapy, independent of the other treatment modalities. Some of the most common affections are loss of bone mineral density, weight gain and obesity, myocardial infarction and sudden death, metabolic syndrome and insulin resistance, dyslipidemia, loss of libido and erectile dysfunction, fatigue, cognitive decline, vasomotor flushing, to mention a few. All these alterations can have an impact on quality of life and even lead to more serious complications such as fractures and cardiovascular complications. We present recommendations for prevention, early recognition and treatment. The different modalities for androgen deprivation therapy have particular side-effects profiles and indications should be made in an individualized manner. Androgen deprivation therapy is a useful tool for some patients with prostate cancer but every effort should be made to avoid related complications. The use of guidelines and educational programs for both, patients and urologists, are extremely useful strategies.

Single-site laparoscopic partial nephrectomy: Where are we going?

AIM: To review an evolution of laparoscopic surgery, there has been a growing interest in laparoendoscopic single-site surgery (LESS).

METHODS: A comprehensive electronic literature search was conducted using PubMed database to identify all publications relating to LESS-partial nephrectomy (PN). The research includes articles published from April 2008 to January 2014. We focused our attention only on articles in which were cited the single-site surgical technique (laparoscopic and robotic), tumour stage and grade, mean tumour size, intraoperative variables, blood loss and transfusion rate, length of post-operative stay and complication rates, Clavien classification, positive of surgical margins, pain assessment at discharge.

RESULTS: A total of 9 studies were collected with 221 patients included. The mean patients age was 62 years. The mean tumor size was 2.35 cm with a mean operative time of 181 min (range 111-270 min) and 58.3% were done by robot. The mean ischemia time was 23.6 min. The 25.8% of patients underwent an unclamp LESS-PN. Mean estimated blood loss was 296 mL and median length of hospital stay was 4 d. The rate of severe post-operative complications (≥ Clavien grade III) was 5.4%. Not all surgical series of LESS-PN or Robotic-LESS-PN shows conversion in Multiport Laparoscopic or Open Surgery. Regarding oncologic outcomes, surgical margins were positive 4% of patients (9/221), no distant or port-site metastases were recorded.

CONCLUSION: LESS-PN and RLESS-PN are feasible and associated with reduced postoperative pain, shorter median hospital stay, shorter recovery time, and better cosmetic satisfaction without compromising surgical and oncological safety.

Is periprostatic adipose tissue associated with aggressive tumor biology in prostate cancer?

The prevalence of overweight and obesity and their health-related problems have been increasing. Obesity is increasingly recognized as a risk factor in different types of cancer in humans. The mechanisms supporting the link between obesity and cancer development have not been fully understood. Leptin, a circulating cytokine produced by adipocytes, may influence prostate cancer (PCa) progression in different ways. Body mass index seems to be an unreliable predictor for the development of PCa, but its influence on progression and poor oncological outcomes seems to be clear. Given the fact that abdominal fat is the most metabolically active fat, with different metabolic and paracrine effects, related anthropometric measurements may lead to a better estimation of PCa risk. Metabolically active periprostatic abdominal fat may also play an important role in releasing cytokines and growth factors that may promote tumor cell proliferation or even create a favorable environment for aggressive tumor biology. Different imaging measurements, e.g., periprostatic adipose tissue (PPAT) thickness, may be significant predictors of PCa. Several genes in the PPAT of obese men have been identified to contribute to chronic immuno-inflammatory responses which eventually lead to cell cycle alteration with oncological potential. In vitro studies showed the importance of PCa and its interaction with its microenvironment particularly in patients with aggressive PCa. Different types of cytokines, such as interleukin-6, may promote a tumorigenic microenvironment. This article endeavors to review the current literature on the association of PPAT with aggressive tumor biology in PCa.

Non-pharmacologic options for the management of voiding dysfunction in multiple sclerosis

Multiple sclerosis is a neuroinflammatory condition that can cause significant bladder dysfunction manifesting either as overactive bladder or impaired bladder emptying. Patients will often complain of urgency, frequency, nocturia, urgency incontinence, hesitancy, straining to void, and incomplete bladder emptying. While these symptoms can be treated with pharmacologic agents, often patients will require more significant treatments. Patients should first be evaluated with urodynamics in order to adequately diagnose the pathologic condition causing their symptoms. These interventions include catheter use, injection of botulinum toxin, neuromodulation, urethral stenting, sphincterotomy, suprapubic catheter with bladder neck closure, bladder augmentation and urinary diversion. The purpose of this review is to examine the evidence supporting each of these treatment options so urologic providers can better provide for this unique and complex patient population.